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By Sean Clancy, OTR/L, CHT
February 8, 2010 I left frozen Chicago for balmy Fond Paresien, Haiti. The University of Chicago graciously cosponsored a field rehabilitation hospital with a group of other academic institutions and Non-Governmental Organizations (NGO's). I was one of an eight member team. We were the second team sent by the University of Chicago Medical Center. The team consisted of physicians, surgeons, nurses, a pharmacist, a physical therapist and myself, an occupational therapist. We flew to Santo Domingo in the Dominican Republic and took a bus to Haiti. The field hospital is located in Fond Paresien, Haiti, just twenty minutes drive from the Dominican Republic border. It is located on the grounds of an active orphanage. The hospital was on half of the walled in 100 acre tract lent by Love A Child Ministries. The camp was roughly fifty acres of tents, outbuildings, and open space.
This is the view via helicopter of
the entire compound.
I knew Haiti was a poor country pre-earthquake and there was a stark contrast crossing the border from the Dominican Republic. It was an alien landscape. Dusty white scrubby bushes, void of trees, and displaced people huddled groups were scattered everywhere resting in whatever shade there was. The houses we drove by were unaffected by the earthquake but, seeing the quality of construction first-hand, it is a wonder that the homes lasted through hurricanes.
The condition of the people was on my mind the entire bus trip to the camp. Prior to leaving, I thought about trying to go to Port Au Prince to see the devastation of the buildings. Once at the Field Hospital, all I needed to see was the rehabilitation patients. I saw the devastation in their eyes and heard it in their stories. The therapy staff resolved to make a difference in the short time we had. My time was precious. I had only 2 weeks, until the 22nd of February, to make an impact. Being a Certified Hand Therapist, I set out to build an upper extremity caseload among the 250-plus patients in the camp. These people had not received much therapy, if any. They were in a myriad of physical conditions. Therapy systems were not in place. Medical records were poor to nonexistent. People would reach under their disheveled mattresses and drag out barely legible scratched x-rays. I would use the sun in an attempt to decipher them. Usually I could at least see the bone and sometimes the fracture line.
Example of houses along the
journey through Haiti.
Destroyed buildings in Port Au Prince.
Destroyed buildings in Port Au Prince.
Taken by Mike Sorenson UCMC
The condition of the people was on my mind the entire bus trip to the camp. Prior to leaving, I thought about trying to go to Port Au Prince to see the devastation of the buildings. Once at the Field Hospital, all I needed to see was the rehabilitation patients. I saw the devastation in their eyes and heard it in their stories. The therapy staff resolved to make a difference in the short time we had. My time was precious. I had only 2 weeks, until the 22nd of February, to make an impact. Being a Certified Hand Therapist, I set out to build an upper extremity caseload among the 250-plus patients in the camp. These people had not received much therapy, if any. They were in a myriad of physical conditions. Therapy systems were not in place. Medical records were poor to nonexistent. People would reach under their disheveled mattresses and drag out barely legible scratched x-rays. I would use the sun in an attempt to decipher them. Usually I could at least see the bone and sometimes the fracture line.
Row one of the Fond Paresien
Rehabilitation Hospital as I
saw it the first morning.
The conditions and mission were discouraging to say the least. However, the people were there with their wounds, surgical scars, and missing limbs waiting for us to get them off the ground. The direction I received was simple “rehabilitate these people” Our team and I went to work charging headlong into the camp extracting all the information we could. I logged people with humerus fractures, above/below elbow amputations, various crush injuries, brachial plexus injuries, and hand fractures. Although predictable, I was taken aback by the amount of untreated compartment syndromes. I listed the patients and the possible splinting needs for the patients. Some required treatment and some HEP’s until their casts were removed. Others required additional surgeries. For example, the female patient with a long cast I saw the first morning. I noticed how loose the cast was. It was most likely applied without follow-up or x-ray by means of closed reduction. Immediately something did not look right to me. I slid my hand inside the extra wide cast, to feel the proximal portion of a humeral midshaft fracture nonunion. I checked her for radial nerve palsy which was thankfully negative and referred her to our surgeon. She was scheduled for surgery. The surgeon used open reduction and external fixation via a plate and screws successfully to reduce the fracture non-union. I gave her a home program to decrease edema and maintain unaffected joints with good return.
These are examples of the heart
wrenching “surprises” we were
finding during our sweep
of the camp.
These are examples of the heart
wrenching “surprises” we were
finding during our sweep
of the camp.
My colleagues and I felt we needed more information to proceed with all these patients. In the clinic, as therapists, we strive to obtain surgical and radiological reports to strengthen our treatment and protect the patient. We want to know everything. In Haiti, everyone was a puzzle that must be figured out. Special thanks to Diane Davis, PT, Kris Alden, MD, and Mario Ferretti Filho, MD. These devoted team members began to solve the physical riddles of what was under the skin, the weight bearing status, and necessary procedures. There have been disasters prior to this. Most of these involved famine, infectious disease, and/or sanitation issues. This disaster had these components and more – an impending orthopedic disaster.
Diane Davis, PT with small portion of
her caseload in the shade.
When I volunteered to go to Haiti, I knew that I wanted to employ my skills as an Occupational Therapist and a CHT. However, in Haiti I was one of the few therapists for an excess of 260 people. This meant I had to do anything and everything to assist the people in their personal return to function. I acquired new skill sets as a result. I can make foot drop splints and AFO’s, crutch train in Creole, and safely carry people from helicopters. Splinting was difficult. I made the decision to attempt splints using One Cast™. This is used primarily for post surgical splinting. This was one of the few materials I could choose from. It consists of a strip of fiberglass surrounded by padding. This was relatively effective in the absence of thermoplastic. A detraction of this technique was that it was hot and it required splint checks everyday mostly driven by my paranoia of skin breakdown. The splint did hold up to the heat of the day and was quick to fabricate.
My choices of material.
The people of Haiti that I worked with were by far the most amazing patients I have ever had. In the fourteen days that I performed my duties, I never had a patient refuse therapy. The people were only getting Tylenol for pain. It was unprecedented and it was such an honor to know them. The first week we discharged over twenty patients between Diane and myself. The camp furnished supplies for the people and assisted in their return home or wherever their final destination was. Most of the discharge destinations were back to Port Au Prince with family and neighbors. They will pitch a tent in their yard and survive with their support system. In my opinion, this will hamper the rebuilding effort of the city but, conversely it may be their best opportunity to exist. Others chose to live at the Internally Displaced Persons Camp (IDP) a mile down the road.
In an intense routine of dawn to dusk therapy, we moved through hot tents and were called to triage. This made the days fly by. It was important to maintain hydration and get lunch, which was the only meal for the day. Time was ticking and we were receiving periodic assistance from American and foreign therapists. Special thanks go to the Ecuadorian, Brazilian, Argentinean, and Baton Rouge, Louisiana, therapists who were the reinforcements when we despaired at the daunting caseload of 260. Each group brought their own cultural twists on rehabilitation that were puzzling sometimes, but always welcome. Without these therapists some of the most important actions we took may have been unattainable. They assumed responsibility for some tent rows. They also cared for many of the ambulatory patients.
The rehabilitation staff from Argentina,
Diane, and I in the PACU
Diane and I moved people that haven’t budged since the earthquake. We had to change ambulation aides, identify foot drop, and be clinically diligent for missed injuries that could jeopardize their function. We learned quickly to work outside the tents, in the shade, and if giving out supplies to assist patients hiding the transaction. People would hound you if they saw you with a cot, lotion, or shoes. This was a regrettable situation that could make moving amongst the tents virtually impossible. Keep in mind that for the most part these people have nothing and anything of value is worth getting. I kept this premise in mind anytime I was approached by a completely healthy person seeking to sleep on a cot and not on the ground. Upon confrontation they always accepted "no" to these requests. I wish we could give everyone lotion, shoes, clothing, and cots. But the reality was that these supplies had to be to be rationed to those who could benefit most.
Two children posing for a picture for
my camera.
There were orthopedic surgeries performed at the camp in a Quonset hut that may have doubled as a sweat lodge. I mentioned that I might want to observe some surgery I quickly lost my desire after seeing the drenched surgeons after an hour in the hut. There was great communication between surgeons and therapists in Haiti. They verbalized how nice it was to have a therapist around. Many of the surgeons rejoiced at the fact that they had a CHT in camp. I was able to assist them with many patients. Changing Post-operative dressings under a tree is something I will never forget. Never in my career have I had to shoo away bugs during dressing changes. Most of the patients with hand involvement had MP collateral ligaments that were shortened by a month of poor positioning. It was frustrating to see so many things that we, as therapists, try so hard to prevent.
Inside the 100-plus degree
surgical hut.
The x-ray capability was limited to very small views. X- Rays could only allow a view totaling a third of a long bone. One patient received a plate for her midshaft humerus fracture and distal radius and ulna fractures. When the surgeon tested the range it was evident she had another radius and ulna fracture proximally. He fixed one of the bones and promptly ran out of plates. I fabricated a fracture brace out of some interesting material. I have never seen it before. It may have come from a foreign country. I found the material searching through the piled supplies in the orthopedic room. It was cooler and lighter than OneCast™. It was lightly padded but, provided the support and protection I required. I would have preferred thermoplastic. The splint was a success. Later, she was able to begin some gentle active assistive elbow range. We increased her digital AROM and maintained her shoulder ROM. Her wounds were closed and she was progressing nicely when I left.
Kris Alden, MD reading x-rays.
Many of the hand patients needed prompting to complete their HEP’s. Unpractical in the states, I monitored compliance by verbally motivating them as I walked by their tents. I achieved somewhat of a pavlovian response as they would start working as soon as they saw me coming. I am pleased to say that the people with amputations, fractures, and wounds progressed under my care. The frustration manifested itself in the untreated compartment syndromes. There is a poor prognosis in these patients. One patient, a young girl, unfortunately was pinned by her back and arm underneath her house. I found her with an adult prefab thermoplastic splint on and multiple open wounds over her forearm and hand. I am sure a medical professional thought they were helping her by applying the “right” splint. The prefabricated splint is a one size fits somebody. She wasn’t that person. The splint was applied pushing her into a claw hand deformity. Polar opposite to what I would have wanted. Despite her wounds, the wrong splint, and her hand deformity, she was a little pixie she was skipping and dancing around the camp. She was very difficult to find after lunch. She was my first target every morning. I serial splinted her. Finally with a lot of sweat (mine) and some tears (hers) she was in the right position. Her wounds closed and the only setback was her frolicking: she fell and skinned her dorsal proximal phalanxes. I am pleased to say she recovered and I was serenaded periodically with sounds of “therapy therapy” as she ran past. Unlike this little pixie, most hand patients were in slow progression. I saw everyone on my list daily.
Yoodmina after the sweat and tears.
It was worth it.
It was difficult to perform occupation based therapy in the manner I had been trained. The language barrier and amount of time allotted to each patient made narrowing focus difficult. I did what I could; inventing the materials I needed along the way. For example, there was a 20 y/o woman that I saw in triage. After the primary assessment I found that she had significant scarring of her extrinsic flexor tendons secondary to a full-thickness skin graft to her anterior forearm. She was protective of her arm and was not using it at all. She had collateral ligament tightness of digits 2-5. To my dismay, she had also ruptured her 3rd and 1st dorsal compartments rendering her thumb unable to extend. This made using the hand difficult to say the least. Occupationally she was unable to care for her little sister, dress herself, or complete grooming tasks with both hands. I fabricated a splint to maintain her thumb in midrange extension so that she could use a weak three point pinch during childcare and ADL tasks. The splint wasn’t pretty, but it was functional. Working through a translator she understood her HEP and splint use. Later I observed her tidying the tent using the splint.
Crossing over to the gait training side there was a 13 year old boy I was seeing that sustained a right brachial plexus injury. He hadn’t moved from supine since the earthquake and was in a spica cast for a LE fracture. I consulted the surgeon and he cut off the cast. It was like cutting Hans Solo out of the carbon in Empire Strikes Back because it was as though they had dipped the child in a vat of plaster 20 times. The cast was three inches thick in some areas. The child was returned to his tent shaking and shivering but free from his plaster prison. Thankfully, he had no skin breakdown. The next morning, wearing clothes for the first time since the earthquake, Diane and I stood him. He ambulated max X 2 like a Marinette for 10 feet. I will never forget him or the smile he had while working. It couldn’t have been easy and it couldn’t have felt good physically.
The days were filled with endless gait training, hand therapy, wound care, and calls to triage the newest ambulance, helicopter, or bus. There was always more to do. Everyday I found someone that had been missed. My caseload swelled. The nights were filled with laundry, bathing, brief relaxation, and sleep. I was buzzed awake every morning around 0430hrs by mosquitoes followed by cows, dogs, and of course the stereotypical roosters. I woke up, dressed, applied deet, and 50 SPF sunscreen. I drank a liter of water while eating some granola on the way to the morning meeting. I lost 12 pounds over these two weeks. I must be leading a sedentary lifestyle because my stamina improved enough to play soccer with the Ecuadorians and Haitians the second week. I was terrible yet found enough skill to score some goals for the Ecuadorian team. At night, I learned to Salsa and Merengue. Fortunately, I am an Occupational Therapist and I don't have to pay the bills by dancing.
I cannot say enough of the professionals I worked with. They are the best of the best. These are people who could adapt the minimal things on hand to intervene with the highest standards of care. These medical professionals are a reflection of the people who pick up the pieces after disasters restoring a quality of life to people who had no chance otherwise. They are selfless, brilliant, and a credit to their chosen professions. It was an honor to serve with them. I am confident that the team I was a part of made life better for the people we contacted.
The Haitian people were resilient and receptive to a culturally different perspective regarding therapeutic intervention. They have a sense of community that is not present in most of the United States. They are visual learners. They playfully ruined my elementary French. Until I spoke with more of a Creole pronunciation, they would delay completion of tasks. In such misery, the Haitians were able to smile. It was a great honor to serve the Haitian people through my time there. I will not forget them. Although, I can’t be certain what will come of the country as a whole. Hopefully, there are people we rehabilitated who could change Haiti that may never have risen from the ground.
Little girl who greeted me everyday
with a smile on my way to
change her grandmother’s dressings.
Picture of Jean Paul and me after
his weight bearing
status was determined
Sean Clancy is an Occupational Therapist. A graduate of Eastern Michigan University in 2001 he has worked in many occupational therapy settings. He completed the HealthSouth Hand Therapy Fellowship Houston; Texas in 2002. He is a Certified Hand Therapist since 2008. Sean has spoke numerous times at regional and national level conferences. Most recently, he spoke on the Flexor Tendon Rehabilitation portion of a break-out session at the combined ASSH/ASHT meeting in San Francisco. He is active in the American Society of Hand Therapists and is a member of the Practice and Reimbursement Committee. He currently works at the University of Chicago Medical Center where he is the program coordinator for the Hand Therapy Department and a senior faculty member of the medical centers Physical Therapy Orthopedic Residency Program. He can be reached at sean.clancy@uchospitals.edu.
Volunteer opportunities are now being accepted for 2010. For further information on HVO, please visit our Web site at www.hvousa.org.
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