The husband begged Mark Coughlin not to let his wife die.
She was being treated in a soccer field, which had been turned into a makeshift clinic. Her leg had been severed in the collapse of their Port-au-Prince home during the earthquake that shook Haiti on Jan. 12. An infection was spreading through her bloodstream and time was short.
Inside a neighboring boarding house, a 13-year-old girl had lost most of her foot when her school collapsed. A hospital could take both patients for surgery but there was not enough gas in the SUV to transport them.
By the time they found fuel and got to the hospital, it was too late. The woman died on the operating table.
That's when Coughlin, a 46-year-old musician and video producer, hit an emotional brick wall. He couldn't sleep. He lost his appetite. He cried.
"I felt like I had failed," said Coughlin, who volunteered to go to Haiti with other members of the Catholic Church of St. Monica in Duluth. "I felt really terrible. What could I have done to get that woman help faster?"
The toll of Haiti's devastating earthquake is likely to extend well beyond those directly impacted. Relief workers and volunteers who parachute into disasters to help may find themselves stepping into a psychological minefield. They may have trouble eating and sleeping or get angry or very sad. Because of their exposure to extreme suffering, these workers may experience vicarious trauma or compassion fatigue, experts say.
Coughlin had volunteered in Haiti before. He had witnessed the misery that comes from extreme poverty and a dysfunctional government. Still, "none of us had ever faced a catastrophic situation like we did this time. All of us felt the weight of this."
Part of the reason is that the devastation was concentrated in a high density area. Haiti's capital was nearly flattened. Corpses rotted in the street. Yards doubled as makeshift emergency clinics. Water and food were scarce. Doctors and humanitarian workers quickly ran out of supplies. People were dying who should have survived.
Coughlin, though, is lucky on several fronts. His stay in Haiti was brief, so he quickly returned to normalcy. He has a supportive family; and a brother who is a trained counselor. His brother prepared him for past missions and was there to talk when he returned from this one.
"He helped me kind of identify what was going on with me and that it was normal," said Coughlin, who still dreams about Haiti every night and can't wait to go back. "I'm doing much better now."
Increasingly, humanitarian groups are recognizing that caregivers need care as well. It's an issue that became more apparent following the 2004 tsunami that killed about 250,000 people in several nations including Thailand, Indonesia and Sri Lanka.
Each week, Lynne Cripe of Atlanta-based CARE joins in a conference call with others from nonprofits and humanitarian organizations to share information and coordinate ways to help staffers in Haiti cope with stress.
CARE has taken steps to make sure its staffers are emotionally ready, said Cripe, director of employee engagement support and communications. Those going into crisis situations must undergo a pre-departure briefing that includes information about the situation on the ground and potential risks and challenges. They are required to take one week of rest for every four weeks on the ground. Once home, they're given the option of going through a post-deployment briefing.
"This is the first major emergency where we've tried really hard to have a systematic approach to how we prepare people," Cripe said. "Before, people would just get on a plane...We want to do it better this time around."
Eighty percent of CARE' staff already in Haiti was affected in some way by the quake. Those staffers, all but one Haitian nationals, lost husbands, brothers and cousins. Dozens of workers have been sent there from other countries.
"There's been a real shift," said Lisa McKay, director of training and education services for California-based Headington Institute, which provides counseling and training services for humanitarian groups. "People realize how important it is to pay attention to some of the psychological stressors involved in humanitarian work. In the past, the needs of the staff came in a distant second."
It's especially important for workers who are nationals of the country where the disaster occurred. In addition to providing relief for others, those staffers must deal with their own pain and loss. The United Nations mission was hit particularly hard. The agency lost about 85 people and still has dozens missing. The dead included Hedi Annabi, who headed the UN mission in Haiti.
If a caregiver is personally affected, the trauma is magnified. Consider the experience of Mia Pean.
Pean has gone to Haiti three times since the earthquake, the first time to get her father whose leg was crushed when his home in Port-au-Prince collapsed.
Pean, who has homes in Lithonia and Plantation, Fla., helped coordinate logistics for volunteers and nonprofits. The trips have been especially painful because she grew up in Haiti and has relatives and friends who still live there. She has cried, gotten angry and is losing her hair.
"When I came back here the first time, I did not understand the normalcy of life," she said. "Nothing was chaotic. It took a minute before I got adjusted. How can God's children be treated like that? It does something to your psyche."
To lessen the stress, Pean runs two miles a day and prays -- a lot. "That's the only time I find refuge, when I'm in touch with God."
Rick Klomp, a behavioral scientist at the Centers for Disease Control and Prevention and an expert on workforce and responder resiliency, said organizations have to make sure they don't stretch their resources too thin. Relief workers and responders "are not immune. They're not bullet-proof" to the landscape around them.
He said pre-deployment briefings includes information about security, equipment, travel aspects of the trip, stress management and self-care. CDC also has an employee assistant program available for staffers.
In Haiti, he said, "there are a huge number of stressors. You're going to see things that most Americans don't see." For instance, "I have a two sons and a daughter, so I'm sensitive to things that impact children."
Experts suggest several coping mechanisms, including taking a break from the source of stress, which could mean taking a few minutes to yourself, reading, and keeping photos of your family nearby. Some people like to write and pray. Others say they focus on errands and projects back home.
Habitat for Humanity has counseling options, in addition to chaplains, for staffers going to and returning from disasters to help them "deal with the enormity of the situation."
Mario Flores, director of disaster response and field operations for Habitat, recently returned from Haiti. He's worked in Angola, Nicaragua and Thailand. "I have to tell you, in terms of comparative analysis, Haiti is one of the worst, if not the worst, I've seen."
"I think it's very important for humanitarian workers to discipline themselves and be prepare for what they will be experiencing and witnessing, especially in the first days after the disaster" he said. It's important for workers and volunteers to also be realistic about what they can accomplish.
He had been to Haiti before, so he knew the challenges. "Don't be too tough on yourself," said Flores, who often takes photographs of his family with him. "Keep in mind that you are not going to be able to do everything for everybody."
And in the end, workers say, they must remember to take care of themselves.
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