Tuesday, May 15th, 2012--Trauma (Guesly 2 of 2)

Guesly:
I am walking back to the room with a nurse when I hear my name being called urgently outside. I once wrote that I have my own preferences for how I would like to practice medicine, but my previous trips to Haiti have taught me Haiti does not care about my preferences(No Guardrails), and I must expect the unexpected with every step.

I emerge from the hospital door in time to see a Haitian police truck rushing through the rocky courtyard maneuvering between the tree trunks. I know from my past experience that whatever can get the police stirred up and rushing headlong into the mission cannot be good! I have often seen Haitian police officers standing on the street or sitting underneath a tree like they do not have anything to do. Maybe I am being a little harsh, but that makes the sense of urgency they bring all the more alarming.  Once I get a closer look into the bed of the truck I see five people. They are bloody. Some were screaming, and others look to be in shock. Just as my thoughts are coming together, The driver screeches to a halt, raising a cloud of dust which quickly envelops the vehicle. As the dust settles I hear "Dokte! Dokte!" and I rush to the truck, calling for some of our team members to help.

My mind flashes back to earlier this morning when majority of our team traveled to La Croix, about 4 hours away from Fonds Parisien. I had assigned myself to remain behind as the lonesome physician, thinking La Croix would have a greater need for doctors while I managed the relatively peaceful clinic in Fonds Parisien.

But I do have help here. I have Erika, a nurse who has been to Haiti multiple times. My medical assistant Kari has also been here before. Another nurse Trish is on her first trip to Haiti. The McLaughlins are a husband and wife dentist and optometrist, both Haiti veterans. The other team members are several first-timers, students from Corban University: Esther, Amanda, Courtney, Margaret and Caitlin.

One of the policemen fills me in on the crash.  these five were riding in the back of a tap-tap when they were all ejected after a head-on collision about fifteen minutes away. Tap-taps are the the primary mode of transportation in Haiti, They often start as pickup truck with makeshift modifications like added benches for seat and a solid metal cage for cover. One tap-tap could be packed with more than twenty passengers in the back. Although they are often very brightly and festively painted.

Watching them pass by on my various trips to Haiti, I have often wondered if the riders realize how thin the line is that separates a normal ride from a death sentence.

Though there is a swirl of activity, and things appear chaotic, some things do not change no matter where we are.  We must work systematically.  Erika and I start to examine the passengers to determine who is most critically injured. Erika asks for anybody who can walk to get out of the truck. One woman with minor road burns, several superficial lacerations gets out. In the furthest part of the bed of the truck we both agree that a woman laying there needs our help first. She has respiratory distress, facial swelling, scalp laceration, severe road burn to both buttocks and hips, severe abdominal pain, and pelvic pain. Once we stabilize her pelvis, survey her for other injuries, and start IV fluids, we turn our attention to the next woman. She has no obvious head trauma, but is sitting up complaining of severe abdominal and pelvic pain. She does not want to be touched. Just like the previous patient we are concerned about pelvic fracture and internal , and know we need to get both of them to a hospital with a surgeon.  She has less severe road burns and laceration but complained when I examine her pelvis, hips and abdomen. Similar to the previous patient we stabilize her pelvis, complete our survey, and start IV fluids.
We move on to a male patient who obviously has a severe left leg injury. He is an older man possibly in his early fifties, older then the first two patients who appear to be  mid-twenties to early thirties. He sits quietly with his left leg below the knee completely internally rotated with his big toe touching the floor and his upper thigh and knee remaining in the neutral position. While several of the nurses help I cut his pants legs off and notice that he has a closed, unstable proximal tibia and fibula fracture with marked deformity and a distal tibia and fibula fracture without noticeable deformity. I work on placing a splint to stabilize his left leg while Trish and Erika fight with him to start IV fluid. It is strange how he does not fight, resist, or act like he is in pain when I am placing the splint  to his left leg, but he fights with two nurses because he did not want to be pricked by a needle.
Lastly, we turn our attention to the less severe injured of the five. There is an older woman in her late fifties to early sixties. At first glance, she had multiple large road burns. The burns start below both of her eyes and forehead which indicate that her face has struck and skidded on the rough, dusty road. Her arms are a mess of large burns extending from her elbow to her mid forearms, her mid thigh to her knees, and her lower legs. Looking at her toes, I notice that most of the skin has been rubbed off with the most involving the inner aspect of her right great toes. All are bleeding. She is quiet with glassy eyes, in shock and does not seem to know what was going on. With initial assessment and secondary assessment I do not notice any major head, lung, or internal injuries. Could this be a concussion or minor brain injury possibly?  She does not have any pain when I examine her head, neck, chest, abdomen, and pelvis.  She has severe pain with evaluation of her knees. Once she was stabilized we know that we need to get four of the patients to a hospital with a surgeon. 

When I arrived on campus few days ago, I notice that only one of the two donated ambulances was parked at the mission. I was told that one of the ambulances is in Port-au-Prince being fixed, and the other ambulance is not functional.  Yesterday, before the accident, one of our team members Jerry King who is an engineer and a mechanic from the Mennonite mission help fix the ambulance that has been parked at the mission for weeks.

With only one ambulance I know we will have to arrange all the patients to fit. Getting them to a hospital Port au-Prince would take us over an hour without traffic, but heading there in mid day traffic will be worse. I know I can not take the chance of leaving any patient behind as there would be no physician  to assess them if something goes wrong. After careful arrangement, we get all the patients to fit. Three of the patients are secured to gurney and one patient is secured to a seat with a seat belt. Erika and I jump into the back of the ambulance, and we  ask Amanda, a student from Corban college, to join us.  When the door closes, the ambulance driver takes off like a rocket, jolting all three of us against the side of the ambulance as we are not yet secured.  Unlike the United States where people usually recognize the importance of yielding to an ambulance siren , in Haiti there is no awareness from the other traffic as our driver attempts to pass other vehicles going over 70 miles per hour while avoiding potholes, other vehicles, pedestrians, and animals.  It is easier not to watch, and Erika and I are busy diving to hook back IV fluids that have come loose, aiding one of the patients who is vomiting, soothing the other patient who has just been vomited on, addressing wounds that restart bleeding. Through all this chaos, I have to keep strongly reprimanding the driver in Creole to slow down as I am afraid he will crash us, and what good would that do?
After an hour and a half of white-knuckle driving we make it to the hospital where I give report to a French trained physician. While the craziness of getting these patients to a hospital that is better equipped to handle trauma is important, what is even more gratifying is that we find a hospital that is willing to care for them. Teams before have had huge problems with that (Jeff's Story)  Haiti, must have a better solution! We need to continue to help improve the facility we have at Haitian Christian Mission to handle any situation. 

I am thankful for having the amazing team members: the trained medical personnel as well as all the Corban students who responded while we were dealing with this trauma and showed great teamwork and willingness to help.