Thursday, March 4, 2010

A few thoughts as I reflect on my two weeks in Haiti

By Mark Haseman, RN

As I sit before my computer, a mere 4 days since returning to Chicago following my 2 weeks at University Hospital in Port-Au-Prince, I can't help but feel pangs of guilt and perhaps a bit of jealousy. I know there is someone else in "my tent", working as hard, or harder than they ever have, likely way behind on fluids and nutrition, without adequate space or resources, and loving every minute of it. As I grow older, time passes faster, with the calendar now behaving much more like a clock; still it amazes me how quickly my time in Haiti flew by.

Even more amazing is how much can be accomplished, under what can only be described as deplorable conditions, by a group of dedicated, committed, passionate, and ever so hard working professionals with singularity of purpose. I won't even attempt to name names, as I do not want to risk missing anyone. Those of you who served know who you are and what you did and I salute all of you. I know I will think of you often when I return to "work", and will not feel that sense of global camaraderie that was so prevalent in those 2 ER tents.

Our team arrived a month after the earthquake, during the commemorative 3 days of national mourning. Of course, people didn't stop getting sick, they just stopped going to the ER so they could mourn and pray. The number of patients had been comparatively low as a result, but the respite ended abruptly on Monday. At one point on Monday the hospital administration, toting a bullhorn, announced to all that only the sickest people would be treated and all others should come back another day. Guess they don't have to worry about Emergency Medical Treatment and Active Labor Act here!

For the most part, by the time we arrived, direct quake related injuries were few and far between. However, there was still the occasional fractured ankle here or arm there, and even a woman who had suffered 2 pelvic fractures and a fractured ankle. She arrived with her family, who had carried her on a wooden door as a stretcher. Traveling an unknown distance "from the hills" and in no doubt considerable pain, they finally arrived at the University Hospital a month after her local hospital was unable to provide anything more than an x-ray.

Of course there were plenty of quake related illnesses, in particular Diabetic Keto Acidosis (DKA), a result of diabetics not being able to get any insulin to treat their disease. Even the ER ran out of regular insulin on more than one occasion and was constantly low on normal saline. Laboratory services were very limited, often taking up to 8 hours to get a result, further compounded by chronically short supplies of finger stick blood sugar monitoring equipment.

There were so many cases of malaria (which reminds me, I haven't taken my doxycycline yet today), typhoid, much of which was suspected, as the lab was always out of reagent to run the test, rabies, tetanus, TB, HIV, pneumonia, cellulits/wound infections and a smattering of CHF and asthma. With only 1 oxygen tank per tent and only one regulator to share between the 2, it was very difficult to treat shortness of breath, regardless the etiology. We could give asthma breathing treatments but only to one person at a time via an archaic nebulizer machine. We did have to resort to the occasional SubQ epinephrine, though we eventually scored a supply of prednisone. CHF was a bit more difficult, as we had a limited supply of IV lasix, no EKG machine, and no way to follow cardiac lab markers. Sublingual nitroglycerine, perhaps a nitrodur patch and oral lasix, and hydralazine, or calcium channel or beta-blocker, if we had any in stock. Morphine was usually in adequate supply, however the concentrations available would make any JCAHO investigator apoplectic. For much of the time we were forced to use intrathecal concentrations of 50 mg per 1cc, with a standard dose being 2-4 mg. They told me there wasn't going to be any math!

I haven't even mentioned the volume of pediatric patients, most of whom were treated outside the "waiting area”—a tarp stretched out from the front of the first tent. I really have no idea how many patients were out there during the course of a day, as only the really sick ones made it into a tent. That said, I am eternally grateful to our Pediatric Nurse Practitioners, as well as the doctors and nurses who threw themselves on that grenade day after day. It was a noticeably better environment when they were around.

That leaves us with trauma, of which there was no shortage. Daily, we treated gunshot wounds, vehicular trauma, and the occasional loser of a machete fight. We were fortunate to have 2 portable ultrasound machines, a functioning operating room and usually enough surgeons around to treat those that needed surgery. Ultrasound came in handy a few times gaining IV access in patients and it was the only "pregnancy test" available for part of the time here.

Vehicular trauma was plentiful, and it only took a short bus ride to see why. Narrow streets lined with tents and vendors, thousands of people walking in and out of traffic, and cars, buses, motorbikes darting all over in seemingly random fashion. Cars and bikes passing on the right or left, sometimes 3 across. There was such a constant honking of horns that I began to think Haitians believed horns somehow provided protection while driving.

Patients would occasionally arrive via police vehicle, but as there seemed to be no 911 system or any other way to summon emergency services, most of them arrived via private vehicle. One evening I heard some commotion out front and went out to see what was up: a young woman in the back of a pickup truck had been struck by a car. She arrived with a horrible tibia and fibula fracture. The ED was full, so we popped an IV in her, gave her Etomidate and reduced the fracture under conscious sedation right there in the back of the truck. Fortunately, earlier in the day I had discovered a large, heavy cardboard box full of crap, which I emptied just to clear some floor space. Realizing we had no orthopedic supplies, I pulled out my Swiss Army Knife and carved the box into manageable lengths suitable for splinting material, a scenario that would be repeated many times over the course of the next few days. It was rather refreshing to do conscious sedation without a crashcart or nervous resident checking intubation supplies.

That was Monday—Tuesday would be even worse!

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