Wednesday, February 10, 2010

Correspondence from Leila Hepp, RN, SNP

Driving into Port-au-Prince, Haiti... Large cracks snake way through highway divide. Ongoing and aftercare issues, discharge follow-up, wound healing.. 85-year-old woman, I was about to place a foley catheter, administer colace and start an IV... She had a below the knee amputation yesterday and had been complaining of abdominal pain this AM. She was moaning, I asked an interpreter to tell me what she was saying -- "I can't breathe."

We sat her up and helped her spit in a cup. I tried to give her water and played soothing radio music on the bed while patting her back. Her daughter got behind her on the bed and held her.

Another nurse came in and I went outside to get some supplies and was met by another woman seeking care. She had massive oozing erosion on her left breast that was grossly enlarged.

This is breast cancer, untreated after months and months... I went back into the room to see how the woman who couldn't breath well was doing. They were trying to put in an IV. Looking down I realized she wasn't short of breath anymore.

The woman had died in her daughter's arms.

I took out my camera; it had also died, the screen broken in a fall, dark without an image yet I tried to take photos of the scene, and prayed my camera would be healed and that the woman would find rest. She was so old and had an infected amputation. She was in pain, yet not anymore. But my camera was dead and she was dead.

It was important that I was in the room to sit her up, or she might have died alone on the mat instead of with her daughter.

I took the breast cancer woman to the clinic. They were doing more amputations and didn't think she was urgent, but they put her on the schedule for later.

Someone ran to get me, "the woman's baby has come, but it is dead."

I rushed to the clinic, sitting on the back of a pickup truck, driving by green fields and mountains, my legs dangling from the truck bed with the song from “MASH” playing in my mind.

The mother was alone in her bed, shaking but not hemorrhaging. The baby was in a bowl under her bed.

1/22/10 - baby died premature.

5 months gestation, induced, no fetal HR on doppler, no US available. We dressed the baby and showed it to its mother. It looked like a little alien. We swaddled the boy and gave him a little hat, arranging his body as best as we could.

I took photos with a blank camera, and came to my room and cried. The camera, its dead screen was black and blank, but it held the images, they appeared on my computer and it could still take photos. My camera was healed but hidden.

So are the dead.

A pastor came and blessed the baby. Soon after another baby was on the way from another mother, I rode the truck to the hospital.

The baby was crowning and then came quickly. I taught the new mother to breast-feed. She is alone and homeless now. Her husband is dead, he died in the house when it fell and crumbed during the earthquake on top of him.


I'm sensitive to my team member, this girl, a nurse, who is bossy. Because I'm tired, and she is going going going, 16 hour shifts, 19 hours a day, or 20, sleep 6 hours, or only 5...

I'm tired, and I need to process this time...

At night I pull used tubes of morphine out of my pockets.

Outside, in the day, I'm happy, I love the nature. Rode on the bike with one of the interpreter guys. Many of the Haiti guys talk to me, and it is pleasant, their company. When the patients are discharged, a day after amputation, we ride in the truck, up the road.

Our “ambulance.”

I play my radio and feel God. But I am also tired, yet cannot sleep at night. God is with me and blessing me. People in tragedy are also near to God. And death and amputation are only temporary. We endure. The image endures. The circle of life. In one day, the oldest died, the youngest died, and a baby was born.

I just felt a tremor. They come and go. We were in the clinic, and suddenly a rush for the door. The crowd of people, sudden mass panic, one's heart is set pounding. Fear. In the city some people broke their legs because during an aftershock they thought the building was going to fall on them, so they jumped out of the window…

But we can still play with the village kids. We can look with love into someone's eyes, with whom we cannot speak. The language is the same in the eyes.

Amen.


I ran downstairs and scrubbed in for the breast cancer removal - mastectomy... there were maggots in the boob! It closed up really nicely and I don't think the cancer has impregnated the chest wall. They handed me the dead maggot filled tissue and I threw it in the trash.

In the operating room, we amputate and often don't have even a container for the body parts. So they have ended up in the garbage bin. We thought the cleaning crew was taking out the body parts and burning them in a ditch. Well, turns out the parts (legs, arms, fingers, etc.) went out with the trash and local dogs found them and dragged them into the village!

To remedy the situation we created a body parts only box.

To perform these surgeries, we only had C-section OR kits that included the necessary drapes along with a baby blanket, baby hat and a newborn bulb syringe...

First night in the OR – no tools to perform an above the knee amputation, through femur... after rummaging in the shed men appeared with various saws, “will these do?”

Removing gangrene toes...

Today we did crutch training, some of the immobile are now mobile!


It's been days, days later. And I am frozen, stuck in the non-feeling remembering. The night, when was it? Long ago, or one day only, I can't recall, it blends together but stretches out into an indefinable time, a length of endlessness that, today, is at an end.

…I knew they were coming; we all did so we waited. Rumors of 34 patients from the Dominican Republic boarder, with nowhere to go, open fractures, festering wounds. Coming here, in the night. 2 AM. My brain woke-up, but my body was paralyzed in sleep. Consciousness lucid while muscle and nerves strove to rest.

The rumbling trucks came, the patients -- some wounds infected while other wounds hidden, broken pelvic fractures that do not show through skin.

And then there she was, sitting in the truck, the girl we found in the village, the girl I saw hobble up to our clinic table, barely walking, arms supported by neighbors -- heavy leg edema, full of fluid and skin tight, shiny, elephant legs.

Belly swollen, as with child at full term, but this 15-year-old girl is not pregnant. She was a balloon ready to burst and unable to lie on her back. “I can't breath” her belly pressing on her diaphragm. Short of breath, labored but easier with less fluid on board, no baby; But we felt a mass and it make me jump, startled. Something was there in her belly we don't have an Ultra Sound. Tumor? Grossly enlarged and distorted liver? Fecal impacted intestines?

Urine, I didn't know urine in the eye could transmit HIV I was told... AIDS, end stage liver disease, nephrotic syndrome? We tossed around differentials and while liquid waste began to flow out of her body. I dreamed that night in my short two hours of sleep about a feminine leech, it sucked my cheek frantically, I couldn't get away...

Others have been taken to the hospital ships. The boy with a part of the dura mater visible above his eye, wound open to brain. He was off to sea along with the pelvic fracture patients - the thing I am most disturbed by - the fractured pelvis; it completely immobilizes and we can't fix it or see its damage. Will the edematous girl go? Will she live? I'll probably never know.


We also ran a primary care clinic. Here I am with patients, we'd each see about fifty in one day: There is a woman with hepatitis, notice her yellow sclera, and a wounded child.

These things were after the storm subsided. It beginning was like being in frantic weather, and when it clears we feel the warm air and are happy. But then we know the mud and the mud covers us.

They never bothered me, the amputations; the pus amid squirts of blood. Not until she was dying, somulent. Another patient of ours, of many days. Vacant eyes - no communication except to moan with pain - then it happened. The shift.

I felt it, the change. When this reality begins to fade and another brighter reality surfaces. I have felt it when a person passes into death. I sense movement away from the body. And I was feeling it with her, the women with the above the knee amputation. One of the first amputations I assisted with.

She was septic; we brought her to the operating room. Her flesh repelled me, and only in hindsight I now know why, it was because she was almost completely dead and this was dead flesh. Death in flesh. We cleaned her up, irrigated the wound, “the solution to pollution is dilution.” But she died within the hour...

And I smelled a body, near a collapsed classroom at the village. It was the stench of rotting. Where did it come from?

So they sleep under the stars. In tents made of sheets to avoid falling cement from poorly built sand walls.

Castles made of sand...

Three floors pancaked into one.

In two months the rain will come... and with it infection, gangrene, decay, flies. It will drench tent cities. The solution to pollution is dilution, the dilution of pollution, the water and mud, the ground is never diluted; the sea is polluted. The sewage, no sewer. Pigs in gutters in trash. Don't go inside, the buildings of the dead...


We were welcomed back to the USA by Air Force men, all strong; ushered into cleanliness and food to Miami, supplied with clean diapers and cloths for children.

Whisked away with a USA passport - Disaster evacuation.

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