I just returned from a medical relief mission to the Philippines. It is difficult to describe the experience since I am still processing all of the events that took place but I wanted to put something into words while the individual events are clear in my mind.
When we landed in Ormok, the Filippino army helped us load our cargo into two trucks and two ambulances and we set off for the city. After registering with the local health department we stopped at the hospital to meet the director and to tour the facility.
Ormok is located about 120km from Tacloban which was where the typhoon did the most damage to both human life and property. It was hard to imagine that Ormok had escaped the worst judging by the condition of the hospital. Entire wards on the first floor had lost outer walls, the ceiling, or both and the entire second floor was unusable because the roof was destroyed. As a result, patients were lined up on military stretchers in the hallway, in offices, virtually any place where someone could lie down and in some places where it seemed they could not. Since virtually all of the patients had lost their homes, entire families were camped out in a 24hr vigil around their loved one's bed, oftentimes sharing the stretcher with 2 or 3 people. I was overwhelmed on my way to the director's office. I had no idea how I could begin to help even a handful of the people that I saw lying on those stretchers.
During our meeting with the director, we introduced ourselves and our specialties. When I told her that I was an intensive care unit doctor she very politely apologized that they had no ICU at ODH. Violet would probably have recognized this moment as foreshadowing of the events to come in the next 48hrs. I took it to mean that I would be helping out in the outpatient clinic tent with the volunteers from Mercy Malaysia, a wonderful relief group that was manning that section of the hospital.
After deciding on a plan for the following day we loaded onto the military trucks and headed for our house in Ormok since it was getting late, the sun was setting and we were all pretty tired and hungry.
The most remarkable thing about the house was the family that helped look after us there. They were very friendly, super appreciative of our efforts and excellent cooks! We had cold showers, a generator for lights and a working fridge to keep the San Miguels cold. Even though there were over 30 of us in the house I honestly never felt cramped. I also did not spend a lot of time there once we started working.
One experience from the house I would like to share is my first encounter with Balut. Balut is a duckegg with an embryo inside that is then boiled and eaten, usually at around the 2 week incubation time point. The resulting egg has a well-formed embryo and a large yolk sac. You crack the top, drink the liquid inside like a soup and then eat both the embryo and egg. I was excitedly offered Balut as soon as I dropped my bag. I felt like I was being tested, so I had to give it a go. To be honest, it tasted like chunky chicken soup!
Saturday morning we got up early and were ready to go to work. We were divided into 2 teams: a hospital team and a community team that would go to different towns and set up mobile clinics. I climbed onboard the hospital team ambulance with my stethoscope, a power bar and a bottle of water thinking I would be home in time for dinner. I barely made it back in time for Sunday dinner...
When we arrived at the hospital I met the internal medicine doctor on call for ODH and she asked if I was comfortable manning the Emergency Department while she rounded on the 50 medicine inpatients throughout the hospital and various satellite tents. It was busy to say the least. In about 3 hrs I did 10 admissions and 2 pre-op consults, not to mention a number of outpatient evaluations.
After taking a short break for lunch I decided to see how the rest of the team was doing in the surgical area. I found Nicole in the recovery room tending to a 10 year old boy, AA, who had a suspected abdominal infection and had undergone emergency exploratory surgery. He had a breathing tube in place but since we did not have a ventilator, the team was taking turns bagging him while Nicole adjusted medications and spoke with family members. He was essentially ODH's first ever ICU patient. While I was there taking my turn as the ventilator, our OB asked if I would see a patient who had a problem with swollen legs after she delivered her baby 5 days earlier. Within seconds of meeting JA it was clear that she was in decompensated heart failure and needed IV medication and close monitoring. She became ODH ICU patient #2. ICU patient #3 was a 47 year old woman who came to the hospital 5 days before our arrival with a possible pneumonia. The on-call doctor asked me to have a look at her because she was more short of breath than usual. This turned out to be an understatement and we had to intubate her (place a breathing tube) shortly after I met her. ICU patient #4 was a patient that I had admitted earlier in the day with a suspected MI. The oncall doctor asked me to re-evaluate him after he developed worsening chest pain and had dangerously low blood pressures. He became ICU patient #4. By midnight on our first day, Nicole and I had unwittingly turned the recovery room into what would be recognized in most hospitals as a true intensive care unit.
It was a crazy night. We mixed our own IV medications, pushed our own drugs, traded with the hospital pharmacy for some others, and manually bagged 2 of our 4 patients for over 12 hours straight. Unfortunately our 10 year old didn't make it. I don't want to go into the details but we did everything we could and then some but he still was not able to pull through. It was a painful reminder of why I admire pediatricians and could never be one myself. It is not easy for me when an adult patient dies in the ICU but there is something especially terrible about losing a child. Nicole was unbelievable in the way she took care of AA throughout the night but was even more incredible in the way she spent time with his family. It was a privilege to work with the folks who made up our ICU team that first night.
After AA died, I began to think about the possibility that our other patients in the ICU might not make it through (thankfully they all did). Around that same time I had another equally disturbing thought: What would happen to them if they were still alive on Wednesday morning when our team was scheduled to leave but they still required ICU-level care? Who would look after them? How would they survive? I had not thought about these issues when I initiated a higher level of care to keep them alive in the first place. I had also never considered the issue of resource allocation in a disaster situation. Were we devoting too many resources (i.e. both medication and man-hours) to too few patients?
Before we were able to really delve into these issues about disaster resource allocation, Nicole met baby P. I think Nicole was just walking to the bathroom, getting ready to see some pre-ops for the morning cases when she noticed a 3 month old baby girl breathing fast and turning blue on a stretcher near the ER. Her mother was there crying but there were no doctors or nurses around to assist. She ran for her anesthesia bag and placed a breathing tube to keep her alive. We were able to get a chest xray on the way to our ICU which showed that Baby P had a bad pneumonia and bilateral pneumothoraces (air pockets around the lungs). We didn't have proper chest tubes so Nicole inserted IV catheters directly into Baby P's anterior chest wall to try to evacuate the air. Our medical mission director then McGuivered chest tube bottles to keep the air from re-accumulating. It was amazing to watch them at work.
From that moment on, the rest of the mission for many of us became about Baby P. Baby P is the youngest of 4 children. Her dad is a coconut farmer but his entire plantation was destroyed by the typhoon. It takes 10 years to grow a coconut tree so you can imagine that their family is in a world of trouble financially. At the time she got sick, they were living with her grandmother and 15 other extended family members in a 2 room shack. Her story was very similar to almost every other patient we saw.
Once it seemed likely that Baby P was going to survive the first few hours of her ICU stay we had to devise an exit strategy to get her to the nearest pediatric ICU in Manila (Note that the "we" here is like me saying to Mary that "we" need to get the chocolate stains out of Violet's school uniform). Again, Jojo and Nicole were amazing to watch in action. Ultimately Nicole and two other Op Smile members took 3 ambulances and another C130 to get her to the children's hospital in Manila where she is holding her own at the time I'm writing this.
Overall I had an amazing experience. I am honestly still processing some of the events that I've described and some of the questions that they raised and probably will be for some time. I can't thank JoJo, Nicole and the entire crew of Operation Smile enough for inviting me along and making me feel welcome from the moment I stepped on their tour bus in Cebu. I also can't thank them enough for looking after our 4 students. I also want to thank everyone at ODH who made it possible for me to help take care of patients there.
I hope that everyone is gearing up for a great Christmas and New Year's ahead. While I was writing this I just burned Mary's candied pecans for our neighbor's Christmas party. Some things never change!
Love to all,
Bangon Ormok (Rise again Ormok)!
Brian
I left last Friday morning at 1 am with a group of 4 PUGSOM medical students, 1 Hopkins psychiatry resident and a PUGSOM OB/GYN faculty member. We took the overnight flight to Manila to meet our Vice Dean, Nicole, before heading on to Cebu to join Operation Smile. Op Smile (http://www.operationsmile.org.ph/) is an international group that specializes in performing cleft palate repairs for children in need. They have a very large presence in the Philippines, partly because the founders began their work there over 30 years ago but also because the Philippines has the highest incidence of cleft palates in the world. In addition to the wonderful work they do with craniofacial surgeries, they are also heavily involved in medical relief missions. Nicole has been working with them for years and this is the second time she has organized a PUGSOM group to participate in a typhoon relief mission in the Philippines.
We left with a lot of uncertainty since none of us had ever been part of a relief mission before. I had worked in a rural clinic in Honduras and some of the other docs had similar international clinic experiences; but, we honestly had no idea what to expect. I think Nicole understood this more than we did and set our Manila airport rendezvous point at a place that she knew would be a source of comfort to the westerners in the group...a pancake house! After a stack of corn pancakes (I had to try them...) we boarded a flight to Cebu.
When we arrived in Cebu, the Op Smile team picked us up in a huge white tour bus and we headed off to the Cebu Airforce base to have lunch with the General and then to load our cargo (including us!) into a C130 headed for the city of Ormoc. I have to admit that I was still nervous about the next few days but I was pretty excited to fly in a C130. The excitement was not enough to prevent me from taking a nap lying across our cargo since we had been awake for nearly 30 hrs by the time we boarded the plane.
When we landed in Ormok, the Filippino army helped us load our cargo into two trucks and two ambulances and we set off for the city. After registering with the local health department we stopped at the hospital to meet the director and to tour the facility.
Ormok is located about 120km from Tacloban which was where the typhoon did the most damage to both human life and property. It was hard to imagine that Ormok had escaped the worst judging by the condition of the hospital. Entire wards on the first floor had lost outer walls, the ceiling, or both and the entire second floor was unusable because the roof was destroyed. As a result, patients were lined up on military stretchers in the hallway, in offices, virtually any place where someone could lie down and in some places where it seemed they could not. Since virtually all of the patients had lost their homes, entire families were camped out in a 24hr vigil around their loved one's bed, oftentimes sharing the stretcher with 2 or 3 people. I was overwhelmed on my way to the director's office. I had no idea how I could begin to help even a handful of the people that I saw lying on those stretchers.
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| This was one of the medicine wards at ODH that was severely damaged by the storm. |
After deciding on a plan for the following day we loaded onto the military trucks and headed for our house in Ormok since it was getting late, the sun was setting and we were all pretty tired and hungry.
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| Our house in Ormok was home-base to our team of 30 and a family of 6 that looked after us. |
One experience from the house I would like to share is my first encounter with Balut. Balut is a duckegg with an embryo inside that is then boiled and eaten, usually at around the 2 week incubation time point. The resulting egg has a well-formed embryo and a large yolk sac. You crack the top, drink the liquid inside like a soup and then eat both the embryo and egg. I was excitedly offered Balut as soon as I dropped my bag. I felt like I was being tested, so I had to give it a go. To be honest, it tasted like chunky chicken soup!
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| This is not my Balut but an image taken from Google. It pretty much looked like this though. |
When we arrived at the hospital I met the internal medicine doctor on call for ODH and she asked if I was comfortable manning the Emergency Department while she rounded on the 50 medicine inpatients throughout the hospital and various satellite tents. It was busy to say the least. In about 3 hrs I did 10 admissions and 2 pre-op consults, not to mention a number of outpatient evaluations.
After taking a short break for lunch I decided to see how the rest of the team was doing in the surgical area. I found Nicole in the recovery room tending to a 10 year old boy, AA, who had a suspected abdominal infection and had undergone emergency exploratory surgery. He had a breathing tube in place but since we did not have a ventilator, the team was taking turns bagging him while Nicole adjusted medications and spoke with family members. He was essentially ODH's first ever ICU patient. While I was there taking my turn as the ventilator, our OB asked if I would see a patient who had a problem with swollen legs after she delivered her baby 5 days earlier. Within seconds of meeting JA it was clear that she was in decompensated heart failure and needed IV medication and close monitoring. She became ODH ICU patient #2. ICU patient #3 was a 47 year old woman who came to the hospital 5 days before our arrival with a possible pneumonia. The on-call doctor asked me to have a look at her because she was more short of breath than usual. This turned out to be an understatement and we had to intubate her (place a breathing tube) shortly after I met her. ICU patient #4 was a patient that I had admitted earlier in the day with a suspected MI. The oncall doctor asked me to re-evaluate him after he developed worsening chest pain and had dangerously low blood pressures. He became ICU patient #4. By midnight on our first day, Nicole and I had unwittingly turned the recovery room into what would be recognized in most hospitals as a true intensive care unit.
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| The on-call ICU team on the first night in the new ODH ICU |
After AA died, I began to think about the possibility that our other patients in the ICU might not make it through (thankfully they all did). Around that same time I had another equally disturbing thought: What would happen to them if they were still alive on Wednesday morning when our team was scheduled to leave but they still required ICU-level care? Who would look after them? How would they survive? I had not thought about these issues when I initiated a higher level of care to keep them alive in the first place. I had also never considered the issue of resource allocation in a disaster situation. Were we devoting too many resources (i.e. both medication and man-hours) to too few patients?
Before we were able to really delve into these issues about disaster resource allocation, Nicole met baby P. I think Nicole was just walking to the bathroom, getting ready to see some pre-ops for the morning cases when she noticed a 3 month old baby girl breathing fast and turning blue on a stretcher near the ER. Her mother was there crying but there were no doctors or nurses around to assist. She ran for her anesthesia bag and placed a breathing tube to keep her alive. We were able to get a chest xray on the way to our ICU which showed that Baby P had a bad pneumonia and bilateral pneumothoraces (air pockets around the lungs). We didn't have proper chest tubes so Nicole inserted IV catheters directly into Baby P's anterior chest wall to try to evacuate the air. Our medical mission director then McGuivered chest tube bottles to keep the air from re-accumulating. It was amazing to watch them at work.
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| Nicole and me with Baby P. Her family gave us permission to use her story and her photos if it would help other kids in the future. |
Once it seemed likely that Baby P was going to survive the first few hours of her ICU stay we had to devise an exit strategy to get her to the nearest pediatric ICU in Manila (Note that the "we" here is like me saying to Mary that "we" need to get the chocolate stains out of Violet's school uniform). Again, Jojo and Nicole were amazing to watch in action. Ultimately Nicole and two other Op Smile members took 3 ambulances and another C130 to get her to the children's hospital in Manila where she is holding her own at the time I'm writing this.
On our last day in Ormok the entire group went with the community team on a mission to a town near Tacloban. The army was, as always, amazing. They arrived before us and set up clinic tents, a dental surgery room, and an area where they put on magic shows for the town children. We saw about 250 patients in 3 hours. For most patients, especially the children, we dispensed vitamins, tylenol and cough syrup, but there were a few patients with bad skin and upper respiratory infections that were in serious need of antibiotics. Probably the most important material things we provided were clean water tablets and rehydration packets but I think that our presence there meant more than just the supplies. It's difficult to quantify what effect we really had but seeing the children playing, laughing and running around with our group, I hope that they were able to have at least a few hours free of the worry they've had since the typhoon struck.
The highlight of the afternoon was lunch! The military put on a traditional feast called "Boodle Fight." They prepared rice, glass noodles, chicken, sausage, beef, pineapples, bananas and of course, sardines and spread them out over huge banana leaves that covered a long table. We all gathered around the table and Colonel Fernandez had us turn to the left and put our left hand behind backs. We then raised our right hands and on the colonel's count of "3" we all screamed "Boodle Fight" and began shoveling food into our mouths with our right hands as fast as we could. It was like trying to eat pancakes from the same plate as Tyler. I thought at one point I might lose my hand to a large man with grenades slung around his chest.
After lunch the military took us on a motor tour through the city of Tacloban. Words cannot properly describe the unbelievable destruction we saw as we drove into town. It looked as if someone had picked up the entire city 50 feet into the air and then slammed it back down into the ground. Trucks were on top of trees, entire fields of debris covered areas where I imagine houses once stood, and signs were lining the street asking for food and clean water. I was overwhelmed by the enormity of the task ahead to rebuild the city but I also had a sick feeling in my stomach that another typhoon would likely strike before they would be able to complete the project.
There were a few times during our trip through Tacloban that I felt guilty, like a motorist stopping to view the wreckage on the other side of a 4 lane highway. But I think it was important to see what the people in Tacloban and in other parts of the Philippines are facing. It brought our own short relief mission into a broader perspective.
After our tour through Tacloban, the military brought us back to their headquarters in a town called ByBy where they treated us to a final dinner. I don't remember much after that as I fell asleep in the truck on our 90 minute drive home.
The highlight of the afternoon was lunch! The military put on a traditional feast called "Boodle Fight." They prepared rice, glass noodles, chicken, sausage, beef, pineapples, bananas and of course, sardines and spread them out over huge banana leaves that covered a long table. We all gathered around the table and Colonel Fernandez had us turn to the left and put our left hand behind backs. We then raised our right hands and on the colonel's count of "3" we all screamed "Boodle Fight" and began shoveling food into our mouths with our right hands as fast as we could. It was like trying to eat pancakes from the same plate as Tyler. I thought at one point I might lose my hand to a large man with grenades slung around his chest.
After lunch the military took us on a motor tour through the city of Tacloban. Words cannot properly describe the unbelievable destruction we saw as we drove into town. It looked as if someone had picked up the entire city 50 feet into the air and then slammed it back down into the ground. Trucks were on top of trees, entire fields of debris covered areas where I imagine houses once stood, and signs were lining the street asking for food and clean water. I was overwhelmed by the enormity of the task ahead to rebuild the city but I also had a sick feeling in my stomach that another typhoon would likely strike before they would be able to complete the project.
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| This is just one photo of many. I honestly stopped taking them after the first few minutes since I knew I would never be able to capture the feeling I had with a photo. |
After our tour through Tacloban, the military brought us back to their headquarters in a town called ByBy where they treated us to a final dinner. I don't remember much after that as I fell asleep in the truck on our 90 minute drive home.
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| The blue bottle might explain my ability to sleep on a rocky mountain road on a hard military truck bench. |
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| The colonel and his men made sure that we were taken care of throughout our stay in Ormok! |
We arrived home and packed up since we had to leave the next morning on a ferry to make our way back to Cebu.
Overall I had an amazing experience. I am honestly still processing some of the events that I've described and some of the questions that they raised and probably will be for some time. I can't thank JoJo, Nicole and the entire crew of Operation Smile enough for inviting me along and making me feel welcome from the moment I stepped on their tour bus in Cebu. I also can't thank them enough for looking after our 4 students. I also want to thank everyone at ODH who made it possible for me to help take care of patients there.
I hope that everyone is gearing up for a great Christmas and New Year's ahead. While I was writing this I just burned Mary's candied pecans for our neighbor's Christmas party. Some things never change!
Love to all,
Bangon Ormok (Rise again Ormok)!
Brian
