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Tom Kirsch, MD, MPH, an emergency physician at Johns Hopkins Hospital and co-director of the Bloomberg School’s Center for Refugee and Disaster Response is leading the first of two Johns Hopkins Disaster Teams to Haiti. He has served in a number of other disasters, including the September 11 destruction of the World Trade Center towers in 2001 and Hurricane Katrina.

The team will be stationed at University Hospital in Port-au-Prince, where they will provide health care for those affected by the earthquake.

Dr. Kirsch will send updates from Haiti, which you can follow here or on the CRDR Facebook page.

February 22

The provision of clean water is the most important public health function following a disaster because water is the most critical need of the human body. Without it, we can only function a few days, and survive only about a week. We need shelter too, particularly in very cold environments, but in Haiti that is not an issue. We can go without food for weeks.

The Haiti disaster is a prime example of the importance of water during the emergency relief period. In the first days after the earthquake, the municipal water systems in Port-au-Prince were destroyed and there was little water available for the survivors. People and relief organizations struggled to get water from any source, no matter how dirty, for themselves and to provide it for others. Initially any water may be useful just to keep the body going, but unless clean water is supplied quickly outbreaks of diarrhea and other infectious diseases will spread rapidly. In the Rwandan refugee camps in Goma, Zaire, an outbreak of cholera, spread by contaminated water, killed more than 10,000 people in 1994. Sanitation and the management of human waste remains a critical problem in Haiti even five weeks after the event.

There are many ways to get water to those affected by disasters. The best is clean local sources, or to use any local supply after treating the water to kill dangerous bacteria and viruses. Water can also be brought in from the outside in tanker truck and off ships. Small chemical plants can be set up to treat local water, or to desalinate seawater, or even to extract pure water out of the air. The water is then often distributed in giant bladders (see photo) set up near camps for internally displaced people for easy access.

Scott is the "Water Dude", or "Water Guy" at the University Hospital in Port-au-Prince. We never called him a water boy, because he was way beyond that. He ran the Aqua Sciences water extraction machine near the front entrance of the compound. It is a self-contained, tractor-trailer power by a diesel generator that extracts water right out of the air using some chemical process far beyond my understanding. All I know is that it provided water, a lot of water that was critical for our patients, our work and our survival. He is a lean guy in dark aviators and a battered, curled-brim straw cowboy hat but was a bit of a mystery, always polite, but mostly quiet as he ceaselessly went about his work. He never seemed tired or bothered by the relentless heat and sorrow. Every day Scott started at the control station at the end of the trailer turning dials and pushing buttons like some mysterious Wizard of Oz. He spent most of his day--10-12 hours of it--carrying big shiny Mylar bags of pure water around the compound to the wards, the patients and the tents of various NGOs. His work probably saved more lives than anything I did as a physician. Water is the basis of life and the core of public health and the "Water Dude" made it and delivered.

water

Tom Kirsch

February 16

My last few days in Haiti were a new experience as I responded to a call for volunteers that were suddenly needed in the Petit Goave region of Haiti to replace the volunteers leaving the mobile clinic sites there on Friday. A doctor from Chicago, Stacy, and I set out apart from the rest of IMC and arrived at the mobile clinic where just two IMC nurses had been working with Haitian staff for a week. It was a tent clinic in one of the tent city IDP camps that served the people living there mainly with primary care issues. The tent was supplied mostly with oral medications and some wound care materials.

The IMC nurses gave us a quick debriefing at around 11 a.m. and by noon had left us on our own. Talk about getting your feet wet. We jumped right in with over 100 people waiting to be seen, as the clinic had not opened at the usual time that morning. They were waiting for us to arrive with the restock of medications. We quickly began rolling through the patients. I triaged with a quick initial assessment and vitals while Stacy and two other Haitian doctors saw and prescribed medications for each patient. Everyone got something if only multivitamins, although the Haitian doctors generally provided medicine mainly to treat coughs, UTIs, vaginal infections, scabies and gastritis. Most were mild enough to send "home" with oral medications.

We did receive one obviously sick man on our first day who most likely had TB. The dilemma was then where to send the patient, as we did not have the capacity to care for him in the tent. We decided to send him with our personal driver to the nearest hospital. We found out later the hospital was currently staffed with only one doctor and one nurse and had no functioning X-ray or laboratory.

Stacy and I had a debrief that night about the current situation with the one other IMC staff staying in Petit Goave, Pascal, the French logistician. Pascal´s job had been to arrange everything for us from accommodations to transportion to interpreters, as well as everything for the mobile clinics--including tents, staff, supplies and sites. He also had to gather all the info we needed to best serve patients in our clinics. He was our go to for more supplies to request from IMC or from other area NGOs and for knowledge on what services are available where. It is a big job but he has been doing this for over 15 years, in so many disaster zones around the world, he made it look almost easy. He said Haiti has been his hardest assignment yet.

On Friday night, the three of us figured out that there is an MSF (Medicins Sans Frontier, aka Doctors without Borders) hospital 45 minutes away that would be a better option for referral than the nearby nonfunctioning hospital. We also set a plan to open a second clinic on Saturday, which Stacy and a few of the Haitian staff would go to while I would stay in the current clinic with the rest of our current Haitian staff. Pascal said we would each have a driver, however that didn´t quite get arranged in time so I manned the clinic with no phone, no driver and with no other IMC staff.

It was me and five Haitian healthcare workers and over 100 patients again. I was impressed at how well the Haitians were running things. It was all fine until we received a very sick girl, potentially with typhoid. I had no driver to take her to the hospital or a way to contact anyone to ask for help. She had shortness of breath, a cough with dark sputum, vomiting, diarrhea, and temperature of 104. The Haitian plan was to give her an antibiotic injection and some Tylenol and keep her on the examination table there to recheck her temperature after an hour or so. If it started to decrease, they would send her home and tell her mother to just bring her back on the next clinic day, which would be Monday, for another injection unless she improved. This girl really would have hugely benefited from IV fluids, repeated IV antibiotics, and closer monitoring. I kept checking on her to make sure she was still breathing, as she looked grim, lying face-down on the cot, eyelids slit, no movement. The scream she let out with the antibiotic injection was some extra reassurance she was still very much alive. I continued to work, with glances at her every few minutes. A temperature recheck showed a slight decrease. After a couple of hours, with my last glance, she was gone. They had sent her home. There was no means to do anything more. I still think about her days later and only hope she will be alright.

Saturday, Pascal worked to secure us another driver and to find names of villages with a potential need for more mobile clinics due to either the vast quake damage and displaced persons or the loss of the existing healthcare source from the quake. Sunday was spent visiting these villages and assessing need. Collapsed buildings around Petit Goave are as common as in Port-au-Prince. However, Petit Goave has less open spaces, as in city parks, therefore actual tent cities were not as common. Tents simply lined the streets. Driving took some careful maneuvering and I can only imagine living in one of those tents where cars constantly pass only inches away.

One of the villages we visited was as poor and devastated as anywhere else we had seen with collapsed buildings on top of the already existing state of poverty. It was also a place on the coast where the ocean floor had shifted causing the water level to rise and flood everything nearest the coast. As we were driving through, Pascal said, "I´m sure there's need here, but where are the tents?"

It was interesting to learn that in order for a place to receive donor money and our help there had to be obvious need resulting from the earthquake. They couldn’t just simply need help.

In another village, there was a standing fine facility, which once served as a clinic. The complicated task before us was to find out why the clinic wasn’t functioning now. Was the clinic functioning prior to the quake? Was the facility damaged in some way? Were there staff losses? Were staff just not showing up to work now because the government stopped paying salaries or did the government stop paying the staff because they stopped showing up? So many complexities involved in disaster relief, especially in a place like Haiti where the healthcare system was barely functioning before the earthquake.

Another site Pascal heard of was only reachable from Petit Goave by boat. It was rumored to have been affected by the quake and had not received any services or even visits from outsiders since the earthquake. We put together a mobile boat clinic and sent it out Monday to do the assessment and set up a new clinic there at the same time. Apparently, it was a success. Medical services were sent there and they were affected by the quake, losing their water source as well as their usual means of receiving medicines and food.

I had three and a half short days in Petit Goave and saw and learned so much. And hopefully helped some as well.

"Short" and "hopefully helped some" are my main thoughts as we head home now. The biggest, however, is how will Haiti recover? How long will it take? What more can we do? What more can I do? How do I go home and back to life there? Haiti will stay with me now. I feel a responsibility to spread that to others. To get them more help. And to get back and do more. This leaving now is not the end of anything.

February 11

I spent the last three days doing assessments. We were trying to identify areas with unmet needs with the purposes of determining whether International Medical Corps could fill in the gaps. The areas we went to were literally at the "end of the road."

We drove west out of Port-au-Prince, down the long peninsula that reaches far into the Caribbean Sea, to the towns of Leogane and Petit Goave. The road passes directly over the earthquake's epicenter and so the damage there was far greater than in Port-au-Prince. In some towns, more than 90 percent of the buildings had collapsed. At points the road was ripped and roiled with larger fissures slashing along and across the road.

The road started as a poorly maintained ribbon of asphalt with more potholes than smooth surface but gradually faded away into a scrubby dirt track only suited for feet. Initially we drove through alternating areas of forest, banana or sugar cane farms, and crumbled towns.

After passing through the town of Leogane, the asphalt road became a dirt road as we when headed south towards the mountains through an essentially flattened town with few functioning buildings. Then the dirt road headed southeast paralleling a briskly flowing creek that was lined with shacks and concrete houses. Only the shacks were really left standing because they were made of wood and palm fronds and metal sheets and not the brittle and poorly reinforced concrete that crumbled into dust.

There were three scattered IDP (internally displaced people) camps along the road. The IDP camps were haphazard affairs with tents and shacks thrown together in closely packed groups made from an assortment of tarps, scrap wood and old rusted corrugated metal sheets.

The dirt road ended at the last camp. The last camp was the worst of the lot. Only yesterday, Save the Children had delivered tarps (that had been used to create shelters of a variety of interesting configurations). But here was nothing else there. They did have the creek, which was used for drinking, washing, bathing and probably as a toilet.

-Tom Kirsch
(Johns Hopkins Disaster Response Team Leader, Port-au-Prince, Haiti)

February 11

I'm missing you all tonight as it's so quiet here with only Stacey and Paschal and myself. Although it is a nice change of pace. We pulled into the hotel around 10:30 am this morning. Unloaded and looked through supplies and then set off for the "clinic", a tent in one of the tent-city IDP camps. We got a quick handover and took over the clinic from the leaving volunteers by noon and worked to see the rest of the patients waiting until around 4pm. It was pretty good. Lots of not sick primary care, of course, but one suspected TB, which we had our driver take to the nearest hospital, and one malaria. Otherwise, lots of scabies, mild URIs and UTI/vaginal infections. It was kind of the pan-positive issue. Everyone always has fevers as well. However, once you pry, sometimes the last one was last November. Although, before the deep prying everything is either "since the earthquake" or "since before the earthquake". I think that's how the story of their lives are divided now.

Tomorrow, Stacey is going to set up another clinic nearby in another village in much the same way as this one and I will stay at the one we were at today. They are mostly run by three Haitian doctors and five Haitian nurses (which will split between the two clinics tomorrow) which is really great and it's running well. We provide all of the supplies (some from IMC and some mooched off other NGOs), safekeeping for them at night, and a little extra manpower. Paschal is going to search around during the days this weekend for other sites for more clinics and there's also talk of helping to get the hospital here running again. But we need more volunteers for all of that so he's hoping for more by Monday. (There really needs to be at least some by Monday since all three of us are leaving that day!)

The hotel is beautiful. There a few guests from each of MSF, Oxfam, a German food security NGO, and a few other NGOs staying here. We get dinner although it doesn't compare to the Plaza. I had french fries and vegetables. Stacey had them with some additional plain beef. I suspect that's what it will be every night. And we're on our own for the rest.

It was also a bit misleading to say we're on the beach. You can kind of see the water on the drive into the hotel way beyond the other side of the road but we haven't seen any actual beach nor do I think it's safe to go try and find it. But I may investigate that before we leave.

Rubble and IDP camps are as frequent and devastating here as in Port-au-Prince, perhaps more so per capita although it's not as dense out here. The nurses who left today said there is an aftershock every night at around 2-3am. I am curious to find out if that's true tonight. Although, it would be nice to sleep through the night.

-Alicia Hernandez
(Johns Hopkins Disaster Response Team Nurse, Port-au-Prince, Haiti)

February 5

There is a place in the hospital we call “The Forest”. It is the place where the lost souls end--a purgatory or limbo. In reality it is just a courtyard with some semblance of shade from the scraggly trees and tarps strung among them. “The Forest” is a square of dirt and scattered grass with concert walkways that cross at the center of the square forming an “X”. At the walkway’s crossing is a dead fountain.

Originally this space was used as a patient care area when the hospital was so inundated. It was filled completely with old beds, cots and blankets among tarps strung between trees, and a forest of intravenous poles and dripping fluids. A week ago, we cleared out all the ill people and cleaned the ground of trash and feces.

Now this space is just limbo, a miniature refugee camp. There are about 35 people who have set up camp on the old and mostly broken hospital beds. They have converted the IV poles into tent poles to hold up their tarps. They have brought in sheets, blankets, pillows, dishes and other small reminders of the homes they once had. They do dishes, but do not need to cook since food is available and there is clean water and porta-potties.

This is the place where we let patients with nowhere else to go wander off to once we have completed their medical therapy. We are not suppose to transfer patients to "The Forest,” because there is no one who is responsible to care for them (we don’t have the staff). But sometimes we mention to the most desperate people that they can just walk over there and grab an empty bed until the hospital administration decides they are no longer welcome.

Bernard is one of the lost souls. He is a thin, craggy, elderly gentleman with fizzy gray hair and a lost look in his eyes. He came in, or was brought in for unclear reasons, and was too confused/demented to give a coherent story. He did have a paralyzed left wrist, most likely from a nerve-compression injury after the earthquake and was clearly dehydrated and possibly malnourished. He had no family or friends or the ability to tell us where to find anyone. We gave him fluids, food and a splint and he was done. But there was nothing else for him. I walked him to the Forest and sat him on a bed in the shade. I go by daily to see him. He sits there patiently, legs dangling from the decrepit, rusted hospital bed. He is always in the same spot with old foam boxes of food at his side, biting the corners off the little bags of water volunteers bring by before sucking out the contents. I never see him talk, or even walk--always just sitting there and watching. I wonder what he sees and wonder if he remembers.

There are so many lost souls like him that it is incomprehensible. They come and go like tides every day. Some stay in our “Forest”.

-Tom Kirsch
(Johns Hopkins Disaster Response Team Leader, Port-au-Prince, Haiti)

February 4

For the most part I haul stuff, including patients. Yesterday, I was an electrician and rewired a tent and put in more fans.

-Tom Kirsch
(Johns Hopkins Disaster Response Team Leader, Port-au-Prince, Haiti)

February 4

We arrive to the University Hospital around 7:15 a.m. We have a short debriefing and then we are off to our units. There is no way to know what we are in for each day. I meet with my interpreter and we chat about our previous night. I ask about his family, how his wife and kids are? He always says they are good. It's hard for me to comprehend they are "good" with their home destroyed and having to live in a small tent, meant for two but accommodating five. He says his kids love not going to school. I think to myself that perhaps his children have not yet realized their schools are destroyed and the devastation of the earthquake has taken the lives of their classmates and teachers. After the brief conversation we are ready for our day, both of us know it's going to be long and hot. We don't give the conditions a second thought as we are immediately focused on making a difference--bringing light to the darkness that surrounds so many here.

Arriving at the unit, I take inventory to see what supplies we have for the day. I have learned that many of our supplies are missing. Already patients are waiting for care. The long lines twist down the street. American care is here and the Haitians have welcomed it with open arms. They have a robust confidence in the work we do--often expecting a cure for the incurable. As the chaos begins, there are doctors and nurse swarming the tents. Novice nurses work side-by-side the seasoned healthcare providers. The newest additions to our ER flounder briefly asking questions like "where is this antibiotic, where is this narcotic, will you start this IV, can you figure out what is wrong with patient, I am new here can you help with what I should do, etc." The intensity drives all of us to push our limits and immediately adjust to the demands from all sides.

After 10 hours of craziness in 100 degree heat, we finally come to a day's end and take time to reflect. Have I made the right calls? Have we truly done our best to make a difference? The realization that our Hopkins group will have worked over 1,000 hours within 10 days, does not ease the demands I have for myself and the short-comings I have identified within myself. It's two weeks out of my life--a short time to do the good I set out to do.

Pierre, my translator, has stood by my side all day. He's held my supplies at my side, tidied my workspace, and spoken every one of my words. He comes here every day to make a difference of his own. Knowing his family awaits him, he sets off back to his "home."

Despite leaving the ER for the evening, my mind is continuously rewinding through the day. How will I be better tomorrow? Am I good enough for these people who depend on us so much? I think of each face of each patient, of each heart I have touched. The strain and stress can be overwhelming but I find a strength in those who depend on me. I will return tomorrow with a smile on my face, a soothing touch to my medicine, and shoulders to carry the burden of a broken country.

-Rocky Cagle
(Johns Hopkins Disaster Response Team Nurse, Port-au-Prince, Haiti)

February 4

Day 6 six in Port-au-Prince. Already half-way through our stint here. I can't believe it was only one week ago that we were first flying here. It feels like so many more.

I hit a brick wall yesterday as we have all been working almost non-stop since arrival--some since the minute we stepped off the bus from the Dominican Republic into the hospital. It's the long hard hours in the sweltering heat of the tent, the relentless flow of patients desperate for miracles we can't provide, the lack of sleep, and continuous failed efforts to stay hydrated and nourished. At least one volunteer has succumbed to the pressures every day since we've been here, to the point of being unable to walk and needing IV hydration. I came dangerously close to that point multiple times about every 2 hours yesterday, needing to find shade outside of the tents, and force down some ORS (oral rehydration salts). I had at least 3 liters of ORS plus more water and still couldn't last more than 2 hours in the tent without feeling like I was going to vomit and pass out. I realized I had to take more than the time it took to down a liter of ORS away from this work. Thankfully everyone else realized it yesterday as well and time off is now not only being more welcomed, but mandated. I quickly stepped up to the plate to take the first day off. I finally slept better, I think knowing I wouldn't face the pressures of not only caring for others this morning but caring for myself in this condition. That alone was a huge weight lifted for the night. And I still awoke nauseous and still feel so now. With being awake through the night not only because of the heat and stress and mosquitoes, but because of having multiple trips to the bathroom with vomiting and diarrhea.

But I'll get through it. All of us will (with a few exceptions of early flights home for fear of serious illness). The bonus of doing medical relief is that we all have easy access to medicines and IV fluids with the know-how to provide it to each other. I started an IV on another nurse that went down in the middle of the day yesterday. I have been offered IV fluids and Zofran and Cipro by many of my fellow volunteers. Everyone cares and everyone understands. It's great camaraderie and great inspiration to see what we are all going through to try and make some difference here. And I like to believe it's in the small ways that we are. We are so limited in what we can do for the severely sick and without social work it feels so wrong to discharge those without a home to go to, but that is nearly everyone. I don't know how these people are surviving, but they are. Not only that, they smile and thank for the simplest things--some Tylenol, a little cleaning and fresh gauze on a horrendous wound that covers half their leg which they will have to limp out of here on. And to where? A two-tarp tent, waiting for the next food and water drop off. We pass by their lives, sheltered by the walls of the bus and the walls of hospital, see them cooking and bathing on the sidewalks, bustling to and fro. Life goes on in unexpected ways.

-Alicia Hernandez
(Johns Hopkins Disaster Response Team Nurse, Port-au-Prince, Haiti)

Wednesday, February 3

The day starts about 5:30 a.m. when the hotel turns back on the power. The fans come back on at least. People begin stirring, snores fade away, backpacks rustle and feet pad around. The lights usually burst on at 6 a.m. and then the activity intensifies except for the few still trying to squeeze out a few more minutes of sleep. People dress, food and supplies are gathered.

The bus leaves at 7 a.m. driving less than a mile past normal buildings and lives and crumbled ones and tent camps. Vendors have already lined the streets past the ramshackled tents in the city’s main plaza--food stalls, haircuts, a Gno Kozes (snow cones). Most interestingly the guy with the truck well lit by fluorescent lights and a rack of blenders on the back is making smoothies. At the gate of the hospital there is already a half-block long line of patients waiting to get in.

By 7:15am we have completed our briefing and are pulling supplies. The little triage tent is bursting with people. Report is given by the night team- there are always patients leftover – usually very sick. They bring the sick ones from the rest of the compound back to the ED if they go bad at night, and only the really sick come in after midnight. Patients start pouring in.

Our tents are hot, probably 10 to 20 degrees hotter that the ambient 95F air outside. They have few windows and the power only runs occasionally to run the fans. We lose at least one staff member a day to heat exhaustion. Yesterday it was the 6’2” Amazon nurse from Utah--dizzy and pale then down and vomiting. We run IV fluids and bring them to a cooler area. We have started mandatory fluid requirements and push people to take breaks. We now will have a mandatory ½ day off every five days minimum. The army guys might hook us up to one of their generators so we can at least run the fans. I got pizzas and cold Cokes delivered from the outside yesterday. A strange, and strangely comforting little piece of normality.

The buses head back between 5:30-6 p.m. and it is always a scramble to tuck things away, restock and sign out to the night people. We usually miss the bus and bet the late one.

Debriefing 6-6:30 or 6:45 p.m. (although I usually miss the first few minutes, preferring to sit with my sore feet dangling in the cold pool water and drinking a beer.) Dinner--cafeteria style--is at 8 p.m. Most people start fading out around 9 p.m. The few hardy (stupid? gregarious? insomniacs?) sit on the patio late talking and drinking $4 beers or soda until late surrounded by the reporters furiously working on stories and hogging all the wireless bandwidth.

Finally sleep in the dark conference room with 40 to 50 people scattered around in various odd sleeping arrangements--bed mattresses, inflatable ones, cots, even tents pitched indoors. The stirring, rustling backpack and padding feet gradually fade away and a low-grade background hum of stores rise up and the day ends.

-Tom Kirsch
(Johns Hopkins Disaster Response Team Leader, Port-au-Prince, Haiti)

Tuesday, February 2

Today we saw 470 patients, with 10 hours of clinical care (and 2 hours of other stuff) that's almost 1 patient a minute. It's hot, it's chaotic, and it is repetitively, achingly sad. We have created a system and teamwork that is so efficient it's scary. Of course that means that I am mostly a runner, appropriator-of-supplies, communicator and patient transporter.

We have truly transited into replacing the primary health care systems with people pouring in to get horrible chronic illnesses addressed--horrible, ulcerated cancers, severe hypertension and chronic heart failure, children devastated with cerebral palsy. Mixed in though, are patients dying from untreated illnesses--severe heart failure and asthma, and many with serious infectious diseases that are difficult to diagnose, so we just pour in antibiotics and hope for the best.

The first photo is of the triage area where everyone lines up for care. It is late in the afternoon, after we have cleared things out, when the other clinics, hospitals and field hospitals send truckloads of patients to us...because we're better I guess (laugh out loud)?. It reminds me of the Hopkins Emergency Department.

triage

The second photo is of the entrance to the main hospital building. It still has no power so at night, when it is jammed with close to 100 patients and their families, it is pitch black with flickers of flashlights and low murmurs and moans.

building

This last photo is of  Rocky Cagle. He is a Cardiac Surgery Intensive Care nurse. However in Haiti, he is an all around care-giver, organizer and nursing leader. Rocky is pictured with two of our interpreters--James and Pierre. Both have lost their homes and are living in tents, but still come to work every day and help immensely.

rocky

-Tom Kirsch
(Johns Hopkins Disaster Response Team Leader, Port-au-Prince, Haiti)

Tuesday, February 2

We work out of big, cream-colored tents, maybe 30 feet long by 15 feet wide. There are tents scattered all over the compound, from many different countries, but all with slight variations on the same design with a color range of white to tan.  I guess they are the international standard disaster tent.  We have three tents for our "Triage Emergency Department."  Two tents stand out--the ‘Jiffy Pop’ (look that up those of you born into the microwave era), and the Blue Tent.  The Blue Tent is the infectious disease tent with 6 places for the emaciated people coughing blood that we think have advanced TB. There is an exceptionally brave and unassuming Infectious Disease fellow from California who works there, pretty much alone it seems.  She is quiet and unassuming with dark hair and a serious look about her. And she risks her health and maybe even life every time she steps in there. She works 10-11 hour shifts. At night the patients are alone to cough and gasp for breath.

The patient I sent there yesterday was a 19 year old with what appeared to be advanced AIDS. He looked like one of those classic "refugees" in a starvation area with racks of ribs cascading down his chest, sunken eyes and limp, lean arms and legs. By the time he got to us he was already breathing so hard that he had to sit upright and could only gasp out one or two word sentences. He was sweating and you could see every muscle in his torso working to drag in each breath. We poured antibiotics, anti-malarials, and fluids into him immediately, but because he reported coughing blood we moved him to our "isolation area"--the open space between our two tents under the shade of some trees.

I moved him to the Blue Tent in the late afternoon knowing there was not much to do, but hoping the California ID doc could work some miracle. The next morning I went by and was somewhat surprised to see him from under the tent flap still sitting in his bed. After donning an N-95 mask I went into to the dark cramped tent among the shrunken, slightly stirring bodies to get a better look. He sat exhausted and glassy-eyed, sweat streaming off of him and making small grunts with each breath. It took him all his remaining strength to keep himself breathing through the night and now he had no reserves left. I just tuned and left. He died 2 hours later.

-Tom Kirsch
(Johns Hopkins Disaster Response Team Leader, Port-au-Prince, Haiti)

Monday, February 1

“I Watched 3 People Die Today”: Letter from Alicia Hernandez Nurse, Johns Hopkins Disaster Response Team

Expectations have so drastically changed every hour along the way here that I can't even compare the reality to expectations. We had heard earthquake-related medical needs are over and yet one of the patients we received today was a little girl who had bricks fall on her legs during the earthquake and only came in today for it. She had bilateral femur fractures. I'm not sure how things will turn out for her. The day was filled with the questions "What can we really do for this patient?” and How many resources should we really use?" considering every bag of saline and every glucose meter strip when we were down to 4 of each for the day by noon.

So much of this care involves deciding who to let die. The hard part means watching them die and watching their loved ones deal with their deaths. In these places, you'll see a brother, who's 40-something previously healthy sister just died, say "OK" with a non-chalant shrug when informed that she's gone. Like, "just thought I'd ask". And it seems like they are so hardened to this because they are dealing with is regularly, and with so much worse. But with this particular individual, we had the privilege of treating his father in the same day and keeping his company throughout the majority of the day. Even after his sister died, and worrying about his father's treatment in the same place, he was cheerful and thankful. There was a moment, however, where the hardening softened, and he collapsed down onto the stretcher next to his father that was finally briefly freed of another patient, and sobbed, when he thought no one was looking, for a brief moment.

Each death was different, each patient was different, from gunshot wounds from a riot setting to chronic illnesses sent from other hospitals drowning in the situation, to a women with nothing left we could do, no family, no identity, and who still hung on for hours. There is so much need, and so many people who want to provide, and so many obstacles. And this is just our day 1. We will make a difference. I am determined. I don't know how. I know even less so how than I thought I did 3 days ago. But with the good will and determination I sensed today, it will happen, no matter how slowly.

-Alicia Hernandez
(Nurse, Johns Hopkins Disaster Response Team, Port-au-Prince, Haiti)

Monday, February 1

Work here is hard--12 hour days, essentially on your feet constantly in boiling hot tents with limited electricity. We have truly transited to the primary care phase, although occasional people come in with untreated wounds and fractures from almost 3 weeks ago. There is so little that we can do it seems, with the limited resources we have, and even less to do for an essentially non-existent Haitian healthcare system. We can treat acute infections, but pretty much anything else is almost impossible. People are pouring into us because they think that we can give them the care they can never get in Haiti--horrible and massive cancers, HIV and AIDS, chronic abdominal problems, diabetes, whatever. But all we can do is bandage, fix the acute problem and give a few pills to go and hope that maybe at some point they may get the long term health care they deserve. Still, we see 250 to 350 people a day and give the absolute best care we can considering the resources.

The team has been amazing and has taken over the management of the emergency department. Everyone is pulling their weight (and then some) and using their intelligence, wit and grace to make this place better every day (despite the ongoing chaos).

-Tom Kirsch
(Johns Hopkins Disaster Response Team Leader, Port-au-Prince, Haiti)

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Thursday, January 28

The Hopkins Disaster Team finally arrived in Port-au-Prince last night at 5:30pm after two days of travelling. We arrived at the University Hospital just in time because a large group of providers is leaving tomorrow morning. The staffing is so short that our pediatrician and our Creole-speaking physician are working the night shift tonight to staff the pediatric ward, which otherwise would have been left only to the patients and their families. The first group has been working non-stop for two weeks and is exhausted.

Port-au-Prince has an odd look about it with scattered areas of devastation next to completely functioning businesses. Camps of the homeless are scattered throughout the city. The University Hospital is a strange mix of functioning wards, collapsed buildings and tents from NGOs scattered across most open spaces.

The Hopkins Team is sleeping in a giant conference room at a local hotel, but it is safe and relatively cool and clean. Tomorrow the real work starts.

-Tom Kirsch
(Johns Hopkins Disaster Response Team Leader, Port-au-Prince, Haiti)

Wednesday, January 27

haiti1

"We landed in the Dominican Republic and took a truck ride from Santa Domingo to the border of Haiti through lush rain forest and a field of cacti and yucca. We were stuck at the border for a while, but now finally getting through the border crossing. It’s actually a good sign. There is so much chaos and a massive traffic jam at the border because a ton of supplies and equipment are pouring into the country."

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-Tom Kirsch
(Johns Hopkins Disaster Response Team Leader, Port-au-Prince, Haiti)

Wednesday, January 27

"We are off. Our Hopkins Team is composed of physicians, nurses and mid-level providers. We carry supplies donated by the Hopkins hospital and a local pharmacy (Harrison's). We are prepared to sleep in tents, but there may be a conference room at a hotel we can sleep in. Frankly, I think I'll sleep outside. But there will be electricity available"

-Tom Kirsch
(Johns Hopkins Disaster Response Team Leader, Port-au-Prince, Haiti)

Public Affairs media contact for JHSPH: Tim Parsons at 410-955-7619 or tmparson@jhsph.edu.

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