Haitian Healthcare ← FREE KRAUT!

Haitian Healthcare 25

26 Apr 2010  |  ptbnl  |FK-All

Tags:

If people are interested, I’ll post more of my friend’s experience in Haiti here – they’re longer posts and I don’t want to over-fill the grill.

Background

As most everyone reading this will know, on January 12, 2010, there was a magnitude 7.0 earthquake centered just west of Port Au Prince in Haiti. The earthquake decimated an already shaky government and infrastructure, killing hundreds of thousands and dislocating hundreds of thousands more. Many fled the city, in fear and in search of food or help. Many killed or departing were medical professionals, leaving a relative vacuum in care just at the time when there was an astronomical surge in need. NGO’s and charitable organizations rushed in.

While there is no longer any need for acute earthquake-injury-related care, and although attempts are being made to transition the city’s healthcare back into the hands of local medical staff, at this time there are still not enough staff, infrastructure or supplies to offer basic medical care to the remaining residents of Port au Prince. I am in Haiti for just two weeks as an emergency physician, helping one of those charitable organizations (for safety and simplicity’s sake, I won’t mention which group here) provide that care during the transition period. I will attempt to post daily what I see and hear, as I don’t think an experience like this should go undocumented.

If this is His will, He's a son of a bitch.

25 thoughts on “Haitian Healthcare”

  1. green star oakland Apr 26,2010 11:09 pm

    Today was the day the Haitian doctors and nurses were supposed to take over the running of the makeshift hospitals.

    4/26: Well, as anticipated, there was no grand takeover of the hospital, although I did meet a few Haitian nurses, who seemed generally amused at our presence and attitude, but in a friendly way. And I met a Haitian medical student, who like all good medical students had just enough knowledge and interest to make a nuisance of himself asking questions. They have a complicated system here (compared to our, uhm, completely intuitive system)—medical school is 5 years, then they are “interns” which sounds like it means just about what it means in the US. THEN they go and spend a year in “the countryside,” practicing in clinics, then they return and are allowed to pick a specialty and begin training for it.

    But there are glitches along the way. I’m still a bit confused about where all the Haitian doctors and nurses have been, but I’ve pieced a little bit together. Apparently, strikes of doctors and nurses are extremely common, as is non-payment of medical staff. This was true long before the earthquake. And in fact, the most recent strike/non-payment cycle was ongoing when the quake hit. This med student I met today, named Jenierlo, was supposed to come back to school in October. But they called him and told him not to bother showing up, because there was to be a strike. Meanwhile, apparently any doctors that were working hadn’t been paid for at least 3 months before the earthquake. Then many more doctors and nurses were killed. So many of the doctors and nurses that are coming back are–presumably–broke, disillusioned, wary, and out of practice.

    That said, Jenierlo, the closest thing I met to a Haitian doctor today, asked me if I had a facebook account and pulled out his iphone to look me up. I commented on his “fancy iphone.” He said “no, it’s not fancy. My girlfriend dumped me and I bought it to make myself feel important, I guess.” I asked what he wants to be when he does pick a specialty. He said he’s not sure, but he is sure of one thing. “After this year, I am not training in Haiti any longer. I have one more semester before I am an intern, and then I will go to the united states and try to pass the USMLE and do residency there.” Then he says he’d like to practice in the US for “twenty years or so,” then return to Haiti and “build a big hospital in the mountains.”

    Apparently, one Haitian doctor did show up and saw one of the patients we were managing. For two days no one had been able to get this patient’s blood pressure down, despite trying at least four different medicines. The Haitian doctor wrote an order for a different blood pressure medication, which was given, and her pressure came down. No one actually saw him do this, and unfortunately he left us with the task of figuring out where to send this homeless, family-less woman who had been cared for by a group of nuns until she stopped being able to feed herself and they no longer felt comfortable doing so. But still, it’s a start.

    Today was less interesting, or at least less terrifying. But still a lot of wacky stuff—much of which is only interesting to medical people—I think I saw a true Todd’s paralysis, which is a transient paralysis of part of the body after a seizure. There were several cases of malaria, one of which was so sick she had to be put on a ventilator, then transferred to University of Miami’s hospital near the airport. This transfer involved one guy carrying a rusty military-green oxygen tank the size of a grown man, while walking alongside a makeshift gurney, with at least 5 other doctors and nurses trying to make sure the various lines and tubes they’d worked so hard to place didn’t get pulled out during transfer.

    Don’t know if I’ve mentioned it, but you might have gathered—just before I got here, they moved the ER from a set of tents, where it had been since the earthquake, into the hospital building. Most of the admitted patients still are in tents on the hospital grounds—including the patients with TB, who are housed in two tents called, appropriately “the TB tents.” They are presided over by Megan, an infectious disease doctor who looks about my age, has been here for four months now and plans to be here for about three more months, “at least,” she says. Megan knows all her patients by name, which is amazing, since Michel and [insert letter here]oussaint seem to be some part of just about everyone’s name. Today, she got worried about a patient of hers—6 months pregnant, with TB, and worsening shortness of breath. She had a fluid collection around her lung, and Megan thought that it would help her breathe if that collection was drained. So she came to the ER asking if there was anyone who could do it for her. I was volunteered, and was more than happy to leave the ER, where I couldn’t figure out what was wrong with anybody, and go to the TB tent to do a cut-and-dried procedure for someone with a cut-and-dried diagnosis.

    Before we go to the TB tent, I should discuss the heat a bit. I have literally never sweated so much in my life, including the time I was helping build houses in Tennessee in August. Although that was close. But this time I am wearing scrubs, a fanny pack, socks, clogs, a stethoscope, a headlamp, and my goggles. Everyone who was working in the tents and is now working in the hospital building keeps saying about how much cooler it is than it was in the tents. But I still am drenched five minutes into my shift, I can’t keep anything paper in my pockets or it will be destroyed, and if I go to take a sip of water—well, you can’t take a sip of water. I go through four liters of water in a shift.

    So anyway, I thought it was hot. And then I grabbed the ultrasound and headed for Megan’s territory. It really does look like M*A*S*H right after all the helicopters landed, except less blood and the tents are all beige or silver. The tent I went into must have had twenty or thirty patients in it, a third of whom had family members sitting at the bedside, fanning themselves. Everyone was glistening, including my patient, who was in the far corner. I made her sit up, used the ultrasound to make sure I was right about which side the fluid was on, and then opened the kit I’d brough with me—a sterile package containing a needle the width of a large swizzle stick (and twice the length) with a catheter over it to leave in her chest, a clear pouch and some tubing to attach to the catheter, and some numbing medicine. Plop. An enormous drop of sweat fell off my nose and into the sterile field, immediately followed by another one. I already had my sterile gloves on. Unlike in M*A*S*H, there was no on to order to blot my forehead. I tried my sleeve, but it was already soaked, and I kept missing a spot in the middle of my forehead. Now I could barely see, as more sweat was dripping into my eyes. And more onto the sterile field. I finally just went for it. “Mes amis, mes amis!” My poor patient cried, each time I jabbed her with the needle, which was so big I couldn’t get it to go through the skin. I finally noticed a scalpel came with the kit and just made a little cut in her skin, then slid the needle through, with return of beautiful, wonderful, amber TB-laden fluid. I sewed the tube in place and got out of there.

    If this is His will, He's a son of a bitch.
  2. Leopold Bloom Apr 26,2010 11:44 pm

    is it cool if I copy and paste these to others, like my mom, GSO?

    • green star oakland Apr 27,2010 12:07 am || Up

      I would guess so, but since she’s chosen to make it a closed blog let me check with the author first.

      If this is His will, He's a son of a bitch.
      • Leopold Bloom Apr 27,2010 12:10 am || Up

        okay. I think it would probably just be my mother. And maybe Susan.

        • green star oakland Apr 27,2010 12:19 am || Up

          Thanks for asking.

          If this is His will, He's a son of a bitch.
  3. mk Apr 27,2010 5:00 am

    I’d like to read the rest of these, gso, if your friend is inclined to allow it.

    • FreeSeatUpgrade Apr 27,2010 8:28 am || Up

      Me too, please. My wife, Nurse Upgrade, is also very interested.

      "Kraut will get you through times of no money better than money will get you through times of no kraut."
      • Leopold Bloom Apr 27,2010 9:51 am || Up

        Man, we can upgrade nurses now? No wonder they passed the health care bill–it’s all tiered now…

  4. green star oakland May 3,2010 7:23 am

    Sorry it’s taken a while, but I’ve now got the go-ahead to keep quoting. Her plan is to write an article based on the experience, so please don’t re-post anything on other sites (this is actually a bonuses of having the google shields up here).

    This post raises some very interesting issues about unintended consequences of NGO activities:

    4/30: Today, I was invited to the graduation ceremony for three of the surgical residents. They dressed in suits, as surgeons do for this sort of thing. There were maybe thirty family and friends in the surgery meeting room, lots of cameras, a table full of beautifully arranged canapés, and a bundle of freshly laundered—or maybe even brand new—scrubs on a table in front of the graduates, a gift from the group I’m working with.

    There were speeches, which I hear were moving—I came in late, and much of it was in French. But everything felt a bit forced—I was pulled from a shift to come over because, I was told, more of a “presence” from our group was needed. Who exactly needed my presence is still not clear to me—I can’t imagine that the graduating Haitian surgeons did, although they very politely answered all my questions and posed for pictures when asked. My main question for them, as it always is for graduates, was “what next?” But in Haiti it is a particularly fraught question. “What next,” indeed. This already poor country has been decimated, surgeons in particular need a lot of supplies (witness yesterday’s OR closure secondary to lack of gowns) and staff to function, and these doctors’ medical system has been hijacked. We are hijackers with good intentions, yes, but try to imagine if after Hurricane Katrina the Canadians had come in and started running the ER at Tulane, imposing their medical values while not answering to one single hospital board, county, state or federal government body (including their own).

    But of course it’s even more complicated than that. Overlaid on the awful cycle of strike and nonpayment that was present before the earthquake, is the quake itself and its—not always foreseeable—aftershocks. Just an hour or so before I was taken to the graduation, I had been trying again to understand exactly what is going on with the Haitian medical staff. Somehow, even with the earthquake, and the strikes, and the death of so many nurses and doctors and medical students, it still feels like there’s a piece of the story missing, some further reason why there’s so little Haitian presence in the hospital. To some, it might seem obvious—no pay, no work. But here multiple people have spoken about being desperate to work out of boredom, even if not for money. And some people do show up sometimes. I approached someone I know is familiar with the Haitian medical system from inside it, and asked this person this question “what is going on here?” This person, who specifically asked not to be identified by name (“just tell them your little finger told you”), explained it thus: “First, there are strikes, and there was one long strike, and then there was the earthquake, and no one was paid. Then, after the earthquake came, the NGO’s came.”

    And the NGO’s hired the doctors, and the nurses, and even some nursing students. For money. And that money was both steadier and better than what the Haitian system had been able to offer even before the earthquake. A Haitian surgical resident makes about $150 a month. When they get paid. This is the type of money that rich countries sponsoring NGO’s like the one I’m working for give away to make bookkeeping easier. For example, although I am a volunteer, for some reason I discovered on arrival that I would be paid a twenty dollar a day per diem. That’s two mango daquiris a night at the Plaza with a good tip. OR—four times a Haitian resident’s salary. So simply by offering the same nominal fee to Haitian “volunteers” that they offered to me, they are outbidding the Haitian hospital for their staff. Or so says my little finger.

    So when one of the graduating residents told me he was going to do “some work with MSF” after graduation, and another one asked eagerly if I had any “opportunities” for him, I didn’t have the heart to ask the third. And when I noticed that after maybe ten minutes of allowing the crowd to sample them, the ladies behind the refreshments table were whisking away the trays of canapés, still half full, and hiding them out of reach of the guests, and got to imagining which of the many hungry mouths they were going to use the food to fill, I wished I could give back the one I’d taken, and maybe just get back on the plane and go home.

    and tells another of those mind-boggling stories about health-care in poverty-stricken countries:

    An old man in a wheelchair arrived today. He and his family burst in, shoved past the guards at triage, which was closed for the two-hour change-of-shift break, and began spreading a hand-knit afghan over one of our resuscitation beds. The patient looked pale, but was talking and their story began with three months of symptoms, so I—hardass that I have become—booted the whole family out. Got security to force them to collect their afghan and their suitcases and retreat to join the huddled masses outside the iron gate. Not long afterward, an irate Haitian medicine intern returned with the patient and the family, explaining what the poor family had been trying to, had I listened—that he’d been sent over by the medicine clinic, likely needed a transfusion, Dr. Rob from the day shift had accepted this patient but neglected to mention it to me. So I let them in, and, feeling bad, sat down to talk to them. They were unbelievably nice given how rude I had been, and given the story that they told me, which was: they live in the mountains, in a tiny village. The patient, who is 85, had never seen a doctor, never had any known medical problems. Now he’d been doing poorly for 3 months, vomiting and fainting for the past two weeks. So they decided to bring him to the hospital in Port au Prince. To accomplish this, they gathered 12 men from the village, put my patient on a cot, and hoisted the cot on their shoulders. Then, for three hours they walked, carrying this cot, switching out bearers when one got too tired. After three hours, they somehow garnered a car. Then they switched to another car, and then another, which finally brough them to an outside clinic, which saw them, referred them to the medicine clinic, which saw them, then referred them to the ER, where I promptly ejected them. “Tell that story to America,” our translator said.

    If this is His will, He's a son of a bitch.
    • mk May 9,2010 7:44 am || Up

      What prevents the NGO’s from temporarily employing native doctors and nurses (to supplement the American workforce of which your friend is a part)? Or are they (temporarily employing them)?

      I’m sort of unclear on the second to last paragraph. This seems to say they are:

      So simply by offering the same nominal fee to Haitian “volunteers” that they offered to me, they are outbidding the Haitian hospital for their staff. Or so says my little finger.

      But then I thought the whole point was that the Haitian medical presence was minimal to non-existent.

      Probably I am being dense.

  5. green star oakland May 3,2010 9:55 pm

    From Highland to Haiti:

    5/1: It’s starting to blur. Last night they didn’t give me the walkie talkie to talk to the pediatricians, and there were four sick babies in the ER. And the piece-of-crap cell phone they give you at night to call the folks back at the Plaza with the inevitable disposition problems (for instance — I have a stab wound to the abdomen, continued internal bleeding, and a surgeon but no anesthesiologist, which was the problem that first faced me on arrival) didn’t have any minutes on it, so I got a friendly French sing-song recording any time I tried to call any one. This wouldn’t have been so bad, since the service on my cell phone was actually working and the charges on my future bill seemed trivial compared to what was happening in front of my face, but that @#$% cell phone also didn’t have most of the numbers I needed programmed into it.

    They are also experimenting with a new nightshift strategy where, instead of three doctors and four nurses, they are sending two doctors and three nurses. Which was just barely working until one of the nurses confessed that she’d been vomiting and had diarrhea and couldn’t work any longer. So we put her in a chair with some IV fluids and pumped her full of antiemetics. This apparently made one of the pediatric nurses realize that she was having similar symptoms, so now more nursing time was spent placing a line in HER and giving her meds. And the two of them sat in the doorway of the med room, so you had to climb over them any time you wanted to get anything.

    And then, of course, it turned out to be the busiest night I’ve had yet: I delivered two babies and we transferred another laboring woman and another was crowning just as we signed out in the morning. There were four gunshot wounds, one to the abdomen; the stab wound above; innumerable women with abdominal pain–many with vaginal bleeding and questionable pregnancy status (the thing here is to score an abortifacient on the street and then come in to the ER when you’re bleeding. These drugs are billed as agents to “restore your cycle” or some such, and questions regarding their use, and patient understanding of them are generally met with a shrug, as are your attempts to counsel contraception)—the sick babies above, one of whom had to be transferred to the ICU and intubated; a very young guy who was struck by a truck and came in cold and pulseless; a 13-year-old with appendicitis (I presume: there’s no CT scan available, but me and the surgeon I rousted by trotting myself, my iphone, and a translator out the front gates to where the phone worked, all agreed) who couldn’t go to the OR until the morning because the anesthesiologist I finally scared up to do the stab wound surgery was just off the plane from Boston and simply couldn’t stay awake any longer; two bleach ingestions (this, thank goodness, is no big deal, and the doc I was working with turned them away at the door); and then an assortment of people with fever who were very hard to assess given that we ran out of the developer for our rapid malaria tests—which people said were expired anyway. Most of them I left for the day team to figure out.

    And then there was the prisoner that Keith, the doctor I was working with, called me about. He had apparently murdered someone in full view, and the crowd commenced to attack him, at which point he was arrested and brought for care for a laceration on his head. Keith sutured the laceration, then called me because the patient was unresponsive, and he thought we might need to transfer him somewhere to get a CT scan, since he was at risk for an intracranial injury, having had the head trauma. Having worked at Highland, where all county prisoners are brought for medical clearance prior to incarceration if there’s any signs of illness or injury at the time of arrest, I am not unfamiliar with the patient in custody who becomes suddenly unresponsive when it appears that his stay in the ER is winding down and his transfer to jail is imminent. But I have to say, this guy was good—we ground our knuckles into his chest, we squeezed his trapezoid muscles with all our might, we poked between his toes with scissors, and still he didn’t awaken. But something about the way his eyes rolled back in his head, and in particular the way he actively resisted my attempts to open his eyes (even a drunk guy won’t do that) convinced me he was FOS, as we say (you’ll figure it out). I thought for a second, then grabbed his lips and clamped them together with one hand, and held his nose shut with the other hand, and waited the horrible thirty seconds while I wondered if I was suffocating a guy with a brain injury, until he moved and shook me off, proving himself to be the really amazingly good faker we’d thought. The police thought this was hysterical. I am wondering when I became who I am now.

    If this is His will, He's a son of a bitch.
  6. green star oakland May 4,2010 10:16 pm

    I don’t think I could be an ER doctor.

    5/2: We set off for work in the middle of a rainstorm like you see in the movies, where the audience knows the protagonist should just STAY INSIDE and not go out looking for trouble. But they never do.

    Just the sound of the rain on the roofs and pavement was deafening. The water was coming down so fast that just the force of it pouring down from the sky was causing splashback—the places where there was standing water looked like fountains. The thunder and lightning were loud, close, and unnerving—mainly because I was desperately trying to remember how you treat a lightning strike victim. When we got to the ER, the power was out. Inside, all we could see was the little bobbing glimmers of each provider’s headlamp against the blackness. I was coming on to work with one other doctor and three nurses. The nurses I knew were amazing. The doctor I’d just met a day or so ago, and although he is an ER doctor, he trained in internal medicine and then switched to emergency medicine before they required you to do an ER residency. I’m not sure where he practices today, but from some of the conversations we’ve had, it was clear that Haiti (or even Alameda County, for that matter) would be very, very different for him. For the first time since getting here, I was really, truly scared.

    I sent the internal medicine guy to the back to keep tabs on the patients already in the beds, the lights had come on, and I had seen about two patients in the triage/urgent care area when they told me we had “three gunshot wounds” coming in. Unclear whether there were three wounds or three victims, we all scooted to our little resuscitation area, where at least we have some oxygen, and got ready. So we looked kind of silly when they walked the first one in. A young girl, maybe twenty, she’d been shot in the mouth. Miraculously, though, the bullet (if that’s what actually caused the damage, which they swore it was) had just grazed her lip—the force had knocked out her two front teeth and broken a third, and she had a laceration that needed repair, but she was other wise OK. We sent her to the chairs to wait her turn. She’d apparently been in one of the multi-colored bus/taxi’s here that they call tap-taps (because they get so crowded that the driver can’t see if passengers have made it on board, so they tap twice on the side of the vehicle to let him know it’s safe to continue on) when somebody opened fire, hitting her and two other people. The second guy was brought in moments later: shot in his left forearm and right calf, but seemed generally OK. And the third? “They’re having trouble getting the third in here,” the triage nurse told me.

    Because there is no organized emergency response system in Haiti (this was true even before the quake), patients are often dropped off by friends, neighbors, co-workers, or strangers. Gunshot wounds are often brought in by the police, who mainly drive pickup trucks, which helps them double as ambulances, although they leave something to be desired when it’s raining. I headed outside, and could immediately see the problem. The sides of the pickup truck were high—on tiptoes I could just barely peep over and see the motionless guy in the bottom of the bed. He looked to weigh about two hundred pounds. The tailgate was stuck, and there was no safe—or even sane—way to hoist this guy’s slippery dead weight out of the truck and then get him to the ground and into the ER. I climbed into the truck.

    I would love to sound all cool about this, and I have to admit that as I was tottering over the edge of the truck bed in the dark and the rain to squat next to this poor guy in the back of a Haitian police pickup, I had a moment of feeling pretty hardcore. Then everything fell out of my pockets: my alcohol swabs, the &#$%ing cell phone we have to carry, the walkie-talkie, my pens, my alcohol hand sanitizer, the precious KY jelly packs we’re so short on, all into the river of blood and grime in the bottom of the truck bed. Funnily enough, that exact same thing happened to me on my first day of clinical rotations in medical school. Some people never learn.

    Kelly the amazing nurse climbed in with me and we assessed the guy—no spontaneous breathing, no pulses, cool skin, and at least three gunshot wounds in his abdomen and chest. I asked someone to grab the ultrasound for me, and they brought it back wrapped in a garbage bag, so I could check for cardiac motion. None. I pronounced him dead, and Kelly gathered up all my stuff, took it inside, and wiped it down with alcohol before returning it to me.

    When I came back in, I noticed Jernierlo, the medical student who has latched on to me, sitting in the triage chairs. He’d asked me the day before about a pain he was having just below his left shoulder blade. I suggested ibuprofen, he said he was worried it would upset his stomach, then I offered acetaminophen, which he tried, but said it wasn’t working and seemed unsatisfied with my evaluation. I couldn’t get him to explain to me exactly why he was so worried about this pain—I really can’t think of a single serious thing that is even remotely likely in a guy in his early twenties with two days of left upper back pain, and I told him so. I tried to figure out exactly what is going on with him, and he told me that he’d just recently found out that a girlfriend of his, who is American and lives in the US, is pregnant, and they plan to keep the baby. I thought (and still think, I guess) that maybe he’s having a fair amount of stress over this and some muscle spasm as a result. That night he facebooked me that he was still having pain, and wondering if I could do an X-ray. I told him I thought it would be low-yield, but that I could do it if he wanted. So when I saw him in the chairs, I wrote the requisition for the x-ray, and sent him on his way. He returned, it was normal as I expected, we talked again about his symptoms, I again suggested Ibuprofen, and I refused to give him anything stronger when he started hinting. When he started asking if I could check his oxygen saturation just as they were rolling in a stab wound, I shooed him out. Today I wrote him to ask if he’s feeling better, and here is his response:

    Dr Shannon ,

    it’s a good experience to be once at the patient place . And see all their grief and frustrations … I. came to see u with a pain last at the first time for 12 hours , u sent me home with anagesics . I agree , it wasn’t an emergency . But 24 hours later I came with that pain and telling it NEVER stop even with 2000 mg of paracetamol . I see now how the patient feels when he suffers and have to wait just because he cannot demonstrates his degree of pain . I didn’t came te bother u , I came because I consider as a friend and thiought that u would understand me better ( maybe it was too earlier for that …) it’s been 3 days now and i didn’t sleep and my back still hurting me CONTINUOUSLY . I will not do ER if it’s mean providing care only to clearly emergency people . It would take u only 10 mn to see me but u’ve judged me status by only looking at me and send ne home with analgesics the 1st time and ignored me the 2nd time .

    Oddly enough, that’s bothering me more than the dead guy in the truck.

    _______________________

    I always hit these great ending points as I write these installments and then realize that that point wasn’t even halfway through the shift. The rest of the night was characterized mainly by obstetrical care: we saw ten laboring pregnant women, six of whom I sent to the obstetrical hospital (crossing my fingers that they would not deliver before they made the thirty-minute trip), four of whom delivered in the ER—two of them by the other doctor in the ten minutes during which I made a well-timed trip to the restroom. There was a kid you’ll hear about in another post, and a woman that, to my shame, died without our noticing it after being put in a bed. She was 78, and I had been rude to her son when he tried to get my attention as they waited in triage. It was not my proudest night.

    If this is His will, He's a son of a bitch.
    • FreeSeatUpgrade May 4,2010 10:37 pm || Up

      Damn, that’s harsh. And these accounts are riveting. Does your friend work still work at Highland when she’s not on vacationing in tropical paradises?

      "Kraut will get you through times of no money better than money will get you through times of no kraut."
      • green star oakland May 4,2010 10:45 pm || Up

        Yes – half time in the Highland ER and half at Children’s Hospital.

        If this is His will, He's a son of a bitch.
        • FreeSeatUpgrade May 4,2010 10:55 pm || Up

          My Ma-in-law probably knows her; she’s been a critical care nurse there for like 25 years.

          "Kraut will get you through times of no money better than money will get you through times of no kraut."
  7. green star oakland May 5,2010 12:56 am

    Someone alert reztips – Port-au-Prince and Oakland have comparable violence.

    5/4: There was a magnitude 4.4 aftershock yesterday, around 2:20pm Haiti time. I was asleep in my bed after a night shift, and had just enough time to wake up, realize what was happening, and wonder if I should get under something, when the shaking stopped. I was able to go back to sleep, after reminding myself that the hotel I’m in already survived a much bigger quake (and shoving away thoughts of what exactly that bigger quake might have shaken loose). But apparently it sent a mini-flood of people to the ER—cuts, broken bones, burns, car accidents.

    Burns are a big thing here—without electricity in the tents, people cook over open fires or portable cook stoves. At home, if you see a baby with any sort of burns, you have to immediately think about calling child protective services. Here, it could be simply a matter of the older brother accidentally kicking over a candle while playing, setting the infant’s sheets ablaze.

    Another big thing is rape. Tents, escaped convicts, high stress, displaced people, heat, frequent power outages or no lights at all…you can imagine.

    And then there’s the other violence—we probably see somewhere between three and five gunshot wounds a night, with a couple of stab wounds as well. Which numbers, to be fair, may actually be remarkable for how small they are. Port-au-Prince’s population before the earthquake was around 700,000. After the earthquake, the population is estimated to be 500,000 or less. Oakland (from whence comes most of the penetrating trauma I see at home) has a population of around 400,000, and I’d say the number of gunshot wounds and stab wounds that will come in to the ER in a typical night in Oakland is roughly similar to here—and that’s with a functioning police force, good street lighting, and, I think it’s fair to say, generally better living conditions.

    For instance, even the worst tenement houses in Oakland, while often decrepit and rat-infested, generally don’t just fall down. Last night a car pulled up, and a man got out carrying a child, head completely wrapped in a bloody shirt. I unwrapped it to find an unconscious child covered in dust, grit and gravel, with a gash the size of Texas in his forehead. The man who brought him told us that he had been in his own house, heard an enormous crash, and run outside, to see that one of the abandoned houses across the street had collapsed, essentially crushing the house next door to it, where this child and his family lived. The neighbor ran across the street and was able to extricate the child first. He brought him in, but was desperate to get out of the ER, to go back and try to pull out the kid’s parents.

    I was just glad the kid was still breathing, since Tania, who went home yesterday, has had multiple dead or dying three-year-olds dropped off when she’s been on, and always seems to get the really dramatic stories. She told me that the other night a car pulled up and dropped off a limp twenty-something-year old. The story? Sitting in the bathtub when an electrical wire fell from the ceiling and into the water. Dead on arrival.

    My whole stay in Haiti I’ve been treating patients complaining of palpitations—no evidence of anything clinically wrong with them, but they’re constantly aware of their hearts fluttering and pounding in their chests. I’m beginning to understand why.

    If this is His will, He's a son of a bitch.
  8. green star oakland May 7,2010 2:41 pm

    And the last of these, encapsulating all that’s right and wrong with what’s going on there.

    Last night was my last shift. I was happy to go out on a night shift, since that’s when things really are crazy. So of course, nothing happened. And by nothing, I mean NOTHING. Well, sure, there was a 30-week premie dropped off, still with a slick of amniotic fluid on her cheek. She’d been born about an hour and a half before at an outside hospital. The mom was still at that hospital; the baby arrived in the arms of her father, who apparently had been told to just drive to us as fast as he could, since she was having a hard time breathing.

    We happen to be well supplied with pediatricians at night now, since, for political reasons that I don’t totally understand, the American pediatricians have relinquished control of the pediatrics service during the daytime, so they now only work at night. There’s also an anesthesiologist. So I let them work on the baby while I went to call Big Paul.

    I can’t believe I haven’t mentioned Big Paul before. Big Paul works with Global DIRT—those guys (and a girl) who I noticed tromping through the ER one day, when I was still bewildered by all the NGO’s. Which I still am, but I’m starting to understand Global DIRT—they are a small organization, started by two marines right after the earthquake. Their mission seems to be small-scale medical transport and networking. And they are extraordinary at it, in part because every member of their team has given up on sleep, food, water, and personal safety.

    At any rate, there is a list of phone numbers taped to the whiteboard in the ER: the OB hospital (the hospital’s OB/gyn doctors are on strike and have been the whole time I’ve been here), the ambulance driver, MSF France, MSF Spain, the University of Miami Medishare. But, as Rob warned me when he handed me the @#%$ing cell phone on the first night, no one ever answers those numbers anyway. Nevertheless, when I needed to transfer a patient, I used to call all the numbers, one by one, cursing the phone and the non-answerers all the way. No one ever answered. Now I just call Big Paul, who in the US is a fairly high-powered fashion photographer, but here is simply my savior. (I swear that first part is true. Here’s his website, and here’s his blog, which interplays interestingly with my own for the past few days. Guess who the “doctor with desperation in her eyes” is.)

    So, I called Big Paul. He answered the phone “Hi, Shannon, what is it?” since by now he recognizes my number on his caller ID. I explained that I had this premie that I wanted gone, and that, of course, Miami medishare hadn’t answered the phone when I called the numbers I had. “OK, call me back in 8 minutes,” he said.

    I walked back into the ER to check on the baby, setting my alarm as I went (Hey, the guy who can get this baby off my hands wants a call in 8 minutes, I set a timer). Four minutes later I got a text “Can take baby to UM. Get ambulance ready. Little Paul will be there in five minutes.” Yes, of course there’s a Little Paul. Although he’s not so much little as he is littler.

    So I set off to find the ambulance. Actually, the ambulance was easy—there were two parked by the ping-pong room. It’s the ambulance driver that was hard to find. Twenty minutes I tromped around the campus of the hospital, banging on any car with anyone sleeping in or around it, rattling the gate of any gated building, and interviewing anyone sitting around who looked vaguely official. “Welcome to Haiti,” the grinning guard accompanying me kept saying. No one would even admit to ever having HEARD of an ambulance driver. Except the guy in the morgue, who hopped right up and acted like he knew exactly where he was, but then started leading me to all the places I’d just looked. Meanwhile I’m madly texting Big Paul, who I later heard was trying to finally relax poolside at the Plaza, having handed the case off to Little Paul, but was nevertheless taking breaks to text back with one watery hand. He had some kind of phone number for the ambulance driver, and although the morgue guy took the credit, I think it was Big Paul that I can thank for the fact that the ambulance driver suddenly appeared, apparently entering the campus from the front gate. So off the baby went, just thirty minutes after presentation, with a pediatrician, Little Paul, and an oxygen tank in the back of the ambulance.

    And we went back to doing literally nothing. I have never had a slower night at any hospital ever. I read about complications of childbirth. I read an entire mini ultrasound textbook on my phone. I fleshed out the biographies of everyone I was working with, including the ICU attending, who is a cardiologist in Canada. But, he informed me, there “once you’re a doctor, you can do anything.” I’m sure it’s not that simple, but in addition to cardiology, he does ICU and emergency medicine, and I got the idea that he’s pretty sure he could also walk on water, if he bothered himself to try. He also learned that I was a resident, at which point he asked who was “supervising” me, and seemed unconvinced when I told him that even at home, I can work unsupervised as long as it’s not at the hospital at which I’m training. To be fair, I don’t totally understand that, either.

    Then it was 5:30 in the morning, and I was just beginning to think about walking around and making sure nothing needed to be done for the patients remaining in the ER before we signed out at 7am, when Hazel came running over from the ICU side to get me. When you see a nurse run, you should, too, so I did, and she led me to a corner bed in the ICU, where an intubated kid, maybe about 14 years old, had apparantly pulled out his tube. His oxygen saturation was now 50%, according to the monitor (normal is 100%), and there were no ICU staff in sight. As I snipped the tape holding the tube in his mouth and pulled it out the rest of the way out, then tried to get a mask to make a good enough seal on his face so that we could bag some air into his lungs, I realized who this kid was.

    This kid has diphtheria, and was known to me for two reasons. First, Sean Penn himself (who has been over here essentially since the earthquake, lending his name and funding-generating-capacity to a clinic here, while also occasionally staying at the Plaza) had transferred the patient to us, and then arranged for enough vaccines to cover all the unvaccinated Haitian staff, patients, and family members put at risk by the kid’s presence. Second, my new friend Keith, a self-professed “old-timer” ER doctor, had intubated the kid. He had described this intubation at the pool after his shift. Diphtheria causes a “pseudomembrane” to coat the tonsils, nose, throat, and airway. According to Keith, that’s an in-apt term. What he saw, when he looked in the back of the kids throat, was “Malt-o-Meal. Nothing but Malt-o-Meal. It just looked like a big grainy mass of gunk.” When you are intubating a patient, what you are trying to do is to shove away all the soft tissue in the back of the tongue and throat, while also lifting up the jaw enough to expose a hole the size of a pea, that is located deep down in the neck, right around where the adam’s apple is in men. You are then attempting to hold the jaw and soft tissue up out of the way with the one arm holding the laryngoscope (the strength required to do this generally makes my arm start to shake after about 10 seconds) while aiming a plastic tube the diameter of a pencil at that distant pea-sized hole. On the way, there are landmarks—you sweep the tongue out of the way with your laryngoscope, then note the epiglottis behind which you know that pea-sized hole is, then you lift that up, hoping to expose that hole, then hoping that you don’t lose your view, either because your arm gets tired or someone jostles you, while someone hands you the tube and you advance it through that hole.

    The idea of a mushy-cereal-like substance covering all of those landmarks and that pea-sized hole strikes fear into the heart of any ER doctor. So we were all crowded around, listening to hear what Keith had done. He described how he took a bougie, which is a long, thin, piece of rubber, thinner than the intubating tube, and poked it where he thought the hole should be, then got the right feel as the bougie went down the trachea. He then slid the intubating tube over the bougie, and slid out the bougie. This had worked well, and he jokingly made the motion of brushing his hands off nonchalantly. We all laughed because we knew that, as long a time as he’s been doing this, he was terrified–and then so, so relieved.

    That kid had now managed to pull out the tube Keith had been so lucky to get in. And we couldn’t seem to get his oxygen saturation up with bagging. I was the only doctor there just long enough to ask someone to get the intubating supplies, and then the ICU team returned. This is always a tricky situation in medicine—generally the first person in the room remains in charge, unless someone arrives who knows the patient much better or is more senior. The cardiologist/ICU/ER attending had both things going for him. I offered to try to intubate the patient, but he said no, pointing out that he and “two ER doctors” (you could hear the subtle stress on the word doctor, as opposed to resident) had worked for twenty minutes to get the airway the last time. I stepped aside and handed him the supplies.

    It is hard to overestimate the stress level surrounding the unplanned, difficult intubation. This kid’s bed was in the corner, you can’t get to the head of the bed because these beds have an actual headboard that doesn’t come off, and you can’t do an intubation leaning over it, so you have to angle the patient in the bed. Meanwhile, there is a crowd of people trying desperately to be helpful but getting in each other’s way. And they can’t really help you—once you have the tools in your hand, you will either do the procedure correctly, or the patient will die. It’s that simple. It’s always what they call in medicine a “tight-sphincter moment.” And when it’s a child, your own head starts to do this odd spinning/floaty thing, while your vision narrows down to one tunnel exactly the width of the child’s body. When it’s a high-profile child (which it turns out this one was—I didn’t know this at the time, although I suspect the cardiologist/ICU/ER guy did, but CNN was planning a story on this kid), then—I can only imagine.

    The c/i/e guy passed the tube. I listened over the kid’s stomache, and heard loud gurgling. Not good—the tube had gone into the esophagus, instead of the trachea. The kid’s saturation was now zero. The c/i/e guy tried again, while I went to find a scalpel. When all else fails, you can do a crichothyrotomy—that thing they do in the movies with the pen in the neck. It’s bloody, and some ER doctors go their whole career without doing one, and you need to follow it up with a surgeon to make it pretty. But the surgeons are on strike.

    When I got back, c/i/e guy had tried a few more times without success. I handed him the scalpel. But apparently, while I was gone, the RT had suggested that before we cut into the neck of this 14-year-old kid, maybe he should let the ER resident have a try at intubating.

    All I can say is thank God I’d been sitting there listening to Keith’s war stories. I got the laryngoscope in and thought, “Huh. It does look like Malt-o-Meal. Or maybe polenta.” I lifted the epiglottis, did the little extra hike I always have to do to get a view, got my view of where that pea-sized hole should be. I saw a depression in that granular stuff that looked like it was the right shape. Then that wonderful child did something: he made a tiny effort at a spontaneous breath. I saw a bubble emerge from the malt-o-meal. I kept my eyes on the spot where that bubble had come out, not moving, even when they handed me the tube instead of the bougie (tempted to use it anyway, since it was in my hand, I rejected it, deciding I was going to aim for exact replication of Keith’s story), even when they handed me the wrong end of the bougie. When I got the right end of it, I stuck it right where that bubble had come out. The bougie stopped short after I’d advanced it a bit, just as it should when it hits the spot where the trachea splits into the two mainstem bronchi (if you put it in the esophagus, it will just go and go, since it can curl up in the stomach), and we got the tube in place.

    Unfortunately, by now the kid had lost pulses, since he’d been maybe twenty minutes without oxygen to his brain or heart. We started CPR, and I gave that kid every medicine I could think of to make him better, while his sobbing father (who had been the one to alert the ER nurse that something was wrong, since there wasn’t an ICU nurse or doctor to be found) looked on. Just as I was about to call it quits, I heard someone say those wonderful words: “I have a pulse!”

    Except that, of course, with each passing minute of a code (what we call a bad medical situation like the above), those words become less wonderful, since they become less likely to mean “full recovery” and more likely to mean “vegetative state.”

    I heard that CNN called the hospital the next day to inquire about the patient’s status, since, I was told, “they don’t want to do the story if he’s dead.” I have no idea what they told them, but I doubt that “only time will tell” was the kind of answer they were looking for.

    Tomorrow Shannon flies home from Haiti while I fly home from Paris, and on Sunday we’ll meet up with our respective families and some friends to read “Under Milk Wood” together. My guess is that it’s going to be a little bizarre.

    If this is His will, He's a son of a bitch.
    • FreeSeatUpgrade May 7,2010 3:01 pm || Up

      Please tell her that Free Kraut thinks she’s amazing (which will make her think you’re insane, but narytheless).

      "Kraut will get you through times of no money better than money will get you through times of no kraut."
      • nevermoor May 7,2010 8:36 pm || Up

        Concur

        "There's never enough time to do all the nothing you want"
        • green star oakland May 8,2010 5:04 am || Up

          If I make it home (estimated flight departure time 10:35 1:15 3:30 4:40) I’ll be sure to pass on the Kommendation.

          If this is His will, He's a son of a bitch.
          • Leopold Bloom May 9,2010 12:41 am || Up

            Amazing story. I love Under Milkwood.

            • green star oakland May 9,2010 11:03 pm || Up

              I saw Shannon today, and she told me the sad news that the boy had died.

              She also pointed me to this video of Sean Penn going crazy loco on CNN.

              If this is His will, He's a son of a bitch.
              • Leopold Bloom May 10,2010 1:50 am || Up

                Wow. Sean…I loved Sean Penn. Sounds like he really has a pretty deep understanding of what’s happening there, and he’s pretty pissed about it.

  9. mk May 9,2010 7:45 am

    I am always enormously impressed by people who are constitutionally sturdy enough to undertake things like this, because God knows I’m not.

    That was all really well reported (i.e. not maudlin or self-aggrandizing or hyper-apocalyptic). It was also exhausting and sad and frustrating. If/when she does complete the full article, definitely let us know where we can find it.

    And boy does “they don’t want to do the story if he’s dead” perfectly encapsulate all that is evil about short form, heart strings media.

Leave a Reply