Braden Hexom's memory of the first day in Haiti

"Airport is busy today. Every few minutes we are deafened by the takeoff and landing of commuter and military aircraft. American Airlines, Air France, C-130 USAF Cargo, UN Sikorsky helicopters. There is a lot of traffic going both ways in Port au Prince. Each plane is undoubtedly loaded with supplies coming in, relief workers going out. Many are leaving, there are few left now. Our team is drawing down. We have 160 personnel on the ground now; there will be 30 after I leave on Saturday. We have been told to close the ER. I have had my first fight of the day with the CMO. I came here to help, but I am hamstrung by the need to limit our census. No more admits. They are turning patients away at the gate. If you can bribe the guard or if you know someone you get in. “Send them away,” I am told. I tell my people to see them anyway. The CMO means well, and wants to help, but 30 people can’t take care of a 150 bed hospital on their own. We need to discharge the whole ward so they can move the unit to a permanent structure before the rains come.

Our field hospital is four tents set up right on the airport grounds only a few hours after the earthquake. I have travelled a total distance of 1000 yards from the airplane since I got here. I can see the terminal from here. Two hours upon getting in country and I have found myself appointed as the Emergency Room chief of service. We have 5 ER docs. We had four or five ER nurses, but most have been pulled to cover the inpatient wards. I only have two nurses left. But they are UCSF nurses, and don’t take any shit – they are incredible and get to triaging right away. The gate is blocked and the word is ER is closed, but there are still more than 100 who have made it through and are waiting to be seen. The UCSF nurses start combing the benches, looking for the dehydrated babies and sick adults. We turn away the walking well. 50 get seen in the ER that afternoon, the rest get some Tylenol and go home.

Home – what a terrible word to use here. Home is wherever they are staying. Home is most likely to be a tent or a tarp. There are parking lots jammed full with tents. Whole tent cities within the city. Tents in the streets. They are everywhere. The doctors at General Hospital are living in tents on the roof of a pancaked bulding, sleeping at 30 degree angles as the sloping roof that once stood four stories up now lies just above ground level. Rubble and rebar lie about in piles. People mill about, aimless, lethargic.

Our emergency room is two tarps and an overhead tent. Like ERs everywhere we feel a bit shafted. The other units are in the hard-walled infrastructure tents. With AC. We sweat in the heat, but at least we have shade. Six cots – three medical/trauma, three pediatric. We have a corner where we have lashed tarps together to create a semi-private OB/GYN room. We deliver the babies there. The obstetrician left today, so us ER guys have also now become maternity docs. No one else wants to do it, or don’t know how. I cross my fingers that no one needs a C-section. The closest maternity hospital is across town, on the other side of Port au Prince. It is run by MSF-Holland. Their structure was spared, so it is one of the only hospitals that is still in a building and not tents. I think they do C-Sections there but I’m not sure. Anyway, it’s an hour drive if there’s traffic, so they’re no help anyway if there’s a complicated delivery. I pray we don’t have one tonight.

We divide up, 8 hour shifts are scheduled. Three rotations. It rarely works out that way. I slept 4 hours the first night. I want to make sure that my team gets some sleep. I haven’t slept well since I got here. The staff tent is noisy, hot, stuffy, and I got the worst cot possible. It is one of the old ones. It’s ripped down the side so my butt sags near to the dirt ground. The night workers are packed in a corner near the AC. Clothesline crisscrosses the walkways and you have to walk hunched over in the dark so you don’t get garroted by the wires. I am stuck by the entrance so I hear all the chatter. I can’t sleep. I roll over and slip on my flip flops and head back to the ER to see what is going on.

There are a few kids sucking on nebulizers, an old woman with belly pain, and a head injury. The two on-call ER docs are busy assessing him. He looks bad. Depressed skull fracture. Blood everywhere. Breathing labored. Everyone is sweating – it just pours off of them. It is midnight but still more than 90 degrees and very humid. The referral hospital had a staple gun and had tried closing his head with it. There are staples all over his scalp, in no real order and although the bleeding has stopped, his head is still misshapen and I start considering whether or not we should continue with the resuscitation. It is our first major trauma since our arrival this afternoon, and my team is being tested. One doc is establishing IV access. Malini from UCSF grabs the ultrasound machine. It doesn’t work. We have a backup and she switches it out. The screen flickers and dies every 5 seconds, so we don’t get good looks, but we think the FAST is negative – no blood in the belly. No pneumothorax. Someone suggests we intubate him. Do we even have ventilators, I think? Do they work? Is it even worth it with for a guy with this level of injury?

We do have a ventilator. It works. We even have a neurosurgeon. He arrived today on the flight. We have all the tools we need. It all starts clicking into place. We may actually be able to do something here. Okay, lets intubate. Lidocaine, etomidate, sux. No monitor working but we have a handheld pulse ox. He is in C-spine precautions and we don’t have a bougie. It is a difficult tube but she gets it without any desats. We send someone running into the tent to find the neurosurgeon and the anesthesiologist so they can get the OR up and running. The tent has 150 snoozing staff members, is hot and dark and muffled. They run up and down the rows with headlamps, whispering for the OR staff, trying not to wake the others who have all put in 16 hour days this weekend. Meanwhile the Haitian transporters have carried our patient into the xray booth – a few wood barriers and a portable digital xray machine attached to a laptop viewbox. I don a lead apron and bag him from the portable oxygen tank while they shoot the trauma series. The neurosurgeon arrives sleepy, disheveled, but ready to operate. Our patient is carried straight from the xray table into the sterile OR (how anything can be sterile in this heat and dust, I have no idea, but it works). He is on the operating table and the ER is quiet again.

My hands are dirty. I lather another layer of Purell onto them. There is no running water in the ER. We are all tired but the adrenaline is still up. We start debriefing. We have never worked together before, each of us are from institutions all over the country. But we know our jobs, know what to do, and realize it will be a good week. I head into the OR to check on our patient’s progress."

Branden Hexom is an Emergency Medicine Physician at Mount Sinai Medical Center