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‘This Is Like in War’: A Scramble to Care for Puerto Rico’s Sick and Injured

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SAN JUAN, P.R. — As Hurricane Maria pummeled Puerto Rico, María Martínez Espada, 86, slipped because of a water leak in her apartment and broke her hip. Almost a week later, doctors at Hospital del Maestro have not been able to operate because of a shortage of medical supplies.

“The pain is a horrible thing,” Ms. Martínez said from her sweltering third-floor bed at the hospital, where the medical director, Veronica Rodriguez, said, “At 3 p.m. it gets so hot that it’s almost impossible to handle.”

For the sick and the elderly, heat can be deadly. Without sufficient power, X-ray machines, CT scans, and machines for cardiac catheterization do not function, and generators are not powerful enough to make them work. Only one in five operating rooms is functioning. Diesel is hard to find. And with a shortage of fresh water, another concern looms: a possible public health crisis because of unsanitary conditions.

In Washington, officials scrambled to show their commitment to the hurricane-battered island as Democrats, and some Republicans, pressed them to do more. President Trump announced that he would visit Puerto Rico and the United States Virgin Islands next Tuesday to reassure residents that the federal government was mobilizing to help rebuild.

“Both have been devastated — and I mean absolutely devastated — by Hurricane Maria,” he said. “And we’re doing everything in our power to help the hard-hit people of both places.”

One step Mr. Trump took on Tuesday was to waive a requirement that would have forced Puerto Rico, which is essentially bankrupt, to contribute money to the federal emergency fund.

Gov. Ricardo Rosselló of Puerto Rico praised Mr. Trump in an interview on Tuesday, saying he had spoken with him five times and had taken part in the Situation Room briefing. “He has been acting proactively,” Mr. Rosselló said, adding that the president declared Puerto Rico a disaster zone as the storm was smashing into the island. But, “we still need more, and the president understands that and his team understands that.”

The governor stressed that what the island had experienced in the past month was an extraordinary disaster. “Puerto Rico, within the span of two weeks, received two Category 4, Category 5 hurricanes,” he said. “That has never happened anywhere. The devastation has been enormous.”

On the ground, Puerto Rico remains a patchwork of desperate fixes, with 3.4 million people improvising ways to get much-needed medicine, diesel for their generators, food for their shelves and water to either drink or bathe in. With no choice, people wait and wait, some as long as a day for gas or hours for food at local supermarkets, which are letting in 25 people at a time to avoid mayhem.

There is some progress. The governor said Tuesday that 450 of the island’s 1,100 gas stations are now working. Two days ago, that number was 181.

Health scares are mounting. Governor Rosselló said Tuesday that getting all of the island’s hospitals working is a priority.

The hospitals have been crippled by floods, damage and shortages of diesel. The governor said that 20 of the island’s hospitals are in working order. The rest are not operational, and health officials are now trying to determine whether it is because they lack generators, fuel or have suffered structural damage. All five of the hospitals in Arecibo, Puerto Rico’s largest city in terms of size, not population, are closed.

Making matters worse, 911 still does not work, officials said.

“What do you think? There has to have been deaths,” said Dr. Rafael Rodríguez-Mercado, Puerto Rico’s health secretary. “I can’t give you a number, but we have to be conscious and realistic. To say no would be a lie.”

So far, seven regional hub hospitals are taking in patients. The island’s dialysis patients are also getting care. But none of it is easy. Hospitals should be required to have backup generators, diesel, a stockpile of medication and satellite phones, the doctor added. Even with those precautions, problems could arise. There is enough diesel on the island, but a shortage of gas tanker drivers — some cannot get to their jobs — and working gas stations. In Lares, the mayor, Roberto Pagan, said the municipal hospital almost had to close yesterday because it ran out of diesel fuel.

“We have been putting out fires,” Dr. Rodríguez-Mercado said. “The hospitals call you and say, ‘I have two hours of diesel left.’”

The potential for a public health crisis is a big concern, he said. Rats and decomposing animals can spread disease, the doctor added. Without running water, people are probably not washing their hands or boiling water often enough, or cooking their food well enough. This could lead to gastrointestinal outbreaks.

“What worries me is the sincere possibility of epidemics,” Dr. Rodríguez-Mercado added.

High mosquito counts on the island could also lead to a resurgence of mosquito-borne diseases, like Zika, dengue and chikungunya, doctors said.

A shortage of open pharmacies is another stressor, especially for the chronically ill and elderly residents. Most pharmacies in Puerto Rico remain closed, although they are slowly beginning to reopen. A CVS spokesman said that 21 out of 25 Puerto Rico-based CVS stores are now open, including 17 pharmacies. The first one reopened last Thursday. A Walgreens spokesman said about half of the island’s 120 stores are open and running on generators, but that hours vary. The stores are also receiving supplies of medication.

But many pharmacies in Puerto Rico are independently owned. With so many people pleading for medication, some pharmacists who know their clients are dispensing drugs without the required prescriptions or refill bottles.

Hospitals still have adequate supplies, and so do many of the open pharmacies, but there are concerns they may run out because suppliers are unable to get to them, said Dr. Victor M. Ramos Otero, the president of the College of Doctors and Surgeons of Puerto Rico.

Even when people find the drugs, they often cannot pay for them. Without electricity, A.T.M.s do not work and stores cannot accept credit cards or process insurance plans. That is what happened to José Castillo when he showed up at the Express Care Pharmacy in Santurce, a San Juan neighborhood, on Tuesday, hoping for a refill on the anti-depressants that help him sleep.

Pharmacy workers were outside, tending to customers on the sidewalk. The manager, Yanissa Serrano, told Mr. Castillo the pills cost 25 cents each — cash only.

“But I don’t have the money,” he said.

Her patience worn out, Ms. Serrano erupted.

“I would have been able to give you your medicine, but three times they robbed my generator. Three! Thanks to the fine people of this neighborhood,” she shouted. “I lost my house. I lost everything. I could be home tending to my apartment, but instead I’m here providing this service to the community, and this is how they repay me.”

Before Mr. Trump’s announcement, Representative Luis Gutierrez, Democrat of Illinois, said on the House floor that, “what I fear is that the federal government is not stepping up as fully and as quickly as we must.”

“This emergency cannot just be treated by Congress, the president, FEMA and the other agencies as just another storm,” he added.

But Mr. Trump defended the response by the Federal Emergency Management Agency on Tuesday.

“We have shipped massive amounts of food, water and supplies to Puerto Rico and we are continuing to do it on an hourly basis,” Mr. Trump said. “We are literally landing water, food, supplies on an hourly basis. And this is an airport that has been devastated.”

But the administration on Tuesday denied a request to waive longstanding shipping restrictions to help get fuel and supplies to the island. Officials argued the restrictions are not hampering shipments.

The FEMA administrator, Brock Long, said at a White House briefing that more than a dozen ships have been sent to the area, loaded with millions of meals and gallons of fresh water, and that 10,000 federal workers were on the ground.

Coast Guard planes are flying in fuel, food and water from Miami and Jacksonville. The Navy hospital ship, U.S.N.S. Comfort, with 1,000 beds and 12 operating rooms, is also headed to the island. And the Department of Defense announced that U.S. Northern Command will have a commander on the ground in 24 hours.

“The issue in responding on an island is that you can’t drive trucks in like you can on mainland U.S.,” said Will Booher, a spokesman for FEMA.

Rosa Valentín, 89, went to five hospitals to get help for her bleeding foot ulcers. A candle in the house where she was staying had started a fire. She was evacuated through a flooded neighborhood, and so the bandages on her legs got wet.

“They said they were too full, they said they weren’t taking emergencies, or they just said no,” said Millie Martínez, her daughter. “Or they said that they had no generator and they had transferred all their patients.”

They wound up at Doctors Hospital in Santurce, some 50 miles from where they started.

At Centro Medico in San Juan, the main hospital on the island, power went out again Tuesday, forcing staff to switch to generators that have to be constantly refueled, said Jorge Matta González, the hospital’s executive director of medical services.

The emergency room, busy under the best of times, is a jumble of patients, doctors and nurses all scrambling to treat 164 patients a day. Only two of 24 operating rooms are working. Outside Centro Médico, beige tents house federal disaster medical teams from Texas, South Carolina and California.

“This is like in war: You work with what you have,” said Dr. Carlos Gómez-Marcial, the emergency room director.

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