Photos by Jason McKay & Alex Cullen.

Diagnosing disease in a fully-loaded modern emergency room is a process that rarely takes place entirely within the walls of the department. A patient is seen for five minutes by a physician. Once orders are placed, a cascade of events begins. Blood and urine is collected and sent to a laboratory. Meanwhile, the patient is sent to radiology for scans and x-rays. A call may be placed to the patient’s primary physician. This gathering of data may take many hours, sometimes warranting an overnight stay without a firm diagnosis. American healthcare workers are addicted to data and lashed to it by fear of litigation, and there is no evidence more incriminating than within an emergency room armed to the teeth with diagnostic and interventional firepower.

This is the only world I had ever known before I went to Haiti for a week of volunteer work as a nurse last month. Suddenly, our misfit gang of nurses, paramedics, and firefighters were thrust into an environment wherein each of us was called “doctor” and the most powerful tool we had was the stethoscope around our necks.

Our clinic is set up in an abandoned amusement park a kilometer north of the U.S. embassy called Bojeux Parc. One enters the grounds between the legs of a three-story tall character that looks like a manic Spaghetti-O, his arms thrust exultantly toward the clouds. Near the entrance are large thatched Tiki-style huts that serve as waiting areas. These huts typically filled up by seven in the morning. Just before clinic opens at eight, the voices of people waiting softly rise into harmonized song, a mellow morning aubade. During a pregame huddle on my first morning there, one volunteer said, “It’s weird how they sing. It creeps me out.” I was lost in the moment, dazed by the drifting hymn. Another, our only actual physician, responded, “I love it.”

On the grassier side of the park, tents have been set up for volunteer quarters. The tents, which are prohibitively sultry and airless during the day, are each furnished with two green cots. A shower of wooden planks and a pipe pouring cool water flanks the mostly-functional indoor bathrooms. Next to the camp is a common hut that has a computer and hosts most meals and meetings.

On the other half of the park, next to a moat which once hosted a ride called the “Disco Boat,” is the clinic. The clinic is a tiled pavilion with an adjacent bar and stockroom that may have once been a concession stand but now serves as the pharmacy. Chairs are arrayed around the perimeter of the clinic for waiting patients. Patients are examined in five beds as well as screened-off rooms for gynecological exams and wound care procedures. Because the clinic is itself closed off from benevolent breezes by hanging sheets, temperatures tend several degrees to the worse during the peak hours of the day.

My first day in the clinic coincided with a general strike in Port-au-Prince, so the doors were closed to the public for security reasons. One patient, however, slipped through in the late afternoon. She was young, a teenager, eight-and-a-half months pregnant with “weeping” edema to both of her legs. She was also quite hypertensive. This struck us all as classic preeclampsia, a condition in which pregnant women develop high blood pressures and subsequent kidney damage. The kidneys then “spill” proteins from the blood into the urine. As a result of less protein in the blood, water in the blood vessels moves to the higher concentration in the tissues outside the vessels, causing swelling throughout the body. This girl had water literally running down her legs.

All of my colleagues from the ER, chomping at the bit, readied for action. We rattled off all the necessary tests and interventions, but our young doc, who also happened to have actual experience in this setting, looked at her and shrugged, obtaining a urine dip test almost as a formality. All of the short-term interventions to lower blood pressure or prevent life-threatening complications in the clinic were less important than fixing the problem itself. She needed the one known cure for preeclampsia, one thing for which we were regrettably not prepared: induced labor. Although it was not what we ER warriors wanted to hear, she needed to go to the hospital instead, so she waddled back out the gate onto the sun-beaten road.

The thwarted adrenaline junkies were to be repaid in full about 24 hours later. We had deliberately felt our way through our first day seeing patients, making clinical judgments, tooling around the pharmacy, giving IV fluids, and otherwise learning the ropes. Afterwards, before the night’s first beers were warm, our doctor approached the group with a Presidente in hand and a mischievous smile on his face.

“Let’s go. We’re getting two traumas.”

Chuckles and sarcastic responses.

“I’m not kidding,” he said as he walked past, toward the clinic.

While the details of the incident remain unclear, what we know is that two of the two-and-a-half patients delivered to us looked busted up. A man, a woman, and a girl of about eight came from the site of a motorcycle accident. Most of our terrific interpreters had already gone home, so the story filled in clumsily. The man, howling in pain, presented with a swollen jaw and a tender right wrist. The woman, the presumed passenger, likewise arrived with a badly fractured jaw but no other complaints. The girl arrived without any injuries or complaints.

The trauma assessments, under the direction of two wildly overqualified ER technicians, ran at least as smoothly as they do back home in the emergency room. We stabilized our patients and prepared them for transport to the nearest hospital before opening our long-overdue second bottle of Prestige, the formaldehyde-preserved national swill.

Our fourth day in country, we packed a couple duffel bags with meds and headed for a refugee camp twenty minutes from Bojeux Parc. Compared with the tent cities we would see the next day, the camp seemed relatively well kept up. Naturally, the arrival of blanc medics was the best show in town, so our rag-tag group of seven or eight volunteers saw at least three hundred patients in ten hours. It was by far the most exhausting but gratifying day in Haiti.

The patient population and spectrum of diseases in Haiti are almost exact opposites of those in the emergency room. America has been virtually ridded of infectious disease while filling with chubby people with a fast-food mentality about healthcare. Haitians are exposed to all kinds of infectious dangers: mosquitoes spreading malaria, typhoid and cholera swimming in the water, tuberculosis floating in the air, not to mention the perils of sexual congress. People simply don’t live long enough to accumulate a cornucopia of chronic diseases. In the throes of malnutrition, they develop slowly and die early. We met one girl who looked about four who we were told was nine. But the Haitians are hardy people who only want a little attention and, at the very least, some kind of pill from providers. As I was told on my first day at Bojeux Parc: “When in doubt, give ‘em Tylenol.”

Luckily, the clinic is an arsenal of antibiotics and other drugs facing a community infested with bacteria, viruses and parasites previously unmolested by medications and therefore vulnerable to simple, first-line treatment. We have plenty of silver bullets, but the werewolves replicate every night, time and time again. I realized that Haiti needs, aside from everything else, a self-sustaining healthcare infrastructure that is focused on hygiene, education and breaking the endless chain of infection. I know I have a deplorable personal record of hygiene, but at least I know better. In order to develop strong minds and bodies, Haitians need to avoid habits that cause crippling disease, no matter how easily one pill can cure it.

America did not conquer infectious disease solely with antibiotics. It took a sea change in popular mores which ultimately fluorinated water, inspected food and produce, and sanctified the rite of bathing and hand-washing. In a country decimated by poverty, it shocked me how upside-down medicine becomes. Nevertheless, all medicine boils down to the cheesy old precept, “an ounce of prevention is worth a pound of cure,” although sometimes shit just happens. I think nuggets of granite wisdom like this are what volunteering overseas is all about.

Previously: Part I: first impressions on Haiti