A Dallas doctor's letter from Haiti

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by DR. BOB PETERS

wfaa.com

Posted on March 10, 2010 at 12:34 PM

Updated Wednesday, Mar 10 at 12:40 PM

Dr. Bob Peters was part of a Forest Park Medical Center team which traveled to Haiti after the earthquake. In a moving letter to his daughters, he recounts his experiences.

Our Gift to Haiti

A Letter to My Daughters

Ashley, Brittany, Stephanie, and Emily,

I think it is good for me to put down in writing some thoughts on my trip to Haiti, but it is hard and I really did not want to do it. So the best motivation for me that I could think of was to do so in a letter to you, my daughters, as a way of sharing all of the details, which I know you are eager to hear. Doing so motivates me to organize my thoughts. I started typing and it ended up being much longer than I thought it would, so I understand if it is too much for you to read. Also it may be more graphic in places than you care to read, but I decided to just put down what was in my mind, as I thought through everything. Some of that is verbalizing in writing the struggle going on in me to reconcile some of the feelings I have dealt with since being back. In any case, here is the story from my perspective.

One of the most remarkable achievements of this trip was the mobilization. The main earthquake in Haiti occurred on Tuesday January 12th at 4:53 pm. Most of us did not hear of how significant it was until the following morning. By Thursday morning, 36 hours after the quake, the administration and physician leaders of Forest Park Medical Center (a fully physician-owned surgical hospital) were in full swing to organize sending a surgical team to the area. Organizationally, this was a massive undertaking. Two private Gulfstream IV jets were secured, surgical supplies were collected out of the hospital's own stock and vendors were contacted to donate more, large quantities of bottled water and MREs (“meals ready to eat” army rations) were obtained, and the hospital’s administration began calling potential team members. I was called around noon on Thursday and offered a spot. Initially, I did not see how I could go because the following Monday was MLK day and that entire day my surgery schedule was full of kids whose parents had counted on their surgery being that day, while they were out of school. When I told my office staff of the offer, they were not about to let me turn it down for any reason. Your mom also was very supportive of me going, being moved as was everyone by the plight in Haiti. Granted, her support was after I told her that we would have a strong US military presence in the area keeping us safe, something that we ultimately found not to be the case within the city of Port au Prince.

The plan was to leave on Friday, the following day, and return on Monday. It takes special permission to land in Haiti with the limited capacity of the airport there. Permission was secured by contacting US Rep Sheila Jackson Lee in Houston. She was even interested in going on the trip with us initially, but this was later disallowed by Washington. It was also required that we have a charity sponsor within Haiti. This was coordinated with CURE International who would help us get where we needed to be within Haiti once we arrived. Nonetheless obtaining the proper clearance to go took us into Friday, pushing our departure to Saturday morning when we were given a specific landing time at the Port au Prince Airport. The fact that we were headed to Haiti with a team and supplies just 3 ½ days after the quake was an amazing accomplishment. But the speed of mobilization also meant that we would be one of the first teams of surgeons to arrive in Haiti.

Unfortunately, that one day delay meant we would now only have two days to work in Port au Prince and raised concern that if we did not quickly get to an area where our services could be maximized, valuable time would be lost. Our prayer was that we could quickly drop into “ground zero” of an area where our surgical skills could be used, if nothing else treating patients, until more surgeons could arrive. Prior to departure from the Jetlinks hanger Saturday morning at Love Field, this multi- denominational group had a time of prayer, asking for God’s presence and protection in our effort. The two planes carrying a total of eoght surgeons, three anesthesiologists, seven nurses, two surgical scrub techs, two search and rescue, two general support personnel , two media persons, and several hundred pounds of supplies left 30 minutes apart so that our landing times in Haiti could be staggered.

The media attention was also of some concern. The publicity our team attracted was fine overall, but no one involved in this effort was going to allow this trip to be a stunt. For this reason everyone felt it was better that Rep Lee was not going with us. This trip was not about appearances. We knew, or at least hoped, that we would be working so hard, that distractions could not be tolerated. As it ultimately turned out, the CBS-11 cameraman and reporter who traveled to Haiti with us became essentially honorary team members in light of the substantial help they were always willing to provide, even assisting in medical procedures in the field.

Upon approach to Port au Prince Toussaint Airport the devastation appeared evident from the air. However, it was difficult for us to compare to what this area of Haiti around the airport might normally look like. No offense intended but we would not normally expect a country like Haiti to be in all that great of shape in the best of times. The airport was well run and secured by US troops. The control tower was damaged, leaning slightly to one side, and therefore not being used. The ground crews rushed us to unload all our supplies off of the planes, so that the planes could leave quickly and make room for others. We were never even asked for our passports. Our planes took off heading back to Dallas after spending less than 20 minutes on the ground. All of the logistics of the next few days would need to work well if we were going to be back on those planes in two days headed home feeling good about what we accomplished.

It took longer for the transportation to arrive that would take us from the airport to our destination hospital than we preferred, wasting almost an hour at the airport. This would be a pattern over the next two days, always being uneasy while waiting for cars and trucks which would typically show up late. We were loaded into two SUVs, the back of an old pickup truck, and what appeared to be a rusted out, unmarked Uhaul truck with no door on the back. All of the drivers were Haitian who spoke no English. Our contact with CURE was going to see to it that we were taken to the correct hospital. The supplies were loaded into the rusted out truck and we put two people back there to protect against someone on the street running up and grabbing supplies out of the back of the truck. The gate to the airport was nothing but a chain link fence gate with US and UN guards. On the other side was an enormous crowd of Haitians lining each side of the dirt road for hundreds of yards. I still have no idea why they were all there or what they expected to gain from standing there just outside the airport gate all day. As we drove out into the city, the gate area would be the last that we would see of any US troops until we came back to the airport two days later.

Within the city, there were people everywhere up and down both sides of every street. It was about a mile from the airport that we first began to see the obvious earthquake devastation - one somewhat intact but cracked building standing between two others on each side that were now piles of concrete rubble with protruding rebar sticking out in every direction . Many buildings were truly “pancaked”- several concrete floors staked one on top of the other as if tent poles had simply been knocked out from between them, allowing these enormous slabs of concrete to fall flat on the floor below. Whatever was in between them at the time this occurred had little chance of survival. The search and rescue team that was with us had some of the most disturbing experiences of the trip. Since many schools in Port au Prince do not let out for the day until 6 p.m. or later, the earthquake happened with those classrooms full of children. In their search, their search they found “pancaked” classrooms full of children crushed at their desks. This image is almost too horrific to contemplate. It is very disconcerting to imagine the thousands of individuals whose bodies are still in such buildings.

On one street, half of the road is blocked by a group of people eating lunch at a table in the street, sitting on chairs as if this were their dining room. If they ever had a dining room it was probably now an indiscernible pile of concrete. We turned up one of the hilly streets on the preferred route to the hospital to find it blocked by piles of rubble and a bulldozer working away. We had to turn around and find a different route. Pedestrians are often within inches of our vehicles staring in the windows at this group of predominantly white foreigners dressed in scrubs. Most people on the street were wearing some form of a breathing filter over their mouth and nose in an attempt to block out the foul odor - either a surgical mask or a scarf or shirt. This odor that would be intermittently discernable was unmistakable to us physicians, being that of rotting corpses.

As we redirected to an alternative route, I noticed a sign posted in front of one amorphous concrete heap reading, “Dead bodies inside. Welcome the US, we need help.” We arrive behind a line of cars all attempting to gain access through a 10-foot high rolling wood gate. All of the cars in front of us were apparently attempting to bring in injured patients. Some were let in and some were turned away. Our Haitian driver says a few words to the non-uniformed guard who quickly rolls open the gate allowing our entire caravan into what was the walled compound of l’hospital Sacre Couer (Sacred Heart), also known as City Hospital. Within this courtyard/parking lot are numerous patients laying on blankets or mattresses on the ground with bandages on various parts of their body and numerous family members sitting at their side. There are IV bags hanging from various poles, some makeshift such as the one which was a tall tree branch stuck into a cylinder block base. There was also a strong odor around the courtyard which we all know to be the unmistakable product of infection with pseudomonas and anaerobic bacteria under many of their bandages. We are met outside by the hospital director and the head surgical nurse. They quickly orient us to the situation and give us a tour.

The hospital was constructed to withstand a 7.0 earthquake. It is still standing but the support beams of the first floor throughout half the hospital are cracked. With the numerous aftershocks (there had been over 30 since the initial quake) the personnel are fearful of working and having patients inside. So the courtyard is the ward. Patients had been taken inside only to have Xrays or to have a procedure done in an ill-equipped room just inside the front doors by one of the three Haitian doctors that had been working non-stop since the quake four days prior. The two true operating rooms are on the third floor and it is felt too risky to take patients up there.

We also met a team of French emergency medical doctors who arrived at this hospital 24 hours before us. They were all dressed in matching white jumpsuits with the letters “SAMU” (abbreviation for the French equivalent of mobile emergency medical service) on the back. None of them were surgeons but they had been doing the best they could to help the Haitian doctors: assessing patients, dressing wounds, and providing supportive care. When they hear that we are a team of surgeons they are very pleased and tell us that we are the first surgeons on the scene. They start describing the numerous injuries in the courtyard, massive soft tissue wounds as well as open (bone sticking out through the skin) and displaced fractures for which they know definitive treatment has yet to be rendered.

By this time it is 3 p.m. on Saturday and we are desperate to get started. We have two more hours of daylight and do not know what the light will be like after that. We unload all of our supplies into a corner of the courtyard that will be our headquarters. The sun is shining and the temperature is in the 90s. The patients are moved by their families to various parts of the courtyard to keep them in the shade throughout the day. The French SAMU is using one of the only air-conditioned rooms in the hospital, just inside the front doors as their headquarters. First come, first serve, I guess. Nonetheless, we launch into work immediately.

The surgeons divided up into teams with nurses (who were awesome by the way. The nurses and other support staff were major contributors to how we were able to accomplish so much in such a short period of time. Every member of our team was remarkable). There were three general surgeons and the rest of us were surgical specialists, such as plastic surgeons, ENT, but only one orthopedic surgeon. After making rounds to assess the injuries in the courtyard, it became apparent that the vast majority of the injuries needing immediate surgical attention were orthopedic in nature. Once we had time to think about it this only made sense. Being now four days after the quake, any major abdominal, thoracic, or head injuries would not have survived to that point. Those injuries would result in early demise. What were left were severe orthopedic issues of the arms and legs, and severe they were. Most of the fractures were open, which is a major issue for infection even in the best of conditions. Once infection sets up inside bone it is extremely difficult to eradicate due to the minimal blood supply present in bone. As the first surgeons on the scene we are now confronted with a massive number of infected, open fractures and crushed limbs that have all had four days to fester in the open air. As we examined one wound after another, all of which were draining pus and showing early signs of necrosis, it became apparent what surgery was going to be dominant in our time in Haiti - amputation. It was sad to think that this was going to be our main contribution, our primary gift to the relief effort in Haiti. Despite our various specialties, we were all going to have to be orthopedic surgeons for the next two days.

The first amputation took place just after nightfall on an open gurney in the courtyard. Although an attempt was made to be discrete it was still in view of all present. The patient, a middle-aged thin man, was given a regional anesthesia block by injecting the femoral nerve in the groin. A below the knee amputation (BKA) was performed in the light provided only by the mercury vapor lights far overhead in the courtyard and the Eveready headlight brought by the surgeon. There was no electro-cautery available, which is as basic a tool to surgery as a tape measure or a level is to carpentry. Electro-cautery controls the general bleeding of the small blood vessels present in all tissue, allowing the surgeon to focus quickly on tying off the major blood vessels. There is also no powered instrumentation available, such as an electric surgical saw. So the bone is cut above the infected area with a wire saw known as a Gigli saw. It is an abrasive, thin wire with handles on each end similar to a lawn mower pull. The same tool is available at Home Depot and used by plumbers to cut through PVC pipe. It is pulled back and forth with both hands rapidly until it saws through the bone. In the lower leg there are 2 bones that must be cut, and it can sometimes take a couple of minutes to saw all the way through both. This patient lost a lot of blood, making a significant puddle on the brick-paved courtyard, but he survived. His stump was not closed. It was left open so that the now healthy tissue above the previous infection could slowly heal inside out. Closing the wound could trap infection inside again, resulting in a repetition of this process. It was decided that it was best to use a room inside the hospital that was part of the Emergency Room for amputations from then on. Although there was still no electro-cautery available there was better light and it was less unsettling to the rest of the patients waiting in the courtyard. The remainder of the first night I was the courtyard surgeon. One patient after another was brought to me with open wounds, fractures, and even injuries that had yet to be assessed. It was at this point, early in the evening, that I noticed that the French team and the resident Haitian doctors were no longer around. They had left and were finished for the night by 6 p.m. I could understand such with the Haitian doctors. After all, one of our main goals was to give them a reprieve, allow them to rest. The French team leaving was something I did not understand. We were now the only doctors within the compound. This made the first night an unbelievably trying experience because new patients were coming in the gate non-stop, now that word was out that we were there. Nearly every single patient I saw needed some type of Xray. Unfortunately, midway through the first evening the Xray department began to run out of film. This required rationing. So if a patient had a bruised and swollen limb I made a gross assessment for fracture by attempting to bend it at the sore area, determining whether this caused inordinate pain or if I could feel the bone actually bend. If it did not, the patient did not get an Xray. In the US such would be malpractice and would result in missing a significant number of fractures. However, in the face of supply shortages in a disaster zone, such decisions seem to be the right thing to do for the benefit of the greatest number of people. This is a minor example of the kind of shortcuts and compromises made under duress that can result in harm to the individual patient even if intended for the greater good. When there is a negative outcome, as there certainly would be later in the weekend, these decisions to compromise are one of the greatest sources of self- doubt and second guessing. Did I really need to do that or not do that? If I had used more of our limited supply on that patient would she have survived? Since those questions cannot be answered, there is really not a remedy for the doubt.

There were so many fractures to reduce (put back into place) and large wounds to debride that it quickly became evident we lacked enough anesthesiologists. The solution was for the surgeons to administer our own in certain situations. I began carrying a drug called Ketamine in my shirt pocket. When injected it induces a dissociative mental state, allowing for the execution of significant surgery. If the correct amount is used, careful anesthesia monitoring is not essential, even if preferred. At this stage we were way past thinking about what was preferred.

Concrete is a brutal, unyielding weapon. The human body is no match for it. When concrete fragments it forms very heavy, jagged, irregular shrapnel. As it falls to the ground, any body part that it comes in contact with will suffer greatly. Many patients had not only fractured bones, but also lost large areas of skin and muscle. These large gaping wounds cannot be sutured closed. They must be carefully cleaned out and allowed to heal in with the assistance of frequent dressing changes to help ward off infection.

As I unwrapped many of these injuries that had been bandaged by first responders it was apparent that pieces of concrete, dirt, and gravel were still inside the wounds. Such will prevent them from healing and promote infection. Ketamine was administered while the patient lay on the ground or in their parents lap and a Betadine scrub brush was used to scour the wound. Gloved fingers were then used to probe deep into the wound to feel for connection to underlying broken bones (if they were lucky there was none) and to feel for the status of tendons, such as that to the biceps muscle. Sometimes deep in the wound more rocks were found, having been implanted by sheer force of impact. Children were lined up with arms or legs bending in non-anatomic directions. As long as the skin was not open in connection to the fracture they would be given Ketamine while sitting in their mother’s lap, the limb would be set straight, and a plaster cast would be applied. In one such case I spoke to the woman holding the child to give her instructions on how to care for the broken arm. She told me through the translator that she was not the mother but had simply brought the child there because the rest of the child’s family had been killed. Another 13-year-old boy fractured both bones in his forearm. I laid him on a table in the CT scan room to reduce his fracture since we ran out of room in the courtyard. The CT scanner was not being used because the room it was in was severely damaged. His father had been killed and his mother was in another hospital in serious condition. He lived almost two miles from this hospital and had walked there with both of his younger sisters who had fractures and wounds as well.

The courtyard was a very difficult place to be. While attending to one patient there would be five more waiting to catch your attention. Parents were desperate to have their child treated. Family members were begging you to come over to where their relative lay to check on their declining status. Patients returning from xray would thrust it into your hand hoping that they would be next. Going inside to do surgery became a reprieve from the constancy of the courtyard. It was exhausting.

By 1 a.m. Sunday morning the Xray tech and other hospital personnel who had stayed to help us wanted to go home for the night. Our supplies were already getting very low. We needed more IV fluids, plaster, and many more Gigli saws. We were going through our large supply of surgical gloves rapidly since we were dealing with so many infected patients. The gloves were for our protection as much as for theirs, since AIDS is endemic in Haiti. We also wanted tents and awnings. It would be disastrous if we were to encounter rain with all of our supplies exposed. Our team leader called back to our contact in Dallas via satellite phone and gave him a list. By 9 a.m. the next morning our planes were on their way from Dallas with three times the supplies we brought with us, initially. Those supplies were so essential and substantial that they even served the team that would come after us. Our contact in Dallas said that he put the tents on the plane at 9 a.m. that morning in Dallas and saw them on the 6 p.m. news in Haiti being put to use.

We awoke at 6 a.m. Sunday morning (although that suggests that we actually slept. The concrete was our bed for two nights so very little real sleep occurred) and began making rounds in the courtyard. We needed an organized plan for the day so that patients did not get overlooked. By the time we reviewed all of the patients present that still needed surgery we already had enough to keep every surgeon busy for the rest of our time in Haiti, not considering all of those who might continue to arrive. That included only the highest priority patients, which were of course amputations. I counted 12 patients with femur fractures who had been sitting or laying down now for five days, waiting to be fixed. Unfortunately, we did not have the rods and other hardware needed to fix a femur fracture, and since nearly all femur fractures are closed fractures (due to the thick muscle between the skin and bone) these patients were not urgent. We would not be fixing their fractures. That was very hard for them all to hear. I think the fact though that most of the patients going in for surgery so far had come out with amputations made them happy that they were not deemed to be critical. I made a schedule for the order of surgery on a piece of cardboard box and kept a list of all the femur fractures. Then we started to work.

By 10 a.m. it felt like the day had already lasted 24 hours. It was getting hot and patients were being moved around the courtyard by their families to get out of the sun. This made it difficult to stay with our surgery schedule because we could not pronounce their names very easily and were relying on where they were laying as an identifier. About that time the SAMU workers showed up. I talked to the leader who told me that the reason they left before dark the night before is because they felt it necessary to get to their camp before nightfall since they and other relief workers had been shot at prior. That was understandable. We worked out a system where the SAMU doctors would assess all new patients coming in and we would do surgery.

By midday, the number of new patients showing up was increasing dramatically. We were informed that the Port au Prince radio stations were announcing our presence and saying that all of the most seriously injured should go to Sacre de Couer. They showed up being pushed in wheel barrows or being carried on broken doors by their family. They had all manner of materials being used as splints for broken limbs. It was overwhelming. Around 2 p.m. structural engineers arrived to inspect the hospital. I toured it with them because I wanted to hear for myself whether it was safe to use the operating rooms. After a detailed inspection it was concluded that using the operating rooms was most likely safe but that the patients should be kept outside except to come in for surgery or xrays. This meant that in addition to having more space in which to operate that we also now had use of electro-cautery.

Throughout the day, if a patient was deemed to be urgent by the SAMU doctors they would come get one of us to see if we thought that it should be operated on ahead of those already on the list. One such patient walked into the compound unassisted. Her only injury was to her jaw but I could tell immediately that this was serious. She had severe redness and swelling over the entire right side of her neck and the redness extended down into the skin of her upper chest. It was obvious that she had developed a large abscess in the neck from a fracture of the jaw that exposed these tissues to the bacteria in the mouth. She did not seem to be having trouble breathing while sitting up or standing, but she could not lie back without feeling that her breathing was choking off. This is always a bad sign. I moved her to the top of the surgery list and as soon as a space was open inside the hospital I took her in.

I asked the anesthesiologist and one other surgeon to help me with her in the event that an emergency “slash” tracheotomy was needed to secure her airway. She was given a small dose of Ketamine and I opened her neck over the abscess. We removed at least 8 to 12 ounces of pus from her neck while she was sitting straight up on the gurney. She seemed to be doing ok with her airway at that point but I was still very concerned. If I didn’t do a tracheotomy she could obstruct at any time and die quickly. A tracheotomy in those conditions was not without its major issues also. First, I would have to put the tube through an infected part of her neck. If I did the procedure, purulent infection could drain down into her windpipe, causing other complications. A new tracheotomy requires frequent suctioning, which we did not have in the courtyard. If she could get by without one, it would avoid devoting a nurse to care just for her. Also, we did not have any actual tracheotomy tubes. If we decided to trach her we would have to manufacture a makeshift one out of other plastic tubing and find some way to secure it in her neck. We watched her for 10 minutes and she seemed to be stable. I made the decision to wait hoping that now that the infection was drained she would slowly improve. We left her there on oxygen, something which we were running out of, and I went upstairs to do more surgery.

The next surgery was a young woman who had half of her face ripped open. Her entire left lower eyelid was gone and there was significant tissue loss over her cheek. Her eyeball was red and irritated from the exposure it had endured now for five days. Concrete fragments were still embedded in her wound. We pieced what was left back together trying to create some protection for her eye. After this surgery I went down to check on the woman with the neck abscess and she was still breathing fairly well, although she had not woken much from her ketamine. It looked like she was going to make it.

By this time it seemed like the day had lasted a week. Twice I had gone down to eat an MRE only to set it down to address another problem. Everyone on the team had been working non-stop. The patients were fed to a great extent from our supply of food and bottled water. As night fell and our work continued under the outdoor lights I noticed that the SAMU were still there. I glanced at my watch and it was 8 p.m. Patients were still lined up at their initial assessment table. They were hanging with us tonight. Our anesthesiologist from up in one of the operating rooms radioed down by walkie-talkie that his room was about to come available and to ready the next patient for surgery. I looked around the courtyard to see which patients were there and noticed a young lady who I was surprised to see had not already been operated upon. She was in her 20s and had lain flat on her back on a mattress the entire time we were there. She had broken both lower legs. Splints had been placed and her legs wrapped at another hospital, after which she was told to come to Sacred Heart. She was not sent with any Xrays. I asked the mother if she remembered seeing the bone sticking out through the skin after her injury and she answered yes. We had yet to see what was under the plaster splints and bandages. It was her turn. I told her that we would take her upstairs, remove her bandages and splints, and see what needed to be done. Through a translator she begged us not to amputate her legs. She kept saying in French, “see, I can move my toes” which she had frequently heard the nurses and doctors ask other patients to do over the last two days. She hoped that this meant that her legs did not require amputation. I promised her that we would do everything possible to save her legs and would not amputate, unless it was absolutely unavoidable. She told us that she had an eight-month old baby at home and needed to be able to walk. Four of us lifted her off the ground onto the gurney and she screamed out in pain. I could see that the gauze and cast padding on the front of her shins were soaked through with infection. It was at this time that an ABC cameraman thrust his camera in my face and asked me what we were going to do. I said, “we are going to see if we can save her legs.” My statement was broadcast that night on the news in Dallas. Since arriving home I have had more people ask me about that particular patient than any other.

As we were putting her under anesthesia in one of the third floor operating rooms she repeated that she had an eight-month old baby. After she was asleep, we removed her bandages and splints revealing wide open wounds in the front of her shins where her fractured tibias had once protruded. When we moved her legs, a large amount of purulent fluid came out of the wounds. Both bones were broken in both legs and the legs below the fractured area were so infected that they looked as if they would fall off without any help from us. Amputation was unavoidable. It was a very sad moment but one that everybody on the team had faced over and over again that weekend with many patients. The worst part was afterwards when the sound of crying could be heard continuing into the night out in the courtyard as these patients awoke from anesthesia to find that they indeed had required amputation. What will their life in Haiti be like now? We had really only succeeded in helping them trade one problem for another, which although not as life-threatening, is no less daunting. The limit of our ability to relieve suffering was and continues to be very humbling. It is difficult to have a positive feeling about providing a service like that. It does not feel like much of a gift. I came downstairs after this surgery to find that my patient with the neck abscess had died.

While we were still together as a team in Haiti it was easier to keep telling each other and ourselves all of the right things: that we had done a great service for the people of Haiti, that someone had to do it, that if we had not come to Haiti these patients would have all died, that compromises had to be made, that these are tough decisions and someone had to make them. We had all dealt with individual patient tragedy on a smaller scale before under more controlled conditions in our medical practices. We are all professionals who have learned to do what we have been trained to do and move on. All of these reasonings are true and it is good to be reminded of them. But I think most of us could also sense that something different would be required of us personally in order to process these experiences than anything we have had to access in the past. Witnessing human suffering on this scale, in such overwhelming conditions, results in a large debt of “experience processing.” Psychologically, it is like being in a very difficult college chemistry or advanced calculus lecture in which the professor is teaching so fast that you do not have time to contemplate and understand the data. So all you can do is take voluminous notes and hope to later sit down and make sense of it all on your own.

Unfortunately, the psychological notes from experiences like Haiti are kept all in the mind, and the mind can at times be an inaccurate note taker. It seems that the notes even corrupt themselves and become more inaccurate with time, so that the good you initially thought you did becomes less good with time, and that which you think might have been better if done differently weighs more heavily as having ought to have been obvious. Retrospect is at times an excellent teacher but at others it is an unrelenting task master. Physicians speak sarcastically of the “retrospectoscope”, that tormenting instrument with which we look at the past and that makes the “correct” choices that we now think might have been better seem so apparent as to be retroactively obvious. This is the common burden of decision makers, but there is an analogy there for every human being in the way we reflect on our past.

After a few restless hours tossing on the concrete trying to sleep we awoke and packed our personal items for home. We were leaving all of our supplies for the surgical team from Florida that had arrived late the night before and who would be taking over the care of our patients. As we waited for our transportation to the airport (which was over an hour late) some remarkable things happened. I was standing in the courtyard next to the orthopedic surgeon when a young woman, who had undergone amputation of her right arm up to the shoulder by him the day before, walked up. She wore a long sleeve shirt with the right sleeve dangling empty. She looked at him very forlorn and said something in English but with such a strong Haitian accent that we could not understand what she had said. I could tell that he was afraid to ask her to repeat it, afraid of what she might have said, likely because after she awoke from the anesthesia for the amputation the day prior she had asked him over and over in anguish why he had cut off her arm. But he did reluctantly ask her to repeat herself and it was very clear the second time as she looked him straight in the eyes with all sincerity and said, “thank you.”

After that our favorite translator Gregory came over to me and said that the patient who had undergone the bilateral BKAs the night before wanted me to come over to her stretcher. She was still a little groggy and looked very sad, having cried during the night as many of our patients had done after surgery. She spoke to Gregory in French and he translated, “she wants to have a picture taken with you so that you will remember her.” This was profound to me. I think it was her way of saying that being validated as a person is so important, especially in the craziness of tragedy, being remembered among the masses, even though our paths crossed for only a very brief but significant time. Although we may be so limited in what we can do medically to reverse their suffering, we had come along side them as fellow human beings to share their burden, and that is Christ-like. That was our real gift to Haiti, to be with them in their suffering. I told Gregory to tell her that I would be praying for her and put my hand on her forehead. That is the only time all weekend I had touched one of our patients without wearing surgical gloves. I felt that it was important to do so. That is my favorite picture from Haiti.

We arrived home late Monday to a hero’s welcome. As we pulled off the runway at Love field we could see a crowd waving signs and American flags and there were several news camera crews there. I cannot speak for everyone on the team, but all of this seemed very incongruent with the way I was feeling. Certainly, it was very encouraging and a great deal more encouragement has been offered over the days since that time. But it is as if sharing in the enormity of human suffering in the way we did, and in some sense irrationally struggling with feeling impotent and even partly responsible for adding to it, had implanted something into our psyche that can’t be reasoned with. It has a high resistance to encouragement. It even argues back, “if you only knew all that I failed to do, then you would not be so complimentary.” It reminds me of Oskar Schindler struggling at the end with the additional good he felt he could have done and how those thoughts overwhelmed in his mind all the good he did do. It is a heavy weight that granted is somewhat irrational, but must be worked through nonetheless. The encouragement that helps the most is when I can tell the person “gets it” and the majority of those seem to be women. I think it is more intuitive for them than it is for us men. I have appreciated their perceptiveness a great deal. Your mom is the best of all. She and Emily have been good listeners.

The thing that has helped me the most since I returned is seeing several of the team members after we had been home a few days, hearing about the depressed feelings of many and the second guessing that some have been doing. It reassures me that it is part of the process for all of us. I am trying not to fight it too much anymore because I think the internal struggle is there for a good reason. God is in it. I think in some sense it is a way in which our hearts continue to share in the sufferings of the Haitians, even though we are no longer there. What we feel now is inextricably connected to our having gone to help them. It is a big part of our ongoing gift to Haiti that we continue to carry an emotional burden and be impacted by our experiences there. With that I know, God is well pleased. It has helped me to see our present emotional struggle as a good thing. But of course our experiences are a gift from the Haitians to us as well. There is a great deal more to say on that topic, but this is too long already. I love you all very much.

Dad

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