1020A Phoner Haiti 1 - 27 Listen on Posterous

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I received the following from Anil on Wednesday, January 27, 2010 at 20:58 ET. I've also made minor spelling and grammar corrections and have tried my best to fill in missing words. I've added hyperlinks where I thought they might help.

From: Anil S. Menon

Sent at 20:48 ET/Haiti Time

US Armed Forces in Haiti

As a member of the Armed Service, I am very proud of our humanitarian effort. Not only did I arrive in Haiti with the permission of my commanders at the 173rd Fighter Wing, but I have also worked with the 82nd Airborne and the U.S. Navy to move 50 patients today to receive definitive treatment. These complicated surgeries could be performed only on the USNS Comfort, and we expect another 50 tomorrow. I got into this business to help people, and thanks to this support we have the capacity to help to the fullest.

--

Anil Menon, MD is a clinical instructor at Stanford School of Medicine focused on surgery and emergency medicine. His research interests are Aerospace Medicine, Emergency Medicine, and Wilderness Medicine. He graduated from Stanford Med in 2006, received a degree in mechanical engineering in 2003 and became a full ER doctor in 2009. He has practiced medicin in combat in Afghanistan and will be practicing aerospace medicine next year at NASA. Menon is a flight surgeon assigned to the 173rd Fighter Wing (F-15s) of the Oregon Air National Guard, and he's part of a team sent to Haiti by Stanford.

This entire series is chronicled under the HaitiDrDispatch tag

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The top five rules in a disaster.

1) Smile and Care 

"It means more than any treatment you might render." [Stanford Hospital Palliative Care Nurse] Garrett Chan told me this, and I am believing it to be true. The more I do, the more questions I get asked, the more directions I get dragged in, the more important it seems to be there when I'm there.  The people that smile the most, that I will remember, and the situation I will always remember positively was my very first patient.

My first patient ever

He was 16, and he had a swollen leg with obvious cellulitis. I met him on day 1, and his 1st through 3rd toes were completely necrotic and hanging off his foot like autumn leaves. I was overwhelmed that day, but I couldn't walk away, even though he was supposed to be someone else's responsibility (by our triage system). Everyday, I stopped, smiled, changed his dressing, and eventually got him to see Dr. Pier [Boutin], who removed those toes, and now see him everyday in the post-op area. Someone said he will probably win an Olympic race. I wouldn't be surprised.

2) Be flexible - Every day is a new day.

On the first day, I was a mostly an intern, seeing a few patients, referring them to the surgeons, and sweating to see everyone that walked through the door. Some of the time I might have been a tech, a nurse, a transporter, or a scribe. On the second day I replaced Bob Norris to run an area, know all the patients, and triage the patients for the surgeons.

On the third day, I spent much of my time taking Bob's job that he just vacated: running the triage pre-op area and doing more administrative work, meeting with 

surgeons so they don't step on each others [toes]. A few doctors came, wanted to help, but really only wanted a few specific tasks, things that they found fulfilling (reductions, no nights, of course the minority). A disaster veteran, Dr. Tascone who has made 25 trips to 

Africa as part of a reconstruction process, took the night watch. 

This leads me to the third point.

3) Keep the broader goal in mind

You came to help in any way, and with that, all other problems are solved.

4) Work until you drop

There was a plastic surgeon by the name of Silver who could barely walk by the end of the day. He was older, but he maximized his effort, and I figured I could do the same.

5) Take care of yourself

I think you can recover physically like Dr. Silver, but it's more difficult to be present emotionally day after day. That's why I write, and that's why I appreciate all the support I have received.

[Note: the second part of this email will be published in a separate post]

--

Anil Menon, MD is a clinical instructor at Stanford School of Medicine focused on surgery and emergency medicine. His research interests are Aerospace Medicine, Emergency Medicine, and Wilderness Medicine. He graduated from Stanford Med in 2006, received a degree in mechanical engineering in 2003 and became a full ER doctor in 2009. He has practiced medicin in combat in Afghanistan and will be practicing aerospace medicine next year at NASA. Menon is a flight surgeon assigned to the 173rd Fighter Wing (F-15s) of the Oregon Air National Guard, and he's part of a team sent to Haiti by Stanford.

This entire series is chronicled under the HaitiDrDispatch tag

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I received the following email from Anil on Saturday, January 23, 2010 at 03:48 (am). He wrote it at the end of his sixth full day in Haiti. I've made minor spelling and grammar corrections and have tried my best to fill in missing words. I've added hyperlinks where I thought they might help.

Some good friends depart
(Note: Anil is in the very center of this group)

The Anatomy Of A Day

Each day brings a new challenge and a completely different job description, and it can sometimes be a blur. If I remembered, I took a moment to scribble down what I was doing. Maybe it would help me make more sense of everything or improve my process. 

For the past few days we have been waking up at 0600 and drinking coffee for breakfast. Chris Sloan, an astronaut candidate and [emergency medicine] doctor from UCSD, brought one of those portable hypoxia monitors. My heart rate had gone from a resting heart rate of 50 to 85. Everyone was about the same, with all of us hovering in the 90s. That could only be from a lack of water intake. They say you shouldn't eat protein if you are in a survival situation when you have less than a pint of water per day because it requires water in order to be utilized. I wonder if that is true if your urine output is near zero. 

It didn't matter because none of us seemed to have time to eat anyways. Most people managed a Powerbar. That isn't surprising for people who work in the [emergency department] unless you are talking about [Stanford Clinical Associate Professor of Surgery] Ed Klofas. 

Around 0700 everyone crams into the bus and makes the 3 minute trip to the hospital. We start at the supply room and make a box of injectable antibiotics like ceftriaxone and ceftaz and grab a few of the more exotic ones if they are visible. 

The most concerning thing is wondering who made it through the night, where they might be laying today, and what new challenges the day would bring.

Anil S Menon

Sent from iPhone

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For the first time, we have pictures! Anil sent the following images at approximately midnight, as in 12:05am ET/Haiti Time

These images are also available as a large slideshow on Flickr.

Rounding with Bob and Jen
As in Robert aka Bob Norris, chief of the Emergency Medicine Division at Stanford School of Medicine and Jen, one of the nurses also from Stanford

Visiting
Looks like a little girl visiting a family member or friend.

 

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These posts from Anil have been the most compelling reports from Haiti that I've read or heard on any media. They've made the whole Haiti situation so real to me and his humanity really shines through. Thanks to him for taking the time to get the word out, and to you for reposting.

Thanks a lot, I'm so so tired, this really helps.

I received the following email from Anil last night at 11:07pm ET/Haiti Time. I've made minor spelling and grammar corrections and have tried my best to fill in missing words using brackets and add some light styling for readability.

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I woke up to a text about an aftershock

From Anil at 6:21am

Wow aftershock hit at 0600, and we all scrambled out of the hotel, tired and delirious. I don't think it was big but the chandeliers are still shaking. A reporter freaked out and just jumped out of his window. He has an ankle fracture now.

Anil Menon, MD is a clinical instructor at Stanford School of Medicine focused on surgery and emergency medicine. His research interests are Aerospace Medicine, Emergency Medicine, and Wilderness Medicine. He graduated from Stanford Med in 2006, received a degree in mechanical engineering in 2003 and became a full ER doctor in 2009. He has practiced medicin in combat in Afghanistan and will be practicing aerospace medicine next year at NASA. Menon is a flight surgeon assigned to the 173rd Fighter Wing (F-15s) of the Oregon Air National Guard, and he's part of a team sent to Haiti by Stanford.

This entire series is chronicled under the HaitiDrDispatch tag

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I received the following as a series of 17 text messages from Anil. I've made minor spelling and grammar corrections and have tried my best to fill in missing words using brackets and add some light styling for readability. I've also added a few links to the medical terms and any news events referenced. 

Ohh you got me started, today was a blur because we were pushing so hard. There was a 70 year old woman, pulled out of the rubble today. She was thin, talking to us but quite stoic like everyone else with a tibia and fibula fracture. 

There was also a 14 year old girl pulled out yesterday. The family was sitting for dinner--mom dad and three children--when the ceiling caved in, and they spent all this time finding this girl (the other two died). The dad brought her in because she had pain in her right leg and now couldn't move it. 

The leg was tense, swollen, painful, and appeared to be a fracture which transformed into a compartment syndrome. Heather, our nurse, and I attempted an IV and couldn't get one because she had no water in her system. There was one vein in her neck I could see but her skin was so tough for a young girl, because of dehydration, that I thought I would fail, but with a little luck, I saw a flash of blood and we started giving her fluids. Given the OR precedence for infected, open fractures, I didn't expect her to get an operation and feared we might lose her leg. 

A Belgian group of nephrologists brought some dialysis machines. Soft spoken and concerned, they offered their service today, and they had the ability to check blood levels of electrolytes with an i-Stat machine. I wasn't sure about the utility in our acute ward with the complexity of doing dialysis. 

We started with this girl and to our surprise her creatinine was 9 and potassium was 7 [baratunde note: i'm not a doctor, but some quick web research reveals these numbers are astoundingly high] and the nephrologist got a little nervous. He wanted to take her, so I started a central line in her right groin for dialysis, her father watched with hopefulness and trust that I couldn't believe because my interpreter, who was helping out, couldn't explain things perfectly. I save my morphine supply for the little girls so I think she was okay (if I didn't have that morphine it would be too painful for me). They took her to dialysis, and she came back looking a lot better. A lot better. 

It is worth saying that the next 3 creatinines we checked were 14, 9, and 11. The nephrologists were overwhelmed and didn't even want to check them in that older woman that was rescued because they were full. 

A woman told me that "no matter what you Americans did in the past, you were here when we needed you, and I love you". It was good to hear that. The 82nd airborne arrived today and have made it a lot easier for the hospital to function. I also think we'll have food and water for patients. Thanks for all of that.

Anil Menon, MD is a clinical instructor at Stanford School of Medicine focused on surgery and emergency medicine. His research interests are Aerospace Medicine, Emergency Medicine, and Wilderness Medicine. He graduated from Stanford Med in 2006, received a degree in mechanical engineering in 2003 and became a full ER doctor in 2009. He has practiced medicin in combat in Afghanistan and will be practicing aerospace medicine next year at NASA. Menon is a flight surgeon assigned to the 173rd Fighter Wing (F-15s) of the Oregon Air National Guard, and he's part of a team sent to Haiti by Stanford.

This entire series is chronicled under the HaitiDrDispatch tag

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I received the following as a series of 30 text messages from Anil. I've made minor spelling and grammar corrections and have tried my best to fill in missing words using brackets and add some light styling for readability. I've also added a few links to the medical terms and locations. 

After yesterday's heart-wrenching update many of you asked what could be done. I passed that question on to Anil, and he answers as best he can in his first text back.

Anil Menon

(7:24pm)

I think people in the U.S. can help by keeping this on their conscience beyond the immediate suffering. Imagine the post earthquake devastation?

(10:31pm)

There is a beautiful luxury hotel called the Villa Creole where the likes of Sanjay Gupta and Anderson Cooper and their respective entourages are staying. The owner took pity on us and provided a floor of her conference hall for some of our group to stay in. The other half is staying on the floor of an abandoned building, in tents. The end outcome of this is that I got to see the huge machine of 100s of people that bring us live feeds from the epicenter, and I wondered what I can add other than write texts as self-therapy. They serve a valuable role of generating help and awareness but also have a specific bias. I feel guilty even camping in this place, but I'm glad for the opportunity to take a deep breath before going at it the next day. 

Today was more hopeful because more help came and more people were helped but also brought with it more complications. Our ER was supplemented by a few additional doctors. Tracy was exceptional. She started reducing fractures from the moment she hit the door, and together we couldn't get a line but put ketamine directly into [the patient's] femoral vein and quickly reduced her hip dislocation. The scary thing is that when our pain medications ran low we had to continue to change wounds and reduce fractures to provide care, and it wasn't easy to induce more pain. More pain meds are on the way. 

The vast majority of injuries are delayed treatment of huge lacerations and fractures. Lacerations can't be closed after this time period because they will trap infections and become worse, so you leave them open, keep them clean, cut away dead tissue, and bandage then up. One cute 8 year old who still had barrettes smacked me when when I began changing her bandages. She was seriously upset. It was funny at first, then tough as I saw the big lime sized chunks of tissue missing on both legs. Luckily, unlike many others, they were not infected, so I cleaned them with betadine, and packed them and bandaged them up. I can't say she smiled afterwards, but she didn't cry, and she looked at me quietly, and for a moment things were okay. 

When a femur or tibia fracture comes in, we check to see if it is open and has penetrated the skin or is closed. The open ones go to the [operating room], they are usually infected, and usually lead to amputations. That means [people] who would have just broken their legs and be back on track in a few months, are losing their legs. The closed fractures, no matter how bad don't have priority for the OR and can't be x-rayed, so I put them into place as best as I can estimate, make a splint and give them Tylenol and send them home. I know home doesn't exist so i feel bad, but there are so many people to see and very limited post operative space. That said, new buildings open up.

Bill Clinton stopped by (but our [Emergency Dept.] director Bob Norris was too busy to look up. I also have a feeling he voted for Bush). A crew of 30 Haitian doctors from New York showed up, and a few Swiss pediatricians. The army also offered to helicopter out a few complicated patients. It seemed like things were happening, but at the same time with more doctors, more bodies, and no authority, the early organization of [the International Medical Corps] has been difficult to maintain. One ER physician was working with us and then told me he didn't know how to do a splint which made me wonder if he was a physician. Most everyone is very good, and even this guy was very nice. 

Where do they go? What space do they work in? How do we communicate? How do we play nice? Hopefully these questions will be continually solved as it grows bigger. If we keep the big picture in mind, remove any ego, and keep maximizing care it should improve.

(10:47pm)

I saw Chelsea Clinton today and said, "Yo chelsea, we got the Stanford crew here." Bill somehow could get. A few people to the carrier. Not sure if it was a photo op or something.

Anil Menon, MD is a clinical instructor at Stanford School of Medicine focused on surgery and emergency medicine. His research interests are Aerospace Medicine, Emergency Medicine, and Wilderness Medicine. He graduated from Stanford Med in 2006, received a degree in mechanical engineering in 2003 and became a full ER doctor in 2009. He has practiced medicin in combat in Afghanistan and will be practicing aerospace medicine next year at NASA. Menon is a flight surgeon assigned to the 173rd Fighter Wing (F-15s) of the Oregon Air National Guard, and he's part of a team sent to Haiti by Stanford.

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I received the following as a series of 13 text messages from Anil sent at 10:21pm ET/Haiti time. I've made minor spelling and grammar corrections and have tried my best to fill in missing words using brackets and add some light styling for readability. I've also added a few links to the medical terms. Warning: this is hard to read

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