PTSD in Haiti

Posted in Uncategorized by Mike Stay on 2010 March 17

Lucas Williams writes:

[This was written as a response to close friend of mine who is a social worker in the greater Hartford area. She asked me if I had any anecdotes from Haiti that she could share at an upcoming conference on mental health and trauma. I tried to jot down just a few thoughts, but found that I couldn’t stop typing. This is a letter to a friend, not an essay or paper, but I want to share it. I hope that it can be of help to someone else, either to a returning aid worker, or someone who hasn’t been to Haiti yet wants to understand, to feel a little bit of what it is like.]

Dear *****

I’m in Miami right now, I landed last night. I’ve been in Haiti, working as an Emergency Department technician in a field hospital for almost 6 weeks, and it’s more than a little weird to be lying on a friends couch watching TV. I head back to Port-au-Prince on Saturday for another 5 weeks. I tried to write you a short reply about post-trauma and it turned into a novel. By the second paragraph I realized I was really writing it for me, but it just kept on going. I don’t know if this is going to be much help, but I’m sending it anyways, because each time I try and clean it up it just gets messier, and longer.

I think about post-traumatic stress disorder a lot. Before I left for Haiti I thought of it as a Western illness. It wasn’t that I thought it wasn’t real — I just believed that you had to be emotionally “fragile” before the trauma in order to be severely affected by it afterwards. We had a psychologist on the plane with us, and my first thought when I heard she was coming was “what the hell is she going to do?” Haiti is the poorest country in this hemisphere. These people are tough as nails, they won’t need a shrink, and besides, there’s no way she could be effective dealing with such a monstrous language barrier. Less than 48 hours from the time we landed I would feel very differently.

The first day I was in Haiti I didn’t really get to talk to too many people because I was doing procedures (stitching, draining abscesses, wound care, etc.). We set up a clinic in Leogane, but had to turn away at least 100 people because we ran out of time. Haiti has never been safe after dark, much less so now, and we had to return to our camp. The next day we decided to transport patients on a tour bus to our base in order to be able to work longer hours. The team dropped me off in the village, and my interpreter (a Haitian who jumped on our moving bus and said he wanted to help, despite my protests that I had no money to pay him) and I probably talked to over 400 people. We asked each person what was wrong, and if it was something we could treat or send to a field hospital the person got a little scrap of paper with a quick “rule out” diagnosis scrawled on it. For the uninitiated, a “Rule out” is a bit of medical etiquette. I’m not a doctor, so I don’t actually “diagnose” anything. Instead, I write a request to the attending physician, asking him to make sure he “rules out” a particular malady before pronouncing the patient healthy.

Each of our new patients then showed his or her paper to the bus driver (to prove that he was sick, and not coming along only in the hopes of finding food), and took a seat on the bus, which ferried them back to the doctors and nurses at our base camp by the airport.

This was in Cit di Solei (I think), one of the harder hit areas of Port-au-Prince, but by this point it was almost 3 weeks after the earthquake. I saw maybe 5 or 6 quake injuries but quite a lot of quake after-affects. The port was still closed, which meant little to no supplies got in, and there was rampant malnutrition, no sanitization, some TB, a lot of VD/UTIs, shingles, shingles, and more shingles…

But so… much… PTSD. And the funny thing is, we Americans have learned that if you have a medical malady like the Clap, well hey! There’s a pill for that! Just take the Doxycycline for 7 days or whatever, and wear a rubber next time. But if it’s psychiatric, that takes work. And time. And it usually isn’t 100% effective. So, as patients, we consciously or unconsciously hide the aspect of our discomfort that we think would make the doctor less apt to give a medical diagnosis. Maybe when we go in we stress physical symptoms. Maybe we look up other diseases that are more “real” than post-traumatic stress / depression / malaise. There’s shame involved, too, of course. Maybe I’m reading too much of my own personal experiences into this, but I believe we live in fear of the “All in your Head” diagnosis. Because it means we’re weak, because it means there isn’t any quick fix, and treatment for any psychiatric diagnosis is almost always long and arduous and painful.

So with Americans, you have to dance with the patient to get a real diagnosis that both you (as the provider) and the patient agree with. Once the patient accepts the condition, however, we have some amazing resources available in terms of doctors, therapies, medications, and support groups. It’s just about the opposite with Haitians. They haven’t ever learned a difference between an “it’s all in your head” disease like PTSD and a “real” disease like Congestive Heart Failure. They came up to me, one after another, saying things like “Ever since the earthquake…” I can’t sleep, or I have terrible dreams that won’t go away, or I have no energy, or I’m not myself. Headaches, headaches, headaches, so damn many headaches, all starting after the earthquake.

Somewhat early on while I was doing triage in the village, one woman came up and, instead of telling me what her illness was, began telling me about her family members who had died in the earthquake. Imagine that in a Western setting: it was equivalent to walking up to an Emergency room, and instead of giving her “symptoms” she just started telling the triage nurse “my son died after four days, we heard him tapping and yelling beneath the blocks, but we couldn’t pull him out. My two daughters and both my parents died instantly, but my husband died of infection three days ago…”

The triage nurse would probably be crying by this point, but in the end, she’d probably have the same reaction as I did… “I am terribly, terribly sorry, but what can I do? This is an Emergency Department. Are you sick?” And the woman would say yes, she had a headache, and she’d get a couple Tylenol and go home.

Which is to a large degree what I do every day at the field hospital. I’ve begged for social workers / therapists / whatever just to come and talk to these people, but none are available. So I give these patients Tylenol, or sometimes nothing at all, and send them home, and feel like a shitbag.

I’m confronted by the limits of Western medicine, and I’m also coming face to face with what I believe about my own mental health, its reality, and how it affects my self-image. When that woman came up to me I wanted to cry, but it wasn’t because her story was terrible. Honestly, I wasn’t affected by her story all that much. EVERYONE here had unspeakably terrible things happen.

What made me cry, later, when I was alone, was that I wanted to be able to heal her. Not me, but us, meaning my team. Diarrhea, sure, take the little pink pill. That cut looks infected, here’s a shot in the arm and toss back one of these big white pills twice a day. We can cast it, splint it, ex-fix it, drain it, debride it, etc…

But there was nothing I could give that woman that would heal her. And it tore me up. Probably because it’s really what tears me up about myself, and my own struggles with depression and mood swings. There’s no magic pill, no one-shot cure. It’s a long, hard road even for someone like myself, with all the resources in the world available to him.

So she was the first woman who got a slip of paper saying “Rule Out PTSD”. There were quite a few to follow. She got on the bus, right between the twelve year old with testicular torsion and the 70 year old with diarrhea.

I had a hard time with it. As much as I wanted to help her, I’m deeply programmed to make the psych/medical distinction. We had limited resources; I had to turn many people away whom I knew we couldn’t treat. I turned away 5 people with crippling cataracts. We couldn’t help them. They would go probably blind regardless of whether they got on the bus or not, so I chose to save the seats for people we could treat.

But it bothered me. Was I really letting a woman with an “all-in-your-head” diagnosis take up a seat on the bus, while 5 people go blind? I almost sent her away; I came really close. Ultimately, I couldn’t. I put her on the bus, thinking that maybe she could get some relief with a placebo pill. I didn’t like doing that. I felt like a snake-oil salesman. It felt cheap, and condescending.

She came back to camp with us, and when it came her turn, she sat down with the psychologist, who listened as she told her story through an interpreter. I couldn’t hear all of what was being said, but I could watch the body language. It was powerful. 20 minutes later as she stood up to leave, she was smiling. I have no way of knowing if this was temporary or if our presence made a huge difference, maybe allowed her to heal when otherwise she would have withered, I don’t know. I pray that she’s healing, and I believe now that our psychologist maybe saved more lives that night, if you measure lives in content and not length, than all of the other medical people put together.

But I have no way of knowing. And she did get some Tylenol.

Haitians don’t have big billboards telling them that this certain drug will cure their depression. They wouldn’t understand the word if you described it to them, in the same way that we could never understand something like anemia the way that they do. It’s like the old saw about Eskimo words for snow. But hundreds of thousands of Haitians DO understand that right now they don’t feel the same as they did before listening to their loved ones die under the rubble, hearing them tapping but being unable to do anything. They feel listless. Tired. Headaches, stomachaches, their arm hurts sometimes when they sleep on it funny. They can’t sleep, or they sleep too much. They have night terrors. I hear the same thing from patient after patient: “M’alad”, accompanied with the same vague hand wave encompassing their head to their genitals.

So they come to the hospitals by the truckload, hospitals already overloaded with recovering amputees, head wounds, paraplegics, quadriplegics, etc., not to mention the fantastic amount of car wrecks and gunshot wounds that occur each day. The whole thing is going down the tubes. We simply cannot keep up with the number of patients because we can’t cure them with a pill, not even Tylenol, and they just keep coming back.

It is my opinion that, by this point, 90% of medical relief missions are treating the symptoms over and over, and never excising the cancer. These people need to talk. They need their churches. They need their family, or in many cases, new families. Honestly, they desperately need therapists, social workers, and shrinks to come down here by the planeload and volunteer. I was originally very daunted by the language and cultural barrier. Creole is so simplified a language that in order to talk about intangible or complicated ideas, i.e. subjunctive type mood, you basically have to talk around it. It can take 10 sentences in Creole to say what we can say in one. But I’ve come to believe it really doesn’t matter. There’s a lot of power in telling your story, your whole story, to someone wearing a white labcoat or a stethoscope, or a cross and a collar. Sometimes it doesn’t even matter what they say in return, or even if they understand you. Unfortunately, this kind of interaction isn’t built into the Western system of medicine.

Because when the rains start, and we can’t tell the difference between someone with typhoid or malaria and someone with PTSD or depression without a 10 minute examination… This country is in serious trouble. I hate to say it, but I believe more people will die in Port-au-Prince during the rainy season than died during the earthquake. And all those deaths would have been preventable.

I wonder if I’m going to develop PTSD. I’ve seen many things that have shocked me. I’ve been even more shocked by what I knew I should be able to feel, things that I should be sobbing about, but I couldn’t feel anything. I still can’t feel a lot of it. The devastation here is so complete, these people are so utterly lost, you can’t feel it. You can’t wrap your head around it. There’s no reference point, because there is nothing to compare it to. It just is. Yesterday morning a kid (18ish) came into the E.R. with a gunshot wound to the head. It fractured his right parietal bone, and it was definitely a serious emergency, but he was just about as lucky as you can get in terms of actual damage done. He’s doing just fine right now, and he will come out of this with nothing physically wrong with him but a nasty looking scar. I was helping immobilize his head and neck for the first 30 minutes or so, trying to calm him down as well as keep him from moving around, and we talked quite a bit. He was pretty sure he was going to die, I couldn’t convince him otherwise. He was crying a lot, but he was grieving for Haiti, not himself. This is almost word for word:

“This is my country, Haiti, and I loved it. I loved it but I do not love it now. I am afraid. I do not want to live here. I cannot live here. I cannot live here. We have no hope to live here.”

He was certain that he was dying, but he grieved for his nation. Getting shot in the head was more the last straw in a long string of trauma than a single traumatic event. It was like the hopelessness just broke through and overwhelmed him.

There was a big controversy a while back because somebody high up in some NGO asked people to stop donating tents because it was creating complacency. People weren’t rebuilding, just living in tents, waiting for food drops, and coming into clinics or hospitals just about every day. He took a lot of flak for saying that, and was accused of not respecting the Haitian people, not respecting their determination, of treating them like children.

I agree with him. I think donating supplies like tents while ignoring long-term planning is killing this country’s already slim hope for recovery. And I sure as hell respect Haitians. But, with my life being what it is and what it was, I also understand and respect the power of depression, and apathy, and malaise, and hopelessness. Day after day I see beds in tent cities crawling with insects, sitting in puddles of water, because people just don’t bother to move them three feet away to a different spot inside their own tent, or to fix the roof, or to wash the sheets. This isn’t a question of resources; it’s depression. It’s apathy. And when the rains really start, those people will die. Terribly. And it will have been completely preventable. I respect the resilience of the Haitian people. I also understand how insidious grief turned to apathy can be. And I am afraid.

I used to joke that pretty much everyone who had worked at the hospital was going home with some form of PTSD. I meant it only half seriously, but I wonder. I had an anesthesiologist come and bum a cigarette off of me one night. His hands shook a little as he smoked it, and he told me about this patient he just had. She was a teenage girl, left leg BKA (Below Knee Amputee) and had an external fixation device on her broken right tibia. The orthopedist needed to adjust the ex-fix, which is done under sedation.

We usually use a drug called Ketamine for procedures like this. It’s a disassociative agent, not CNS depressant, so we can avoid all sorts of nasty airway and breathing complications that can develop with other drugs. Basically, under Ketamine, you’re not asleep, but you’re not really there either. It’s a great drug, but it does have one drawback. Every once in a while, patients go through something called post-Ketamine emergence phenomenon: intense, dysphoric hallucinations as the drug wears off.

The anesthesiologist told me that the procedure had gone fine, her ex-fix adjusted, and the patient was left in the ICU area of the tent for monitoring. He was heading over to his next case when the girl started screaming behind him. He turned around, and she was sitting bolt upright, pulling at the stump of her amputated left leg, screaming, crying: “Please, please, get the building off of my leg!”

It was like she was playacting. She was holding what was left of her amputated leg down with her thigh muscles, but pulling on it, tearing at it with her arms, trying to pull a leg that didn’t exist anymore out from underneath a hallucinated building. He ran over to sedate her before she damaged her broken right leg any further, and she stopped suddenly, looked right at him, right in his eyes, and quietly begged him to either take the building away, or let her die quickly.

He’s going to remember that for the rest of his life. I’m sure he will have nights where he wakes up seeing her face, hearing her plead with him to take the building away. But is that PTSD? How often do the nightmares have to occur before you can diagnose that? Does it matter? I don’t really know about any of that stuff. But I’ll remember his story as well, probably as long as I live, and I’ll remember how pale his face was as he told it.

Feeling things doesn’t seem as straightforward as it should right now. It seems like there are delays in processing, you feel things in spurts, in bits and pieces, and at random times. Sometimes you are filled with emotion at trivialities; many times you are shocked at your own cold-heartedness and lack of feeling. There are a few things I know will stay with me, but I don’t know yet whether I’ll be stronger because of them, or whether they will haunt me. Or maybe both, maybe neither.

There was the first birth I helped with: feeling the joy and gratitude of the grandmother as she celebrated and thanked God for the beauty of another life (mesi’Dey, mesi’Dey), contrasted with the crushing sadness of the mother so terribly depressed she wouldn’t take the child.

Another time I was sitting under a mango tree by camp after I had finished my shift for the night. I heard a call go out over the radio that we had a critical closed head injury coming in, but the E.R. was well enough staffed that I didn’t feel the need to go in. A few minutes later a second truck pulled up and the Haitian transporters started doing their usual shuffle. I met the first team as they carried a 50 year old Haitian male in, still and silent on his stretcher, but the transport people, none of whom spoke English, were all pointing back at the truck. I put on gloves and headed over to the pickup. In the darkness I saw a Haitian limping and pacing around the gate of the truck and sobbing, and the second team of transporters arguing, panicking. I knew one of the transport team, and he spoke a little English, and he saw me and said: “Doctor,” (I long since stopped trying to explain to them I wasn’t a doctor), “Doctor, help! His leg. We don’t know how to move him.”

I click my flashlight on, and there’s a man, a kid really, lying in the back of the truck. There isn’t much left of his leg between the knee and his hightop basketball sneakers. It looks like a drumstick after a dog has been gnawing at it. I see his face, pale with fear and blood loss. I hear 4 different voices around me jabbering in a language I don’t understand, save the “pie… pie…” that each conversation centers around. The kid’s friend who had been limping around the truck sees the leg by flashlight and starts crying again.

So I take the stretcher from one of the transport guys and show them where it needs to go. Between my guy who speaks a bit of English and my few words of Creole I tell them that I’ll handle the leg. I’ll take care of the leg, the rest of you just move him as you always do. They get it, and all of a sudden there isn’t any more panicking. It’s just action. “En.. De… Twa…” and it’s up, and I’m amazed at how little a leg can weigh when there’s no more flesh or blood in it. I feel crepidus under my hands, and almost stick my flashlight in my mouth before realizing that it’s covered in blood.

And then the kid is on the stretcher, and we’re heading over the dirt and gravel to the E.R. I call out a quick report to the attending, then it’s just training. A: check airway, it’s clear. B: check breathing, it’s steady. C: circulation. Find the bleeding and stop it. I cut the rest of his clothes off with trauma shears, then gauze, gauze, and more gauze. Check pressure, and so on. At this point it’s routine, despite being hit with 3 life threatening traumas within ten minutes while running a late night skeleton crew.

I found out later that the man I passed by on my way to the pickup truck was shot in the back by would-be carjackers as he tried to drive away. The bullet shattered a vertebra, paralyzing him instantly, and his car then slammed into a group of kids, crushing my patient’s leg and causing minor wounds to two of his friends. They all rode to our hospital in the bed of the same pickup truck, driven by a passing stranger.

I remember looking up a couple times while we were stabilizing those three. I remember glancing up and seeing one of the transport guys that helped me move the patient watching me. He gave me a slow nod. I believe that was his way of thanking me for knowing what to do and being able to do it; for not freezing up, and for helping them to do their job and save a Haitian life. I don’t think he would have believed me if I told him the truth: that I had never done or seen anything like that before. I had never responded, alone, to an injury that grave, in a situation where I was the medical authority. In a sense, it was my first blooding.

Later on, while I was taking his blood pressure the kid caught my eye and held it. He was lying in a strange place, naked and afraid, and I remember his unabashed gratitude when I grasped his shoulder and smiled at him.

I remember the translator, another kid named Limage, telling him he was going to have his leg amputated. Just a few hours ago he had to tell a diabetic that he was most likely going to have to have his leg amputated as well. I remember wondering what it was like for him, to tell people terrible things all day in words that aren’t really his own but come from a white man, from a different country, a different culture. I remember Limage walking away for a bit, wiping his eyes. Telling two people that they are going to become cripples in the span of a couple hours is a lot.

But we seriously kicked ass that night. Everyone did their job flawlessly; we got hit with three serious traumas within 10 minutes of each other while running a skeleton crew, and we saved three lives. Those patients got better first line medical care with us, in an E.R. with a dirt floor and only a couple of canisters of oxygen, than they would have gotten in many U.S. emergency rooms. I grasped the young kid’s hand as he left to be prepped for surgery. I’ll remember his gratitude. I saw nurses high-fiving each other as the last of them got carried out. We nailed it, and it felt good. It’s what we have trained for, it’s what we came here to do: to save lives that would have been lost if we hadn’t intervened. It might well have been the proudest moment of my life.

The next day I went back into the ICU to see how the patient I carried in was doing. It wasn’t good. He had lost a lot of blood, and was spiking an extremely high fever. I stared at the stump of his now amputated leg for a while, still oozing through his bandages. I remember not knowing how I felt, being unable to recognize and name the emotions swirling around, and thinking that that was weird. He was intubated, and not really conscious. That took some of the wind out of my sails.

Two days later I managed to check up on him again. He had gotten a shitload (medical jargon) of blood transfused, and the fever had broken. He was conscious, but still intubated. I didn’t expect him to remember me, but I think he did. And the look he gave me was so full of hatred and venom…

I’ll remember that look for the rest of my life probably, long after I forget his gnawed chicken bone of a leg, long after I forget the high fives and the pride and all that. I understand that there’s a grieving process, and that anger is a part of it. But I forget, and so does everyone here. We get bitter. We expect to have our praises sung and expect gratitude to overflow from all of Haiti unto us. We forget that they are grieving. They just had some very terrible things happen to them, and the world doesn’t revolve around us. It put things in perspective for me. I suppose most emergency medicine people get used to this, but I’m still relatively new. No matter how expert our care is, the trauma patients we see will always be in a worse place after we see them than they were when they woke up that day, before the traumatic event. I can be excited that we all did a damn good job, but still, this morning he was a happy, healthy kid. Tonight and for the rest of his life he is a cripple. And that means a lot more in Haiti than it does in many other parts of the world. It’s a stigma. It’s like being demoted a caste in India. It’s a big deal socially, far beyond the physical concerns of dealing with crutches or a wheelchair.

I wonder about him. To have survived the earthquake physically unscathed, but then lose your leg a month afterwards? Almost like cheating the Devil, just to have him tap you on the shoulder when you think you’re home free. I don’t know.

One last story: I worked for three days in a row to arrange transport for a spinal patient. She hadn’t been able to move her legs below the knee or urinate without a catheter since she was hit in the back by a collapsing wall in the quake, one month prior. Even though she spent the first two and a half weeks after the earthquake at a hospital, they didn’t have a working x-ray machine, and she had never had images taken. I finally drove out across town with her nephew to pick her up from her tent city. I remember the massive amount of insects in her bedding as we moved her, despite being surrounded by a loving, previously middle class family. Six of them lived in a ten foot square shelter made of tarps and sheets. Many of the neighbors came out to watch and help, and many thanked me. I cautioned the family not to get their hopes up, that we were limited in what we could do, and that her road would be most likely very long and difficult. I told them there was a very high possibility that we could do nothing at all. I remember seeing tears of sympathy well up in the eyes of the translator, a random man from the tent city, as I told him this. The patient just looked at me and smiled.

We strapped her to a cot in the bed of a pickup truck and rode alongside her. Her husband held cardboard to keep the sun off her face. She was admitted, and the x-rays looked good. The doctors that I talked to were hopeful, but we didn’t have the resources to operate. We were going to have to evac her to the U.S.S. Comfort or to the States, which takes time. I visited her and her husband, who hadn’t left her side, but I was busy. Eventually I forgot to keep stopping by.

Evidently the doctors did too. She checked herself out AMA a week later because no one had been able to give her updates on what was being done. Her husband needed to work, and wouldn’t leave his wife alone in a place as terrible and as depressing as a field hospital is. She didn’t know why she was there. If she was just going to sit in a bed all day, she might as well do it where her husband can work, and where she at least knows her neighbors, and can have all of her family around her, not just her husband.

I ran into them as they were getting into a borrowed truck. I didn’t know that they were leaving until that minute, and I had no idea what to do. I pleaded with them, and I explained through two different interpreters that if they left she would lose her spot in line to get surgery and would likely never walk again. But they were determined to leave. I went with her husband to get her some blankets from the storeroom. He spoke no English. We came back, and I stood there next to the door of his friend’s truck with tears streaming down my face, and I reached out and grasped his shoulder, trying to convey how sorry I was for my failure, for my hospitals failure, hell, for the failure of Western medicine. He looked back at me with embarrassed surprise. That’s it. It was the same kind of look you might give someone who farts really loudly next to you on the bus. There was no grief or dashed hope for his wife’s chances of walking again. I don’t know. I still don’t understand it. I don’t think he had the slightest idea why I was so upset. The cultural divide between us was a yawning chasm, utterly impassable.

As they drove away there was a brief moment where the feelings came in, not just about her, but about the whole country. About how fucking terrible the whole thing is. It was the only time so far that I broke down, cried uncontrollably. For a few moments I felt a small portion of the awfulness that was going on all around me. I felt what it would feel like to be lying in a bed wet with rain and your own urine that you can no longer feel or control, covered in insects, with no real home, no legs, no hope. I let just a little portion of that grief in, and I nearly lost it.

The very next day we had a spinal surgeon arrive with all the equipment necessary on a last minute flight, no real warning. I’m not making this up: the very next day. But, she had left the hospital; she was off the list. And she couldn’t get in. The surgeon did a marathon 48 hours, some insane number of surgeries, and was gone again.

And the weird thing is, I didn’t feel anything about that. Surgeon comes in the next day… I would have thought I would have been pissed, or whatever. But no, nothing. Go figure.

Anyways, I have to stop. I hope all this is helpful for you. I cried a lot writing this; I didn’t expect to. I didn’t realize how much I needed to get some of this out until I started writing. I love working in Emergency Medicine. I will be a doctor someday, and I’ll be doing this for the rest of my life. But Haiti… this is different. It’s hard, dealing with the pain and suffering on such an unimaginable scale. I guess I’ve been stuffing emotions down deep, and when they surface, they aren’t always what I expect. There is a saying in Alcoholics Anonymous about getting sober: “the good news is, you get to feel things again. The bad news is, you have to feel things again.” I can relate to that sentiment right now.

Lucas Williams has been an Emergency Medical Technician for two years, and has volunteered as an operator and first responder for a rural ambulance company in Virginia and more recently as an Emergency Department Technician at Children’s Hospital and Research Center Oakland. He flew to Port-au-Prince with the Wheelchair Foundation and DC3 Global Production Company on January 27th, and has been working in the Emergency Department of the University of Miami – Medishare Field Hospital since shortly thereafter. Lucas plans on attending medical school, and looks forward to becoming a doctor specializing in emergency medicine. He is from Oakland, California.

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