Dr Frederic Jacquot, an orthopedic surgeon from Hôpital Saint Antoine, Paris, took part in the SAMU/EPRUS mission that landed in Port au Prince on January 29th 2010. He worked for 12 days at the Adventist Hospital in Diquini, Haiti. The mission was housed in the gardens of the mangled French ambassador’s mansion.

Six hundred. We are six hundred fellows Frenchmen – and women, some say six hundred and fifty, but certainly not more than seven hundred says the security guard. This is a giant summer camp settled in the gardens of the French Ambassador’s house in Haiti. Tents are randomly built everywhere from the swimming pool to the mansion, one against each other, in a delicate disorder. Logos blossom on the fabric city, identifying their inhabitants: Civil Security, Firemen from France and elsewhere, National Guards (wearing weapons and body Armor, in charge of securing the site), SAMU (Service d’Aide Médicale Urgente, a French Emergency Health organization), NGO’s from everywhere … a colorful but mostly blue and khaki village surrounded by bougainvilleas trees in the purring of the electric generator. The Ambassador’s mansion sits proudly in the middle of all that, once a magnificent colonial house and now a leaning ice cake surrounded by piles of rubble. It hardly survived the seism. The beautiful park serves as a camp for the rescue task force at work in Port au Prince. A precarious housing, but what could you ask for in a wounded capital changed in a second in a field of ruins and a huge refugee camp?

All these people from France and elsewhere work in different locations in the wounded city, mostly in hospitals, organizing refugee camps, sorting the wounded, assuring family regrouping and providing psychological support after the big catastrophe. Some of them arrived just after the seism, others later. Most have stayed here for a few days.

Early in the morning, dressed in hospital rags, civilian clothes or uniforms, all of us converge to the shuttle embarking point (bus, military truck or sometimes a truck bucket) to be delivered at their work site. From the height of the truck we discover the destroyed city: piles of stones, broken churches, leaning buildings, the presidential palace as a big flat upset meringue.

Fig. 1: SAMU/EPRUS headquarters heading home. We stayed 12 busy days there with survival kits and combat rations.

Fig. 2: The residence of the French Ambassador in Port au Prince. The old mansion paid a hefty  price to the earthquake. Its gardens are the home of the French official humanitarian missions.

A post-apocalyptic situation

Houses and buildings on the floor became tombs, somewhat randomly, but in places everything is destroyed. While traveling in those streets, comes a terrible sensation, of a summer walk in Paris’ Père Lachaise Cemetery (The one where Jim Morrison rests). Mangled houses are condemned and closed. Empty buildings with cracked walls look like chapels. Reinforced concrete ceilings and floors have fallen down . Here they are are called “pancakes”. They irresistibly look like flat grave stones. And it is suffocating sensations to think that, behind those closed doors and under those stones are corpses, by thousands. At the time of the seism, medical students were at the faculty attending lectures. Most are still under. The situation is the same at the Nursing school: several hundreds are missing. Some say half the doctors, either active or in training, are dead. These people work late hours; they were in the buildings at the fatidic moment. The high command of the UN is said to have lost at least 250 people, most of them high ranked militaries from all countries, among them 36 French.

All this is just local rumors, for sure, true or false. As in any catastrophe, the local rumor mill is at work.

 

Fig. 3: Everywhere in Port au Prince, centenary old churches suffered heavy damages from the seism.

Fig. 4: Street view, Port au Prince.

The sweeping people

Piles of rubble are everywhere between broken houses, creeks and sidewalks. But life starts again and people sweep with patience, stones and dust disappear and sidewalks are freed. Each day sees new precarious shops appearing on the dust and new products proposed to the peasants. Local trade reappears, fruits, vegetables, medicines (real or fake, at what price, I do not know, but pill being sold singly), in front of the tents and on the verge of the roads facing the front walls of the closed houses.

The city is a huge refugee camp. Every place where the floor is flat, parks and gardens have been invested as a new camp filled with colorful fabric tents from everywhere where families and numerous kids live the whole day. What may these people eat? Not much apparently, products of food distributions and the market, but many are hungry and few share one meal a day. Starting 15 days ago severe denutrition and dehydratation cases were seen at the hospital. Queues for food in front of the stadium have reached a length of half a mile, under scrutiny by the armed UN guards. Those are militaries from Peru, Turkey or Brazil; we‘ll see the Chinese blue helmets and their military police exercising later at the airport.

 

Fig. 5: The huge inflatable tent where “preop” cases stay, a baffled French fireman doctor when confronted to new cases.

Fig. 6: Nurses from the French Guyana SAMU in action on the floor of the hospital tents.

The adventiste hospital

At the hospital, The Chaos has been skillfully organized. The French firemen and Securité Civile have done a fantastic job, and an unadvertised one: organizing the patients care. At the entry point, a “wounded triage” check point (let’s call a spade a spade) located under a tent welcomes queues of patients from the outside; a “preop” station, a seemingly anarchic fabric village surrounding a huge inflatable tent from a Canadian organization, is the location for patients awaiting surgery. No beds, patients lay flat on the floor on canvas or makeshift mattresses with surgical indications. And a “postop” station, tents again in organized disorder with operated patients on their floor. Young 18-20 years old amputees, wounded kids, patients of all ages with packed wounds. One workshop cares of daily dressings, either done with Ketamine or without anesthesia. And the operating room, organized under supervision by an American organization, runs at its maximum capacity nearly two weeks after the catastrophe with daily emergencies just arrived at the hospital. Most have open fractures (from the day of the seism, so several days old…) or bad wounds, but more and more closed fractures untreated at the time.

The hospital is clearly Adventist of the 7^th day, that is its name and all employees follow this confession. Even American organizations working at the place have a strong religious coloration. Not all doctors are adventists, but have a link to the congregation through their hospital or faculty. Patients are from everywhere and all confessions; they came with their families. How many of them? About 200 have hospital “beds”, but with the families 800 people may live at the site around the concrete hospital.

In this tropical agitation, it is difficult at the beginning to understand fully who is who and who does what. Day by day, one may reach a better understanding of the place: each passing day seems to unveil a new international organization active on the field. As I said if the triage and  patient care are clearly devoted to the French firemen and the SAMU, patients are operated mostly by American surgeons doing rotations; The immediate postoperative care are performed mostly by an Haitian organization from Quebec, an organization of the diaspora. Postoperative dressings are made by the French. But other organizations are also active, I meet Baptist healthcare workers and ER doctors from another American organization; and most importantly, meals are served through though all this in square plastic plates by a Chinese organization; one of the managers of which tells me they serve 1200 meals twice a day, a huge task. I stumble upon the kitchen one day while opening a hidden door and discover a bunch of people preparing vegetables for the whole area. “At the beginning”, the manager tells me, “the families of the patients would prepare the meals, but we had a lot of diarrheas and the doctors were all sick. We took over and since then we have had very few problems. We also have a clinic just a little bit further in Diquini, and we also take care of the patients at night when the French teams are back at the residence…”. For sure, the meals are vegetarian but good and it helps a lot.

Other organizations are at work and we see passing Spanish and Czechs doctors. That is a great amount of humanitarian mix…

All the day long, a speaker distils music and canticles at the site. Orators, religious or not, perform talks in Creole or in French, and people are asked to pray for the disappeared or the wounded, or to support people entering the operating room. Once, a French anesthesiologist was taking care of a patient, while the speaker called to pray “for our brother Jean Maurice who is in the hands of god…”. Patients may also be called for operations, because no one is able to find them when their turn has come: “Beatrice Senda is called at the operating room, Beatrice Senda”. Musical variety is present, contrary to the sound quality. Local gospels share zouk accents, they mix with liturgical music and unending preaching.

 

Fig. 7: Adventist hospital in Diquini, Port au Prince: the gardens and the lawn organized as a preoperative ward.

Fig. 8: Mission statement at the Adventist Hospital in Diquini. Haïti … The Christ is always close in all minds in here.

Fig. 9: Young Adventists in the hospital at Diquini. A young security officer at the entry of the operating room.

Amputations

How many amputees? Many certainly, many live under the tents and one sees young children living their life again between two crutches delivered by the container by Handicap International. Whatever the place, the sighting of those young and not so young guys with a missing limb and an empty sleeve or trouser leg is always disturbing. The organizations that specialized in rehabilitation now all have the same attitude: only make prostheses on healed and closed stumps, and so not in the immediate aftermath in Haiti. They just deliver wooden crutches and collect phone numbers (guess what, everyone has a cell phone here…) in prevision of the program. Lots of work in prevision, so many are these young guys; with the experience of “Handicap” and others, leg prostheses now are made as big shoes and allow for a nearly normal life – for below the knee amputees. For up the knee amputations, that is another story.

I am a bit surprised at visiting the patients and seeing the wound dressings, by their good tenure: for sure some are dirty and others show very bad wounds (what can one say of a stump in a kid?) but as a whole, I find very few catastrophes. My fellows are surprised and a bit shocked by the technique used by American surgeons, they call the “guillotine” amputation: cut short, leave open… In fact I have to explain that facing crushed limbs this attitude has been promoted by the International Red Cross Committee itself for more than 60 years as the best technique, the one that treats or avoids the dreaded gas gangrene. The concept is, the section stump is not closed, at least as an emergency; it might be closed as a delayed procedure if everything else is in control. Anyway, that is a strange feature in the human specie, that amputation stumps have a spontaneous tendency to close by themselves when they are not infected.

Were amputations performed without thinking? What is sure is that Haitian people have suffered a harsh traumatism, and nearly two weeks after the seism, they think twice about being operated on by an American surgeon. Them guys have sadly gained a bad reputation from the crisis …

A patient comes at the hospital suffering a bad fracture of the talus bone (the ankle joint bone that cares for flexion and extension). That is a difficult fracture responsible for stiffness and pain, and he is already 15 days from the trauma. He discusses his case with an American orthopedist. “This guy speaks a perfect English” says the specialist. The thing is rare in Port au Prince. In fact the patient presents himself as an English teacher. At the time the seism occurred, he was teaching in front of a class of some 80 students on the second floor at the University. Ten of those people are living now, including him. The unlucky are still under the ruins. Suddenly, he found himself in a blink crawling between the fallen ceilings and it took him three hours to get out of the ruins: two students were before him on the way out, he had to wait for them to extract from the rubble. “If one or the other was dead”, he says, “I would not have been able to got out and I would still be under”. He wants his foot to be operated on since he perfectly understood that the bone is broken and he has a bad fracture. However, he fears to be operated on by the American specialist because he is afraid of being amputated; as an alternative, he wants me to operate on him or be at the operating theatre during his operation, and makes me swear. Such is his fear.

I was in the operating theatre at the time he was operated on, but busy doing another case. He was remarkably well operated on by two specialists from North Carolina, with no image intensifier. They put him into an external fixator. Later, the patient  thanked me warmly for all this.

Apparently, few patients died from gas gangrene just after the seism. Just that may be considered as an important success…

Gas gangrene… My encounters with it taught me that it can kill in a handful hours even a fit and strong patient. If the devil exists somewhere on earth, it is hidden in each ounce of ground and dust under the appearance of the spores of those germs we call “telluric”, as if the fallen merciless deities of the same name would want to bring us back to them. These are bacteriae of the “clostridium” genre. They are incredibly resilient, live without oxygen, infect the dying and contused tissues and kill the living vessels, produce necroses, settle in the main blood stream and produce toxins, kill surely the patient. No easy solution to treat: antibiotics efficient in vitro are prevented to go to the wounds as the vessels suffer thromboses. The only thing one has to do is to cut and to cut fast.

Doug Fartas is the manager of one of the organizations working on the surgery field. He is a general practitioner from North Carolina and has a Master in Public Health. He arrived late on the area to replace a colleague. He tells me that the first doctor who arrived at the hospital just hours after the catastrophe was not a surgeon, but a general practitioner and a manager just as him. The first thing this practitioner had to do upon his arrival was to cut a leg: “They held him a bistouri and told him to cut”. For three days , he had to cut mangled and legs infected with gangrene, arriving at the hospital by the hundreds.

The French firemen doctors present in the area at the moment also remember. One of them said: “When we first arrived, there was nothing here, just the standing hospital and the lawn around, and 3000 patients who arrived with black gangrenous limbs. We had to organize, find tents, sort the patients, bring them to the operating room to the Americans who were operating non stop, sometimes 30 operations an hour. It was harsh, very harsh…”

Did they cut legs that could have been saved? Nobody knows, but they had to do something.

 

Fig. 10: A moving patient’s letter just written minutes before going to the operative room.

Fig. 11: Operative room in Diquini. American and French team in action.

Anne Marie

Anne Marie told me her story with no apparent emotion: “When the seism happened, I was in my car on the road from Canapé Vert, overlooking the city. And suddenly, something happened. There was dust, it was as if the mountain had sucked in all the houses. That is right, the mountain sucked the houses and the villages in the dust. Then the dust settled and rose the screamings, unbearable screamings from those under, that lasted for at least half an hour or so. And then the dusk fell down on the city. I scrambled to my house as fast as I could, and during the journey, I persuaded myself than my house had fallen down on my family and my son, because I did not want to be surprised, and I persuaded myself than my six year old had been killed. I got used to that idea, and when I arrived at the corner of the street, I could see that my house had fallen down and that everybody was under the rubble. All of them were dead except my six year old son. My son stayed under the rubble for six days. Finally, they found a crane from the United Nations to lift the roof of my house. The crane lifted the roof of my house very slowly, bit by bit, and I could see than my son was living at this time. Then the concrete ceiling broke and fell down on my son. My son died at this moment. I thank god every day, because I am living, and I believe my son is living in Heaven where He recalled him. I am not of those who look back, but now my son passed away and we have to rebuild”.

 

Fig. 12:  Operative room in Diquini, Port au Prince, free hand locking of a femoral retrograde nail by a multi national operative team.

Fig. 13: Everywhere in the hospital, la vie continue…

Security

At the end of their shift, tired French teams converge towards the meeting point at the entry of the hospital to wait for the vehicle that will bring them back to the camp. The departure is scheduled before nightfall for security reasons. The two buses are escorted by the National Gendarmerie, a vehicle with two armed soldiers on a mission here. There are rumors that insecurity is growing: armed groups that had been dismantled before the crisis are suspected of reenacting, being strengthened by prisoners who escaped jails after the earthquake. The disaster was not one for everybody at least… As a result, a few days later, these are military trucks of the 3^rd RIMA (elite troops) that convey us through the dust of the destroyed avenues of Port au Prince. Security is a big concern for the French authorities. On Sunday, our convoy will takes two hours to reach the hospital, making detours because of demonstrations, either religious or civil (the famous “hunger riots”?), and the difficulty of running in a maze of streets with uncertain geography. The traffic of trucks is – gleefully – constrained traffic returning to normal: numerous buses painted in a variety of colors and covered with religious maxims, cars and motorcycles. Rules of the road are randomly respected, the horn is king and wrong-way driving is usual on some avenues. The situation is comparable to that of Paris during rush hours, except for the gullied Haitian streets, where crossing trucks proves perilous. We reach our destination at the end of the morning, finding the hospital in a strange sleepiness: no new patients today. Happily, new cases are becoming rare.

 

Fig. 14: Hospital and tents, computer screen projection of an American blockbuster movie to young hospital patients.

Fig. 15: SAMU scrubs and survival kit, the author ready to go to work in the early morning sun.

Life begins again

Whenever a big disaster occurs, wounds and fractures all have the same age since they occur mostly at the same time. The fateful moment happened on Tuesday, January 12^th, at 4:45 pm. Hence, all injuries can be dated with high precision, except those caused by the collapse of buildings after replicas and resulting panic waves. Some patients come to the hospital 15 days if not 3 weeks after the seism had occurred. They display spine or pelvis fractures or – early – malunions showing signs of fusion. Where were they all this time? Before being brought to hospital, they were probably roaming the city looking for food with their families. Day by day, these injuries become less frequent. While the big trauma is behind us, we enter another phase that consists of treating after-effects, among which untreated fractures, deformed limbs and paralyses. We are faced with dazed, durably traumatized people. Amputees, be they young or old, wander on crutches and adapt to their disability. Kids finally play and laugh, they ask to have their picture taken… It’s going to be a massive task to help these people to settle back into normal life, despite wounds.

The city shares the same fate as its inhabitants. Each passing day brings novelty. Small businesses like fruit and drink vendors flourish again on the sidewalks, in front of ruined buildings. Life begins again, but there is no more money, no employment opportunities, and nearly no more savings left. The longest queues now take place in front of money transfer offices, where people collect remittances from family members living abroad. Governments and charities (mostly confessional and American) are said to be willing to inject vast amounts of money into the Haitian economy. As for now, nothing like that has happened, while donors would face a huge task rebuilding the city. It will probably need to be demolished and rebuilt from nothing, hopefully more robustly and in a more organized fashion than before. Clearing the rubble has not started yet. Once started, rubble will take a long time to clear due to the lack of resources. Bodies pulled out from rubble (in what shape?) will have to be buried; it will be another gruesome task.

The future of Haiti is a big concern. Even if sanitary conditions are getting better day by day, it is impossible not to wonder what will become of the million of displaced and homeless Haitians. As for now, they sleep outdoors, but what will happen to them in the rainy season? How will they feed themselves? And, with a healthcare system destroyed by the earthquake within just a few seconds, but for a long time, who will take care of the patients and train the next generation of doctors and healthcare workers? Though French-speaking and Francophile local elites have been hit by the crisis, they have strong aspirations to host scientific, technical and academic cooperation. On the day of departure, Haitian doctors asked me what I could do for them after the acute stage when media and NGOs will turn their attention somewhere else and stop talking about Haiti.

The mission was composed of 13 members. Two surgeons from Assistance Publique – Hôpitaux de Paris, one of whom was head of mission Dr Alain Faye (general surgeon at Hôpital Européen Georges Pompidou), a private practice hand surgeon in Paris, Dr Eric Roulot, and an anesthesiologist at the University Hospital of Grenoble (France), Dr Emmanuel Ringot. The other members of the mission were two ER doctors, four nurse anesthetists, a nurse, a pediatric nurse and a logistics coordinator. After having worked to develop greater cohesion amongst the different organizations present in the area, the mission has not been replaced, passing the torch on to the field workers and medical staff remaining in the area.