We arrive in Haiti during the second night after the earthquake, and the scenes of destruction and devastation are overwhelming. We are silent as we went our way through the street rubble and collapsed buildings to set up our emergency surgical facilities. An estimated 200,000 are already dead and a similar number of casualties lie among the rubble. There are piles of bodies and the smell is inescapable. With our medical facilities destroyed, we have little option but to set up casualty dressing stations in the streets. In the first few days, triage, resuscitation, stabilisation, and surgery were performed outside under the trees. We work hard to control the crowds, but hundreds of people still rush into our open air hospital as the severe aftershocks continue.

There is little water or electricity, limited communication and transport, and constant confusion. “I’ll need lighting in those trees and tents tonight,” I blithely say to one of our logisticians, without any idea how, with most of our equipment delayed, he will find generators or fuel. Somehow, he manages it, and I am again struck by the immense effort that everyone is making. Questions tumble one on top of another. Where are we setting up a mortuary? Can we lend some antibiotics to some medics working nearby? And, repeatedly, where are the surgical instruments and sterilisation equipment now? When will they arrive? Logistics is a nightmare, with the city’s commercial airport initially transformed into a military airport, often forcing supplies to arrive by road via a long difficult journey through the Dominican Republic; materials take days to reach us and even longer to distribute. A medical bartering system develops. “We will take some of your postoperative recovering cases if you can help with these major fractures.” The deal is quickly done.

Our main materials are delayed and flights diverted, yet somehow politicians and half the world’s media manage to arrive at the airport. “There is another TV film crew waiting,” I am told. Too much media, too few nurses, and too little materials. But the main problem is the sheer scale of this disaster, and the concomitant collapse of infrastructure and effective response measures. Returning one night to our tents, set up in the grounds of a damaged hotel, even we stand for a moment and watch the CNN Haiti news reports. As if we haven’t seen enough of it already.

As medics begin pouring in, there is a danger of medical duplication with other teams. Some medics arrive from nearby countries to support mission hospitals, but have minimal back up and limited experience or clear medical plans. It begins to feel like a circus.

Medically, we are well organised, focused, and clear on what we should be doing, even if at times shortages interrupt us. The surgical procedures are for the most part straightforward, dealing largely with open fractures and, as a last resort, amputations. However, obstetric emergencies don’t slow down, as ectopic cases and emergency caesarean sections vie for time and space under the tree.

More staff arrive during the night and stumble into tents, falling over others sleeping on the floor. After 12 days we find a house to stay in, but some of the team refuse to move in and of those that do, some return in the night to the tents for fear of more aftershocks. Helicopters whisk patients away to a US medical ship, only for marine medics to arrive a few days later to ask us to take cases and transfers because they have reached capacity. For the first time, UN MINUSTAH troops and some national police are seen on the street as violence begins to flare up, which also creates security problems for our teams.

Haiti is slowly returning to some semblance of normality, and we are drained and glad to leave. The second wave of medics arrive to expand our MSF facilities and prepare for the long run, supporting Haiti medically as the slow process of repair begins. As Bob Marley said on another island not too far away: “Don’t worry, every little thing gonna be all right.”

Let’s hope so.

Paul McMaster is a retired surgeon who has worked with Médecins sans Frontières for five years, and has been a surgical adviser for the past two and a half years.