Luckily, our nephew David Herzenberg, a newly minted Graduate Nurse, had the youthful energy to write a daily blog, in a classic stream of consciousness style, that is at one person's view of what happened this past week. Here is David assisting Dr. Job Timeny, our Haitian American podiatry resident.
Here is David's vision of the elephant that is Haiti...
David’s Impressions of Haiti
Another day…
I must say, I severely dislike the cot I’m sleeping on. If feels like I’m laying on the stretched skin of a tambourine. Similarities end when I toss and turn on the cot. Rather than the charming jingle of a tambourine, my cot more mimics a creaking door in an Alfred Hitchcock movie. I attempt to erect my mosquito net and acquire my much-needed nighttime comforts. I am deeply saddened that I cannot construct my signature pillow nest. Thus I lay in discomfort and attempt to will myself to sleep. I am actually almost successful, just as my subconscious begins to cross the threshold of my mind my animal brain is thrust into action. The scream of a patient’s mother sends bolts of adrenaline throughout my body. I’m up and running to her room before I realize I’m not dreaming. Apparently the child just had a seizure, and now she is lying, post-ictal, the stares blankly up at the ceiling while her respiratory level continues to drop. “Who has the key to the O2 tank?”, yells our pediatrician. “Key!?” I think to myself. Now seriously, why would you need a key for an O2 tank? On a side note this is the second time I’ve been in a situation where no one had the key for the O2 tank. That’s like putting a combination lock on a toilet.
After much cursing, crying, and possible voo doo, the girl is stabilized and I wander through the darkness back to bed. Struggling to fight my way through my mosquito net into my bed I find myself relating to sea turtles that are unfortunate enough to find themselves trapped in fishing nets. I lie in bed still, and contemplate the unyielding heat. Even at 2:30am the heat is oppressive, the air sits heavy and thick around me. I feel like I could bite the air and spend a good deal of time chewing it. I fall in and out of sleep for the next few hours. Fact about Haiti, where there is no Daylight Savings Time, the sun rises at 4:30 am. Once again I wake up sweating and sticking to my cot from hell. I count at least three mosquito bites and contemplate the possibility of a lifetime living with malaria. … I stagger to the 6:30 am morning meeting, doing my best zombie impersonation… how appropriate for Haiti. I quietly give in to the heat and accept the fact that all the baby powder in the world won’t keep my butt dry.
There is no way I can sum up everything I experienced today. Suffice to say, I learned more today than I did over the past year in nursing school. I must have seen 40 patients myself on the floors. I lost count of how many dressing changes I performed. I struggled with language difficulties. I witnessed children and adults cry. I saw injuries that made me sad. I discharged patients that wanted to stay in the hospital because, while primitive, it was far better than their own living conditions. I scrubbed into two surgeries in which I suctioned, helped suture, and stapled wounds. I learned a lot more about what people look like on the inside. I saw bone being harvested from a hip. I ate rice and beans. I made new friends. I surprised myself. I missed people back home. And finally, I felt really good about what we accomplished today. It’s getting late and there is just too much detail to get into.
Another day…
Drained… totally drained. Again, with the 2:30 am crying. I have a feeling this is a nightly occurrence ☹. Hopefully I won’t strike out with the whole sleep thing again tonight. I’m draining my batteries faster than I can recharge them.
Today was Sabbath, the day God rested… I’m not a god. I awoke to the sound of church music and prayer. Saturday was supposed to be our slow day. Our usual 6:30 am meeting was replaced by 6:30 am rounds so we could get some rest… explain to me how that works exactly? Anyhow, rounds gave way to our frenetic pace, (I assume this to be the standard). I have my hands in a little of everything here, med. surg., OR, ER, social worker. After sweating like crazy in pre and post op, a couple quick dressing changes and finding adequate staffing for the ER, I found myself back in the OR. I seem to be spending a lot of time in the OR, not specifically because I prefer it, but because I feel like I know the least about this area of nursing practice (Its also the only air conditioned patient care area). There are so many protocols and procedures that must be followed in specific sequences. Even the act of putting on your gown requires a significant amount of planning and thought.
I was the scrub nurse in one of the OR’s today. I was responsible for setting up the table, getting all the gear/tools/supplies, getting everyone’s gown and gloves, helping everyone get dressed, setting up the sterile field, knowing the names of all the instruments, killing insects (yes there are flies in our OR because of swinging doors that do not stay shut), and producing the correct instruments when requested by the surgeon. I was basically wearing a really ugly light blue sterile burka. What with the mask, hair net, eye shield, lead vest, gown, shoe booties and two pair of gloves I was following Sha’ria law to the T.
Our first case was a simple wound vac dressing change. Unfortunately we seemed to hit a snag with every step. What was supposed to have taken an hour ended up being more like two to three hours. Our patient’s IV was infiltrated and was of course a hard stick. And to add the icing to the cake, guess who our patient was. Yes, the unfortunate little girl who has been keeping us up every night. A little history on our girl… Compound fracture of the right femur during the January 12 earthquake. External-fixator put on to keep the leg healing straight (think pins and braces), and a skin graft flap in an attempt to cover the skin defect, (think really big open wound that is too wide to close on it’s own). Since January, every team who has come through our hospital has attempted to treat our young lady. In that time her wound has been infected and debrided, and flapped and VAC’d on many occasions. In that time she has developed quite a tolerance to opiate and narcotic drugs. I’m beginning to understand why she cries every night, she’s in pain, not so much because of the injuries themselves, but because she’s in withdrawal. Morphine is hard to get in Haiti. Our team brought drugs with us, but no narcotics, as it is difficult to go through all the DEA diversion paperwork to carry narcotics on the plane.
Attempting to get an IV back into this girl proved to be a challenge. As you can imagine, the majority of her veins are all used up, I’m sure she has been stuck a thousand times by every team since the earthquake. We wanted to change her wound VAC with conscious sedation and needed to have a line in case we needed to load fluids. In an attempt to calm her down, (she was already hysterical), we gave her Ketamine, Fentanyl and Propophol. And during the entire procedure it was clear that she was still feeling it. She kept repeating in Kreyol, “I’m in pain, I’m in pain”, over and over through out most of the procedure. Even at her most sedate she was still moaning and trying to wriggle off the table. We had some trouble getting a good seal with the wound VAC. What’s a wound VAC (Vacuum Assited Closure). Imagine an open, infected wound the size to two bananas, side by side, on a 60 lb. girl’s thigh. Now, imagine a bunch of 1/4” diameter pins sticking out of the femur above and below the wound; each connected by an articulating rod the width of a toilet paper dowel. All this is on a hysterical frightened little girl who has been traumatized, continues to live in trauma and is going through opiate withdrawal. Ok, you with me? Take out the old dressing, and vigorously brush down that wound. Pack it full of new sponge, cut it to fit of course, and seal it with really sticky flimsy sheets of tape. Make sure to wrap each of the six pins to prevent any air from entering or escaping the wound. Now, cut a hole and reattach the vacuum pump. The suction should pull infected fluids out and promote tissue granulation and healing. Oh yeah, and keep the procedure sterile.
Ok, so we do all that and we find out we don’t have an airtight seal. Jiminy Cricket! I’m so sick of wearing this mask and not being able to scratch my nose! I can feel my finger tips pruning up inside my gloves. We work on it for another 45 minutes. That’s it, we can’t get it to seal and she’s been sedated for a long time and we don’t want to keep her under any longer than we have to. I break my sterile field and race back to the hospital ward. As it so happens, a volunteer from another team here this week is a wound care specialist. It’s time to bring in the ringer. We get her in and within 30 min. we have the wound dressed and re-sealed. Guerilla medicine is awesome. It feels so free to conduct our procedures based on need rather than protocol. We are working in reality; the ivory tower of NCLEX seems so alien and distant. I’m going to have to will myself back into NCLEX logic when I return to S.F. But until then I will fully enjoy implementing need-based practice. There is so much more that went on today… I’m just too tired to relay it.
Final thought… I’m spoiled, really spoiled, so spoiled in fact that I have the audacity to complain about my sleeping situation in the face of all this disaster around me. I may not be totally comfortable… but just down the hall are all my patients, just as hot, with broken limbs, only getting one meager meal a day, staring down an incredibly difficult future of rebuilding their bodies, lives and country. They are sleeping on the same miserable canvas army cots as me, and their families are sleeping next to them on the floor. And I complain about heat and mosquitoes… Get yourself in check David!
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Another day…
Before I write anything of substance just know that my feet feel like hotdogs that were cooked in a microwave… all bloated and tight… about to pop and spill foot meats all over. I’ve been standing up all day.
As if the conditions in which we operate aren’t difficult enough, imagine trying to perform surgery without electricity and solely by headlamp. Yikes! Don’t ever get sick or injured in a third world country. But I’m getting ahead of myself… lets start with how today began… or rather how last night ended. I’m trying to write a blog a day which is proving to be difficult. Not because there is a lack of content but rather because I’m so tired by the end of the evening. The lack of quality sleep is catching up with me. Last night the same ol’ song was playing again. Same girl, same weeping. I’m a little ashamed to say just couldn’t face it again last night. I crept out of my cot and made my way into the dining lounge, which is much cooler.
Anyhow, had lots of surgery cases today. Here are some highlights.
1. We took off a guy’s external-fixator and opened up his leg. Wow, necrosis… Dead muscle is gross, but dead bone is just sad. The total operation took 6 hours between removing the ex fix, removal of dead bone, insertion of antibiotic cement beads (which I made myself), and application of an Ilizarov cage fixator. This case requires extensive set up. Tons of tools, drills, pins, needles, hundreds of little nuts and bolts of all sizes and variations… Orthopedic surgery is very similar to carpentry… or a really complex piece of IKEA furniture.
2. I did my very first sterile set up all by myself today, Yay, all by my self; I’m such a big boy! (Just a side note, a young man was brought into the ER basically lifeless, and was coded by our team, but without success. This is the second one today like that…) Ok yeah, so my very first sterile set up, we put an ex –fix on a ten year old girl with a fractured femur (very common injury). I had everything dialed in, and was totally sterile. I only forgot one thing…my lead… and yes we were using Fluoro (real time X rays). We must have taken at least 150 x-rays during this case. I found myself ducking and diving behind the other surgical team members who were leaded up. I will consider that my workout for the day. I’ve been doing push ups, sit ups and various other exercises every night… but I don’t think it’s gonna happen tonight. It’s already so late.
3. Last case of the evening, open reduction of a hip dislocation on a 44-year-old woman. Basically her hip was dislocated during the earthquake. We think she was trapped under rubble and her hip dislocated when she was dragged by her leg out from under rubble. The dislocation was severe, so severe the femoral head, (very top of the thigh bone which connects into the hip), tunneled through near by connective tissue and settled near the internal lady bits. The head surgeon asked me to insert my hand into the would and probe into the tunnel to feel calcified bone/scar tissue that had formed and prevented the hip from settling back into place. I almost got up to my wrist. I must say it was kind of exhilarating… I know how strange and perverted that sounds but don’t worry, I’m not a serial killer. We lost power several times during this case and worked by headlamp… that too was exhilarating.
4. I finally left the hospital today and ventured into the outside world. A local Haitian anesthesiologist was kind enough to work with us all day. She worked till 9 pm (well after dark) and expressed her concern regarding driving home alone tonight. Apparently, our hospital is located in the second worst neighborhood in PAP; only to be outdone by our neighboring area of Cite Soleil with is the worst and most violent. So I offered to ride with her to her neighborhood and be followed by one of our vehicles, at which point I would ride back with our transporter. It’s pretty apocalyptic out there. Trash fires, rubble, police, UN soldiers, burned out vehicles, and chaos everywhere. Life it tough… If you are reading this on the Internet, you will probably never struggle through life like these people are. (Obviously myself included).
Every day here is sobering. It’s really difficult to describe in words what I’m seeing and experiencing. How do you describe a hopeless moaning child, or driving through a population wild with desperation in the dark, or hearing that a mother just stopped by the hospital because her baby is dead and is asking for verification so she can have her child buried for free, or the look of gratitude when you see a patient smile even though you know he doesn’t understand you and is scared out of his mind. I’m not a poet; I’m trying my best to bring you guys here with me, its not all mosquitoes, heat and insomnia. This stuff is a real guys… it’s real and I don’t see any solution.
Sleep, glorious sleep! Finally, a full 5 hours. I feel moderately recharged. Today began without power or water, kind of crummy considering you wake up sweaty and gross. The one comfort I’ve been able to keep constant is my oral hygiene. It took a while but I was finally able to brush my teeth today. There is nothing worse than smelling your own bad breathe inside a facemask in the OR for hours in the heat.
Today’s highlight: I drove with Aunt Merrill and a translator to the Red Cross to get blood for two patients whose labs made them ineligible candidates for surgery. The first, a little girl who needs a high above knee amputation who has a hemoglobin of 3.5 and the second is a young man struck by a car with a femur fracture with a hemoglobin of 5.0. Getting blood is a major chore, as there is only one donor/collection site in PAP, at the University Hospital (much grittier than the name sounds). Families are supposed to donate four units for everyone that they get, but certain blood types are in high demand, and our patients fall in that category. We were so desperate to get him blood that Merrill actually donated her own blood (she’s O-negative) for him yesterday. Even so, we had to come back the next day to get the two units we needed for our patients, as it was a Saturday and the technician who cross matches the blood doesn’t work after a certain hour. Of course this being an island third world post disaster country, nothing happens quickly. So they asked us to wait till today. Waiting for blood is never good. So we make the trip back to the Red Cross to get blood again today. And once more we are asked to wait an additional day. This, we cannot accept, our patients condition is growing more critical and an additional patient requires a transfusion as well. We attempt to explain our situation to the receptionist at the Red Cross without any success. Everyone else waiting in line at the Red Cross, (all Haitian) have similar stories if not worse.
Let me back up for a min. Obviously we had to leave Adventist Hospital for this particular adventure. We hired a Tap Tap, which is basically a covered pick up truck with an open tailgait that are used as communal taxis. Most are extremely colorful and painted boasting either religious references or music lyrics. The Red Cross itself was shockingly in disrepair. How may advertisements have you seen by the Red Cross asking for donations for Haiti? Seeing the actual Red Cross in Port Au Prince makes me wonder where all those donations actually go. This country went through its worst disaster in recorded history and the Red Cross which is multimillion dollar NGO only sponsors 1 blood donation site in all of Haiti, and its dilapidated, understaffed, and falling apart?!
We even offered to pay for the blood, but were informed by the Red Cross technician that the blood was free, albeit with a long long wait to get it. We finally got our two bags of cross matched blood, in a neat little cooler on a bed of ice. Ironically, as we are leaving, a California surfer dude in Banana Republic clothing driving a brand new shiny, tricked out SUV with a Red Cross logo pulls up, beeps and waves at us… is this where your Red Cross dollars are going? To pay salaries, hotel fees, and buy new SUV’s for expat relief workers? How about updating the blood collection center and hiring more technicians so that people don’t have to wait two-three days for their emergency blood transfusions. Whatever…
Don’t remember if I described what driving in Port Au Prince is like. I took some video and I’ll post it when I get a chance. Although it’s not as bad as Sri Lanka or Java, it’s pretty darn bad; the combination of short burst acceleration and roads that are totally messed makes for dangerous travel. I almost messed in my pants when we were speeding down a one-way road into oncoming traffic, on the wrong side of the median, during rush hour, for like 5 minutes straight!
So we get back, we are heroes, we transfuse the blood, we break and anticipate surgery. I sit down to check my Facebook and begin this blog. That was almost 5 hours ago. A team member runs up to find the rest of us. Our little girl is getting her blood, but suddenly starts to bleed heavily from her leg. Starting off with a Hgb of 3.5, and it seems like most of the precious blood we finally were able to transfuse into her is now pooling beneath her leg on the canvas cot. My uncle John applies femoral artery pressure and we rush her to the OR, scramble to prepare, and hope for the best. It was tense in the OR. Aaron our anesthesiologist stabilizes her and John and Scott wrap a rubber touniquet around her groin. We knew she was definitely going to lose her left leg, but we had hoped to do it in a more orderly fashion the next morning. Aaron figures it out. The sudden bleeding must be from citrate toxicity. The Red Cross adds Citrate in the blood bag to keep it from clotting, but if they have too much in the bag, it causes a clotting disorder when transfused into the patient. Aaron gives the antidote (calcium) and her clotting stabilizes. John and Scott proceed with the definitive amputation, now that she stable (if you can describe a Hgb of 3 or 4 as being stable) enough to survive the procedure. Mind you she is an 8-year-old girl with a bad infection from poor treatment that she received for an open femur fracture in another hospital far away. After languishing in the other hospital for a month, her father had the gumption to take her out, and bring her to Adventist. Unfortunately, the foot was dead and the thigh massively infected and swollen when we met her. We had operated on her the night we arrived, draining 2 quarts of smelly pus from the thigh, with the intent of stabilizing her for the definitive amputation. We knew we would have to amputate. Knowing you’re going to have to amputate a beautiful little girl’s leg conjures bizarre sensations. On one hand you feel terrible because you know you will take part in a life-altering event that will most likely affect someone’s life for the worse. (Forget being an amputee in the US, imagine it in Haiti) But on the other hand you are kind of excited to be part of this complex high-risk medical procedure. I still don’t know how I really feel about the whole thing. It was fascinating and gruesome at the same time, I found myself amazed and horrified at the same time. Not so much because of the gore, but because she would have to live, (fingers crossed), with the outcome of this savage procedure. There were many tense moments; no one was totally confidant we could pull this off. Despite all the blood, bone and flayed flesh, the most disgusting part for me was after the leg was actually free. The sound the leg made as the surgeon dropped it’s dead weight into a plastic bag really bothered me. The sickening thud accompanied by the sound of the femur piercing the plastic brought me back to the reality of what we had just done… We cut of this girls leg… Oh my god… we really just cut off this girls leg.
Confused, disgusted and upset, I found myself sitting alone on the front steps post op. I have seen a lot of crazy things on this trip in the past few days, but I haven’t cried. I even walked through a tent at University Hospital when we went to get blood, and saw at least 2 dead or nearly dead babies and managed to remain stoic. But I just let loose tonight; the seal broke and I sobbed, letting all my emotions drain. I dried my eyes and gathered up the strength to go see her in post-op and say a few encouraging words to her fully knowing there is no way she would understand. I did, and I felt a little better. I can only hope that this scared yet stoic little girl derived some measure of comfort from my touch. On my way out of post op 1, I crossed the hall to post op 2 to check on our other guy who received a transfusion as well.
Although we could not communicate well, we knew each other. I always greeted him and we had somewhat of a connection. Kind of difficult to explain. I smiled at him, he did not return. I looked closely, something was not right. He looked paler than usual and was shaking slightly.
Oh damn, transfusion reaction was the first thing that entered my mind. I got a quick set of vitals HR 129 (very fast) BP 130/90 (a little high, nothing serious) Respiratory Rate 25 (elevated), and Temp 104, (really high). I called for help, and our team arrives, the tremors become more violent, the temperature climbs to 107, his heat races, and his mentation changes. We slam some steroids, pain meds, Tylenol, and fluids.
We are trying to cool him down. Ice, where can we get ice? I don’t know who brought it, but now I have it in a basin. Carotid arteries, armpits, femoral arteries, neck, forehead, and abdomen. We pack his body in ice. We put a Foley catheter in him, we run the IV lines through ice baths; There is running, shouting, sweating, running, tripping and searching. All without any privacy whatsoever. Every other bed and family member in this small room is watching exactly what’s going on. And his shaking gets worse, and his speech more garbled. Gradually he responds to treatment, and we set up a rotating mini-ICU. Gratefully, there are some SICU nurses and a cardiologist in the other team this week, and they offer to stay up with our guy throughout the night.
We are not made out of the same things the Haitians are made of; they are so much tougher and resilient in almost every way.
The Days feel like weeks and the weeks feel like days. I can’t believe this week is coming to an end so soon. Although I feel like I’ve been working my ass off, there is so much left to do.
It’s no stretch of the imagination that I didn’t get much sleep last night. Strangely, I’m getting used to running on fumes. I am, however, totally over drinking instant coffee… what I wouldn’t give for a large ice coffee with a Splenda. Soon enough… Anyhow, despite not having adequate caffeine I still managed to power my way though another marathon day. In fact, it’s not even close to being over. Turns out I’m going to have to scrub for a late night case. I probably won’t even begin to prep. the case until 11: 30 pm. Oh god, last one… well, until tomorrow. I think we are going to squeeze in a couple before we head to the airport. I really hope we don’t have any complications tomorrow and we can just make our flights. Not that I’m eager to leave or anything. Haiti has captured a part of my heart. I’m sure this is not the last time we will meet and our paths are destined to cross once more in the future.
There is just so much work to be done. There are so many obstacles to overcome. And there are so many desperate people here. Patients are getting word of our impending departure. I always feel awkward around this time. I’m almost embarrassed that I get to return to my American lifestyle. Like I said before, this is just an adventure for me, something that makes me feel good and gets attention and praise from others. But it’s weird, I’m not some angelic savior, sent from the heavens to save the people. I guess I’m here for a couple reasons.
First, someone needs to go. I have a really hard time watching people suffer. And second, it makes me feel good. A big part of why I do this is for myself. It makes me appreciate who I am and what I have. Although I really appreciate the fact that you have been reading my blogs; commenting and giving me such positive feed back, just know that I’m no hero. I’m not doing anything that is beyond any of your capabilities. Just like Michael Jackson said, “If you want to make the world a better place, just take a look at yourself and make a change”. Yeah, I know, uber cheesy, but very true.
Ok, enough preaching. Lets talk about today. Nothing shocks me anymore, well almost nothing. Today was swelteringly hot, the kind of hot that makes you actually feel like your being slowly cooked. I had that gross wet pant leg stuck to your calves and thighs feeling all day. So again I bounced back and fourth between the OR and Post-op again today. If I wasn’t wet enough from my own perspiration, I walk into Post-op 1 and into an inch deep puddle of toilet water. Apparently a pipe burst in a nearby bathroom and flooded. Ugh, great. Now my scrub bottoms are soaking up poo water and the water line is having a race to the back of my calves. Sigh… But like all toilet tragedies it isn’t the end of the world and eventually gets taken care of. The morning dressing changes continue. I become intensely focused on changing a complex dressing on an Ilizarov fixator. I kneel down on the tile floor silently, super silently. So quietly in fact that I touch down without any sound at all. That’s odd, I look down at the far end of my thigh and am horrified that I just knelt on a turd, a wet, loose, lonely, brown turd. Good thing my knee decided to keep it company….
A bunch of us are in the breakroom when my uncle comes up to let me know that I need to take over for his usual scrub nurse who has been working all day, and at 11pm has hit the wall of exhaustion. There is still one more case to go, and I need to scrub in to fill her place, Our surgeons started a spinal fusion at 9pm on a 23-year-old kid who was recently paralyzed from falling out of a tree while picking mangoes. One more case to go (dressing change on our little 8 year old amputee from the other night). Ok, I’ll write more if I have the energy when I get back from both of theses cases. We’ll see though.
Can’t write any more, need to be awake in 4 hr. Very dramatic case, thought she might bleed to death… never been part of anything like that. She made it
OK, well I wanted to post that last night but the Internet was down by the time I returned from the OR. I ended up catching the very end of the Spinal case. Although I didn’t end up scrubbing the spine, I saw them suture and close. The final case was to debride and do a dressing change for Mia, the little girl who had the amputation and captured our hearts. We didn’t even bring her to the OR until midnight, always a bad omen. I went to retrieve her from post-op one and found the room dark and everyone to be asleep. Rather than wake everyone up, I decided to carry little Mia into the OR. She is so brave, she hardly protested at all.
She knew what we were going to do and what kind of pain she would wake up with. She buried her head in my chest and held on to my neck with her tiny arms. That’s it; she crushed my heart right then and there. It’s a bizarre feeling; causing physical pain to children with the knowledge that it’s for the best. Although I knew I was taking part in an operation that was certainly going to save her life, I had to battle with the reality for how much trauma we were going to cause her, both physically and emotionally. It tore me apart to wake her from her fitful sleep to take her to the OR.
I take care to step over sleeping family members asleep on the floor at the foot and sides of our patient’s beds. It’s truly amazing how devoted Haitians are to each other. They do so quietly, and with out any protest; thankful for the fact their loved one is receiving any medical attention at all. Seriously, think about that. They sleep on the dirty tile floor, most without a blanket, some with the luxury of an unfolded cardboard box to lie on. Each patient has at least one family member who stays overnight with him or her. In the short week that I’ve been here I have never seen a patient alone. The difference between American and Haitian hospital culture is astounding. I walk down the hallway in the dark, guided only by minimal light and a sense of familiarity I have developed over this past week.
We got her on the table and Aaron gave her the anesthesia drugs. She cried a little and went to sleep before she made it to the point of being completely hysterical. We estimated the entire procedure would take around 30 minutes from start to finish. Just a dressing change, maybe a little debridement of any residual necrotic muscle. She goes down, we open her stump back up and are immediately blasted by the stench of infection and necrotic tissue. That smell is unforgettable, and indescribable. There is no known substance or combination that accurately mimics the scent of infected necrotic flesh. Although the wound didn’t look terrible, it certainly smelled that way. So we go in, scalpel, forceps, retractor, Bovie (an electric cautery tool that sears blood vessels shut)…. Sponge…. Hold here…. Irrigation… suction, irrigation… suction, scalpel, forceps, bovie…. Scalpel… And oops… looks like we nicked an artery… bleed, bleed… ok pressure right here with those sponges…. Bleed, bleed. Wow this one is really going, do you think it’s the femoral artery? Squirt, Squirt, Spray, Ahhhh, holy crap, Sponge! More sponges, get more sponges. At this point the sponges are soaking through just as fast was we can press them down. Bright red oxygen rich book flows out from around the sponges and floods the opened stump and runs onto the blue table dressing and down the sides of the table. These shoes are definitely not coming back to the United States with me. The possibility of Mia bleeding to death right here in front of me is becoming a terrifying reality. My uncle John and I are furiously fighting to stop the bleeding long enough to have a clear view of the hemorrhaging artery so we can clamp and suture it closed.
She’s down about 300 ml of blood. We cannot keep losing blood like this. John asks Scott to scrub in and help him search. Although I have learned A LOT this trip, I know when the limit of my skills has been reached. Looking at anatomy books and identifying color coded 3-D models is one thing, trying to pick through a mutilated, necrotic stump for an elusive artery as it is constantly being submerged in rising levels of blood is another. My role changes from stopping the bleeding to retracting the wound as wide open as possible so that John and Scott can search for the femoral artery. We need to find where the bleeding is coming from! It’s really squirting now, high enough where it sprays my goggles and gown. More sponges! We continue on like this for a few more minutes that seem to stretch on forever. Adrenaline pulses through my body and I am hyper aware of every passing second and ml of precious blood that is lost. Damn, we can’t lose her tonight, the night before our departure, not after everything she and her family have been through.
Ok, ok, one clamp on, finally the bleeding subsides. We quickly suture the artery and finally take a moment to breathe. We cautiously continue on with the debridement, and remove bits of dead bone, muscle and tissue. I cannot accurately describe what this wound looks like, nor would I want you to be able to clearly picture it in your head. Just know it does not belong on this beautiful little girl. Life is cruel and indiscriminant. Being here in Haiti, I am reminded of how fragile humans really are; just membranes full of meat and bit of bone. We finish removing the odious tissue and pack the wound full of clean gauze. A couple of loose sutures pulls the skin flaps around the gauze and recreates the stump. We tightly wrap the stump with an ACE bandage. It is so high that we have to wrap around her little waist to get the dressing to stay on. I hope the compression prevents any additional bleeding. As it stands, little Mia is going to have to face a wound debridement and dressing change in the OR every day or two for a while, hopefully minus the severe blood loss. But for now she is stable and sleeping, and we bring her back to bed….Sigh…
It’s 2:30 am; finally time to get some rest before my 5:30 am wake up call from the sun and the heat. One more day. Not even a full one. The days have melted together to the point that I can’d distinguish one from another. I don’t want to leave….
OMG... I am speechless.... I can't even imagine what you wrote... I think I need to sit for a few minutes and just absorb what I just read.
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