The first patients to emerge from the devastation of last week's earthquake in Haiti bore horrific injuries: crushed limbs, broken bones, gashes and open wounds.
In those first few days, amputations became routine for the teams of doctors who ministered to the wounded. There were some cases, fortunately, where such extreme measures could be avoided, noted Dr. Ian Rawson of the Albert Schweitzer Hospital in Deschapelles, Haiti, about 60 miles north of Port-au-Prince.
"We have been doing more surgery in two days than we would normally do in three months," said Rawson, whose hospital has been inundated with patients from Haiti's capital city since the massive quake struck Jan. 12. "We have been able to save some limbs and some lives."
But now, as medical relief efforts in and around the earthquake-ravaged capital of Port-au-Prince enter their second week, doctors on the ground have been forced to adjust. And with more patients experiencing wound infection, sickness worsened by lack of shelter, and malnutrition, Rawson said that both supplies and time are running short.
"It's a race against time with infections," he said. "We have run out of most of our antibiotics, and we ran out early in [pain medications]."
Medical workers on the ground in Port-au-Prince report a similar shift in the cases they are seeing. Brid Kennedy, worldwide regional director of Concern Worldwide, an international relief and development agency that has been working in Haiti since 1994, said that while the doctors with her organization initially saw many cases of fractures and fresh traumatic injuries, "we are now entering a phase of more infectious disease."
Lack of shelter, she said, is leading to an uptick in respiratory infections worsened by nights spent outside in the cool, open air. Meanwhile, unsanitary conditions and a lack of clean water put those who are already healing from injury at greater risk of wound infections and gastrointestinal ills.
"It is a huge challenge," Kennedy said.
Doctors who have previously worked in disaster zones are no strangers to the evolving nature of these situations. Dr. Tamara Kuittinen of the Department of Emergency Medicine at Lenox Hill Hospital in New York was on the scene during 9/11 at Jersey City Medical Center. She saw many "walking wounded" and also had field experience in the days following the terrorist attack.
"There will be dehydration issues for people who have been stuck for almost a week," said Kuittinen, who is not currently involved in relief efforts in Haiti. She added that as time passes, wounds that were manageable in the first few days after they were received can get out of hand.
"With skin wounds you can get cellulitis, [an infection] fractures can worsen, and blood infections can arise," she said. Worse, she noted, survivors may find themselves dealing with indigenous diseases such as malaria and various sanitation issues that have likely arisen in the aftermath of the quake.
"There is a host of issues that a catastrophe like this can bring up," she said.
Making matter worse, the distribution of medical necessities following the earthquake has not been as smooth as hoped in some cases.
"We're a little bit frustrated," Rawson said. "There are stacks of medical supplies in Port-au-Prince, but we haven't been able to work through the log jams to find out where they are."
Rawson added that he expects a second wave of patients at his hospital in the days to come as the decimated facilities in Port-au-Prince become overwhelmed.
"Now, we have people in the hospitals in Port-au-Prince who don't have any resources," he said. "They are e-mailing us and saying, 'Can we send patients?'"
For Kennedy and her team, supplies are a lesser concern; charter flights bearing medical supplies have resulted in a steady stream of medical and humanitarian necessities from the airport, and she expects another shipment Sunday.
But as the specters of exposure, malnutrition and disease loom, her organization's relief workers are using what they can -- from blankets to water purification efforts -- to keep the earthquake's victims as healthy as possible.
"We are heading into the rainy season, and always during the rainy season these diseases go up," Kennedy said. So without adequate shelter in place, these diseases could really go up."