Weeks sometimes go by and I wonder, if I did anything of substance. It's a feeling that partially defines my experience providing medical relief in the the Dominican Republic, in the immediate aftermath of the devastating Haitian earthquake. I am a novice with post-disaster medicine and learned many lessons. The basic organization needed, the potentially disastrous implications of well-meaning decisions and the delivery of care in the context of a crisis were the overarching themes that dominated my stay. Though I had no idea what I was getting into when I volunteered to participate in my hospital's mission, I would like to attempt to tell you what I learned.
We worked primarily in in Jimani, a dusty Domincan town less than 5km from the border of Haiti. It was good choice for our team as it was safe, hospitable, and the recipient of waves of injured patients by both truck and helicopter. Part of our group went to Good Samaritan Hospital normally meant for outpatients and small surgical procedures. Its managers generously made the structure available to volunteers from around the world. Immediately, we volunteered to fill the grey void of health care providers between 7 p.m. and 7 a.m. Communication, something central to any effective medical experience, was our first obstacle. The patients mostly spoke Creole, our Dominican hosts spoke Spanish and we primarily spoke only English (including myself). There were very few volunteers who could speak all three languages, making the simplest tasks arduous.
Merely numbering the patients' mattresses made rounds more manageable. The rule that no health care provider could step on a patient's bed with their shoes was difficult to enforce, but our attempts were appreciated by the patients. Much to my chagrin, our charting system changed daily, progressing from random pieces of paper that patients guarded jealously to cards they wore around their necks. Finally, manila folders filled with scraps of patient information served as a repository for our previous attempts and as a chest for future medical musings.
I would like to think we made a positive difference. During the long nights we gave pain medication, delivered antibiotics, started IVs and often just held our patient's hands. Our biggest victory was when we turned out the lights at a reasonable hour and our weary patients feel asleep. The nights were a mixture of frenzy, beauty and horror. The evening frenzy of prayers and passing out medications often melted into star gazing. Sleep, however, proved to be a fickle beast as Jimani rumbled from aftershocks and children cried out in horror.
Providing care for those whose belongings were limited to the clothes they wore on their backs or the items they could stuff under their mattresses gave me a sense of purpose. I wondered if what we were doing in Haiti captured the true essence of being a physician. Yet, many things troubled me.
It was difficult to understand why certain surgeries had been performed. Often we would open bandages and work backwards to try to figure out what happened to a patient. There were surprisingly few surgeons who made rounds. I admit we were short-staffed, but we were not in Port-au-Prince. We had food, shelter, and we were not performing search and rescue missions. Ensuring quality of care is difficult on a normal day in the U.S., but standards do exist. Establishing standards for the delivery of care in such a chaotic environment may seem impossible, but after my experience, I believe it is necessary.
For example we had an open pharmacy that was bursting with supplies from generous donors. Narcotics were too easily available and subsequently prone to abuse. I immediately posted a sign in the pharmacy that all narcotics needed to be signed out, but it took a pharmacist (who arrived 48 hours later) several days to implement an adequate system. Monitoring the use of medications is a basic medical norm, but it was overlooked because we were in a "disaster" zone.
Equally disturbing, was the system of transferring patients. Patients who needed more specialized care than we could provide were either summarily transferred to the hospital ship USS Comfort or hospitals in Santa Domingo, the capital of the Dominican Republic. Sometimes this required the separation of families, which seemed cruel after such a horrific tragedy. Eventually, a nurse educator intervened and gave white bracelets to patients who were being transferred. These plastic bracelets would serve as the only connection for families already broken by an earthquake -- now further divided by our helping hands. Without even rudimentary systems our good intentions brought unintentional suffering to a people already overburdened with suffering.
Perhaps the clearest example of accidental harm was the decision to try to perform an elective procedure on a middle-aged woman with a large tumor on her tongue. It was a chronic condition which did not require immediate attention. An overzealous physician, caught up in the moment, insisted on doing this procedure. Eventually, the operation was aborted due to heavy bleeding. She still lay in our makeshift ICU when my volunteer tour of duty ended. She had not signed a consent for the procedure, nor did any other patient. Did she understand what happened to her was wrong? Maybe informed consent is simply a nicety of Western medicine that relief workers cannot offer in crisis, but then who guards the necessity of operations?
On our return trip, we met two of the transferred patients in Santa Domingo and they thanked us for all we did. They told us we were "friends of the Haitian people." It made me feel good, but I knew the reality of the relief we provided. It was genuine, but at points misguided. We ignored too many monotonous, but important, norms of American medicine under the guise of being in a disaster and we made decisions without properly understanding their repercussions. When I close my eyes and I remember the week I spent in Jimani, I can only hope that the lessons I learned will help people in the future.