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Six months post earthquake in Haiti – we won’t forget

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Nursing Times’ resident Haiti-based nurse Fi Stephenson on helping patients in the earthquake-hit country six months on.

Gosh, I cannot believe it is now six months since the earthquake here in Haiti. When you are ‘in it’, It seems that nothing really changes until one stops and reflects on the realities of life. Time travels so fast. Reality can seem crazy when you have the opportunity to step back and really look at what is actually happening. The seemingly unreality to us foreigners is the all too real, harsh reality to the native Haitians. Six months … wow… there is still rubble on the ground, broken homes, tents everywhere, people trying to rebuild their lives, grieving for lost loved ones, grieving for their loss of normality, grieving for their loss of limbs, grieving for the loss of their mobility and body image. Six months is a long time in our busy day to day lives - Have we forgotten? Where is Haiti anyway?

At work in our Spinal & Rehab Unit (now recognised as being the only dedicated SCI unit in Haiti), our Healing Hands teams have continued to do a tremendous job since mid April, having brought their specialist spinal knowledge with them. They have been instrumental in helping me educate and empower the Haitian nurses, doctors and physio assistants. We have been fortunate enough to have had a Spinal Rehab Medical Director from Toronto as well as from Switzerland fly over at different times, plus a specialist spinal nurse, physiotherapist and occupational therapist for two – four week stints. Their team co-ordinator had done this sort of thing all over the world for 15 years so really knew his stuff too. Reflecting on the timing of their involvement… it couldn’t have been more perfect. Their introduction to the team and patients came at a time when our SCI patients were becoming more medically stable, and their incredibly huge and deep pressure ulcers were healing, so there were becoming less bed bound.  Some of the patients were recovering from spinal fixation surgery so the next steps of their recouperation could be addressed - principally bowel and bladder management and specialised spinal physiotherapy and occupational rehabilitation therapy.  One of the Healing Hands Team remits was to help with education for the patients and Haitian nurses, and having come over from Canada, the Toronto team had been able to bring spinal specific information with them in French! Now less can be lost in translation …… phew! ….  this has been a problem at times as our translators are not medically trained and so I can  never be entirely sure that what I have said in English or French is what is actually translated into creole.

We have also been really fortunate to have a Haitian spinal rehab doctor, (working with Healing Hands in Port Au Prince), fly up to work with us for 3 days per week. It is wonderful as he knows the Haitian culture, the history, the (non-existent) health care system and has helped me to gain a further insight into why things are the way they are here. It is so sad to hear from him that, out of his medical school year that graduated, he is the only Haitian doctor left practising in Haiti. All his fellow colleagues have gone to the States to earn an incredible wage and ‘live the good life’. His simple comment on this tragic fact was;  “I am Haitian, this is my country, these are my people, and I became a doctor to help them”. Why is it that the smell of money can affect people in such a way? It certainly does not buy happiness. He explained to me that he felt rich inside his heart as he had his health, a beautiful family (who had all survived the earthquake), he had been privileged to receive a good education and he was now in a position of doing what he felt was right by helping others. We really are lucky to have him working with us J

I have seen some ghastly wounds that really should not even begin to heal, suddenly proliferate with granulation tissue – why is this? Is it because these people have an amazing ability to heal? Or is it something to do with our  ‘simple’ and holistic wound care regime? None of the wounds have become infected and have either completely healed or are now much, much smaller – tiny in fact! We have had visiting plastic surgeons come at various times to specifically assess their wounds. In a nutshell, they have all been delighted to say that their skills were not needed. So what is the magic formula? Well, from a wound care point of view, it really boils down to the simple basics…. strict position changing to relieve pressure, passive exercises to get the circulation going, individual assessment and consistent treatment of wounds, aseptic technique, cool (where possible) rooms and clean (where possible) sheets. Nutrition has been a key ingredient too; fresh fruit juice daily, fresh vegetables, freshly cooked food three times per day, meat and fish, and plenty of safe water. The food only allowed by the beds, if covered, for 30 minutes to reduce the flies. The patients were also put on a high protein supplement, and multivitamins when they arrived. Their pain was managed effectively so that they could rest and sleep at night and therefore use their energy to heal. From a psychological support angle, we encouraged the patients to go outside on their beds – even just for 5 minutes – to breathe in the fresh air and look at the green grass, trees, grazing cattle and goats and to feel the warm breeze on their face, under the protective shade of the Unit’s verandah. Just being there, talking, words of encouragement, eye to eye contact, acknowledging smile, a hand on a shoulder in reassurance….  I guess, another factor is that people over here are not attacked by the superbugs that we know and fear in the western world. These people are not resistant (yet) to the antibiotics that we have all been popping since we were kids! So the secret to our success is perhaps a mixture of all of the above!

From a urological point of view we are doing the best we can, with our limited resources. We do not have an ultrasound machine (of any sort) and have only limited laboratory facilities that can perform microscopy examination (with the lab tech concentrating and counting under her breath) but no culture or sensitivity analysis.  We have to go by our clinical skills and judgement. All the patients are encouraged to drink water -… you would think this was easy but this has been difficult as a lot of Haitians are chronically dehydrated. The catheters are either taped to the thigh (female patients) or the abdomen (male patients) to reduce bladder/urethral erosion. We change the catheters every 4 weeks unless clinically indicated and change the catheter bags every week. We have introduced intermittent catheterisation and the majority of our patients (or their family) now do it themselves. We continue to monitor them for signs of infection and do twice daily observations of their vital signs so that we can get on top of any infection before pyelonephritis occurs ( a real risk for our SCI patients). To be honest we could be checking temperatures less frequently but I am not sure that this would be a safe option. We had a visiting retired urologist, who has worked in the third world for the past 15 years, come to visit us a while ago, which was incredible luck as he taught me how to perform a very simple and effective bladder function test. Luckily our Haitian rehab doctor, also fluent in English, was with us so was able to directly translate into creole for the Haitian nurses and doctors. We learnt how to do a ‘cystometrogram’ without the high tech, very expensive equipment! …. take one 3 way catheter, 2 intravenous infusion lines, a tape measure (for a makeshift manometer line), a drip stand and a bag of normal saline, oh and 2 clamps … hey presto… the test takes about 30 minutes and we can now measure bladder pressure to ascertain if we are dealing with a high or low neurogenic bladder as well as involuntary bladder contractions to reduce the risk of bladder over distention and pyelonephritis. Whoo hoo! Like all the education, it is like a dripping tap and sometimes I feel like a broken record but it is truly worth it. Especially when the intermittent catheterisations are done on time (without asking) and the charts start to be filled in correctly! I know this sounds like basic stuff, but this is a totally new concept and specialism for the Haitian nurses. I really am so proud of them and what they have achieved…. with this in mind, I have introduced an ‘employee of the month’ award, which I back dated to February. The nurses love this and are very proud of their certificates – and so they should be!

 We have just had our first set of third year student nurses here for 5 weeks to study the theory and practice of spinal cord injury. The Medical Director and I were approached by the Cap Haitien University professors and asked if there was a possibility that their student nurses could be seconded here to learn - Word was out that we had a good standard of care and they wanted to be part of it! Needless to say we jumped at the chance as it is important to remember that these students are the educators of the future…. It has been a real joy to be part of their education. They really wanted to be here and learn. Every week day we taught something different related to spinal cord injury and it was wonderful to have the Healing Hands team’s specialist knowledge to feed our ‘information hungry’ students. The five weeks were completed with an exam, and a case study presentation to their tutors, followed by a celebration of completing their 5 weeks here, with a huge cake, and the handing out of their well deserved certificates! The next set of students start on Monday, and I have managed to get some of our Haitian registered nurses to agree to teach SCI related subjects (having passed their own SCI exam), the Haitian physio assistants (who have achieved their competency skills) to pass on their SCI knowledge, and  patients to be part of the curriculum to talk about SCI care from the patient’s perspective (the expert patient)…. I can’t wait!

It is sometimes only when things are stopped that you realise how much you have come to rely on them. Funding is the main reason for withdrawing aid. New priorities, new projects, new calamities elsewhere in the world, and ofcourse money does not grow on trees….. One prime example was the use of a german helicopter and crew.” German Help One” was an incredible support to us and had enabled us to safely transport our patients with unstable spines for xray and operations. They had delivered vital medical supplies, wheelchairs and tents, and taken patients to Port Au Prince on discharge. It was a shock when I learned that their funding had been withdrawn. I think that this was way too soon. There is still so much help of this nature needed over here. There are villages and towns that are still completely cut off due to collapsed roads. The majority of roads here are merely bumpy tracks meandering through the hills and mountains. I know that the crew were devastated that they had to return home. They could see the need for their services - They had been busy seven days a week. What a shame.

Sometimes things are just too close for comfort …. I got word from my sister back in the UK that my niece, Sophie, had sustained a whip lash injury whilst playing on the trampoline.  She was immobilized by the paramedics and went by ambulance to A&E, with numbness and tingling symptoms in her limbs and accompanying neck pain…..what a shock for my poor sister – I know I felt stunned when she told me, but I am relieved to say that Sophie was alright; The CT scan was normal and she was sent home the next day….(re-reading this, I realise how much we take things such as CT scans and professional emergency care for granted)…. It just shows how accidents can happen so easily and potentially with such dire consequences. Thank goodness for ‘on scene’ and fantastic paramedic training. Over here, there is none yet. On a daily basis, injured people are scooped up, put in a ‘tap tap’ and taken to hospital or just taken home. No log rolling or spinal support. No pressure to pulsating bloody wounds. No stabilisation of deformed limbs. This applied to Stephen, our 24 year old tetraplegic . He told me that he remembers walking down an alleyway to meet some friends and suddenly being crushed under a wall when it had fallen on him during the earthquake. He was able to attract attention by moving his arms and hands. He was pulled from under the debris by some locals and then could not move any of his limbs – He had broken his neck (Cervical 6 burst fracture).  ….. It was not their fault. They did not know any better and they were trying to save him, having all suddenly gone through the massive earthquake that had rocked their lives. Their adrenalin surge of ‘fight and flight’ must have been incredibly high.

Thankfully there are high level talks here in Haiti now about addressing the emergency response issue so hopefully this “scoop and shoot” way of dealing with accidents will become a thing of the past.

The other issue is though; what happens when they get to a hospital for ‘treatment’……? I went to a local public hospital the other day with an American RN who had picked up 2 young men the night before and taken them to a public hospital. These men had been in a road traffic accident. He told me that when he and the doctor he was working with had got them to the “ER”, a hospital doctor literally cast an eye on the new patients and had written prescriptions for medication, syringes, needles and then that was it. The RN had personally taken donated medication to this particular hospital a few days before, but the staff insisted that the patients had to pay before they were treated. He and the doctor took the prescription, went to the hospital pharmacy and personally paid for the items. What else could they do? When we got there the next day to check on them, one of the young men had died, the other one remained flat on a trolley – in his same blood stained clothes. None of his wounds had been touched and were covered in flies. People just walked past him. It was as if the hospital staff were oblivious to his needs as a human being. Is it the case that when a caring person is subjected to this all the time and feels powerless to change anything,  they become numb to it all? Is this why it becomes accepted normality? It really was shocking to see.

In the last month we have admitted 2 paraplegic patients on humanitarian grounds from a public hospital. They had been hospitalised since the earthquake. Both had horrendous pressure ulcers. Lionel had lost 10 children as well as his wife in the earthquake. He was alone and had been found by our medical director in the hospital having been left in the ER a few days before. The story goes that he had been discharged from a hospital in the Dominican Republic a week before and had ended up there. No medical notes and no medication since his arrival. He had no money so had had no treatment. When we tried to find out about him, no one seemed to know anything. I am glad to say, that although he still has to deal psychologically with his immense loss of family, job, money, home, health, normality, he is now pain free, is learning to walk again, putting on weight and his wound is healing really well.

The other patient, Brian, was so severely cachexic he looked as though he was knocking on death’s door. This gentleman had been in the same hospital and supposedly ‘cared for’. He had had no family to look after him; his wife and child were killed in the earthquake when they had all been praying in a church - the wall had collapsed on top of them all – he had sustained a spinal cord injury. Three days after the earthquake he had required an above knee amputation. His other family members were presumed dead. We found him in a pitiful state with pieces of paper covering his infected wounds, and flies all over his filthy stained sheets. He was starving and dehydrated…..  He looked like a withered old man but in reality was only 34 years old. How and why can medical staff allow this sort of neglect to occur in a hospital……? How can a health care system improve when the basics are not addressed adequately? With all the money pouring in from the western world over the years into Haiti is it not reasonable to assume that patients would get food, water and their basic human needs (and rights) met? One question; Where is all the foreign money and aid going?

To end this on a more positive note though, his grade 4 sacral decubitus (pressure ulcer down to and including the bone) sustained in hospital is now granulating incredibly well. Clean shaven, with his cheeks filling out and a twinkle in his eye, he has told me he finally feels safe and cared for. I am proud to say that he is receiving his new standard of care from Haitian nurses J

So, here we are, now six months on following the earthquake that changed the lives of so many people on the 12th January….. It is incredible really to think how much we were able to achieve in the chaotic weeks afterwards.  The Haiti Hospital Appeal (HHA) Charity, a small UK – based NGO (Non Government Organisation), had been building a Maternity and Paediatric Hospital, which was due to open at the end of 2010. A small group of us (3 nurses, a doctor and a physio) had come over to Haiti to help HHA with the earthquake victims of Port Au Prince, paying our way, and as volunteers for two weeks. Many patients had been evacuated to hospitals in the North of Haiti as well as abroad. I remember whilst in PAP, receiving a call from Carwyn asking what I thought about the possibility of opening up a ward in one of the maternity buildings for earthquake victims.( The reason behind this was that the local hospitals were full and although they were willing and able, with surgical teams readily available, they were unable to carry out any further operations because they had run out of beds and space). I just remember thinking; ‘ well, why not? In fact it would be crazy not to answer this call for help’….. We had more UK medical teams lined up to come out so could at least man the ward for some time to come…..  Liz (another RN) and I took up the challenge and came back from Port Au Prince and set to work!

On the 3rd February, we admitted 14 spinal cord injury patients and their displaced families. Since then we have admitted a total of 22 SCI patients and their families. When I think back, from getting beds and mattresses ready, building a ward, employing cooks, cleaners, nurses, translators, creating a ward environment and ward routine, literally creating medical documents (fluid charts, observation charts, nursing care plans etc), getting medical supplies (everything you can imagine from catheters, dressings, gloves, antiseptic gel, diapers….), linen supplies, nurse uniforms, teaching the nurses new specialist skills, getting a generator, buying in and maintaining enough safe water, food supplies, making sure meals were served on time and the generator was switched on when the local government decided to turn off the power supply  …. the list goes on …. We really did have to start from scratch. It seems an impossible task, and especially given the two big and crazy facts; 

  1. We were in Haiti (known to be the most difficult place to work and get things done) and
  2. There had just been a catastrophic earthquake!

It should have been ridiculously impossible, but I suppose when there is something that needs to done, you just get on and do it. I have it said before and I will say it again; Every single person has been a vital cog in the wheel - from all the people abroad who so generously donated their time and money, to all the local and foreign people here on the ground…. together we have created a safe and healing environment for some very sick, chronically malnourished and dehydrated patients….  and they are all, without exception, getting better.

I guess anything can be achieved with hard work, communication, commitment and team spirit! THANK YOU ONE AND ALL!

The reality is that we still have a long way to go. How do you discharge eighteen wheelchair bound people, whose homes were destroyed, into a city full of rubble with pot holed bumpy tracks for roads and no pavements?!

Haiti ….. Nou pap blye ou ….. We won’t forget you.

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