Thursday, May 13, 2010

"Lost Track of Days"

Dr. Mark Courtney is from Northwestern University and is representing the Chicago Medical response team with International Medical Corps in Haiti.

I've kind of lost track of days. It's Sunday. A large group of new doctors and nurses have arrived. That means a whole lot of the old people have left as of last night. We got a room for the 3 of us who deployed together. It's got a single gigantic king bed and smells like an ashtray but it's got a shower -- hallelujah! The shower I took this am was the second since I've been here.

Another improvement is the presence of Haitian staff. Hard to know who will be there at any given time and for how long but at least we are moving in the right direction for now. This is the major challenge during this transition time. We've introduced a very high level of care (by Haitian standards) and transitioning some (not all) of this will be the main work of the future.

There are great examples of excellent care being done exclusively by Haitian personnel. The pediatric feeding tent is a great example -- there are regular measured feedings of formula and measured daily weights and as a result, the kids getting better. One orphan was dropped off at our ED weeks and weeks ago by an aunt has since gained a kilogram. Came in at around 7 months and weighed 3.2 kg. That's about 7 lb. He's been in the feeding tent since then and doing well.

Another example is the TB program. Pretty much everyone gets oral observed medication (given and watched by an nurse). It’s supervised by Haitian nurses but single handedly lead by an Dr. Megan, who's down here on her own for who knows how long. She's essentially put her fellowship on hold to care for these patients.

I'm pretty tired now and eager to get some sleep. Worked the 10-7 swing shift. Am on at 7am tomorrow.

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Wednesday, May 12, 2010

Halfway Through Deployment

Dr. Mark Courtney is from Northwestern University and is representing the Chicago Medical response team with International Medical Corps in Haiti. We'll be posting his updates from the field over the next week.

At this point I am halfway through our deployment.

I have seen a rapid transformation of the emergency department in a short period of time. Right before we arrived they had recently just moved all ED operations out of the tents and inside. That being said, in many ways it is not at all like an ED that you could imagine. To reiterate, we have no X-ray, no CT scan, no air conditioning, no flushing toilet, no running water even. We are using gel hand wash between patients. At one point while working in the ICU, I successfully discharged a patient with congestive heart failure (a major achievement) and the family started unplugging all these fans that were around her. I was a bit upset and not sure what to do about them stealing what to us was a precious commodity until I relized that all the fans in there were belonging of the patients and their families that they brought in.

All our oxygen comes from standing huge oxygen tanks that have to be rolled slowly and carefully around from patient to patient. During one ICU shift, we had to scramble to jerry rig some splicing and tubing to get 5 patients oxygen that normally would be allocated to one. There are no monitors to continuously monitor patients (well that is not true -- there is one but only one and saved for the sickest patient). We transfer patients to "the medicine ward" which is a frightening place with billions of sick patients packed in with near darkness and often no nurses or doctors to see them for days at a time. Honestly it is better to send people back to their home or tent even with severe illness than to the medicine wards which are at times affectionately termed “the catacombs”.

Still in many ways our ED has rapidly evolved to look exactly like an ED back home. This is amazing since there is no history of emergency medicine or even an "ER" in Port-au-Prince. True, they had a pre-existing "urgent" department but this was not in any way staffed 24 hours a day with an emergency specialist. Just 3-4 weeks ago they still were seeing ED patients in adjacent tents. So it is surprising to now see people coming to our ED with things like chronic pain, anxiety, sickle cell disease, hoping to get surgery for a long standing problems or at least a second opinion. These problems in the US are common ED presentations but are best dealt with in other departments.

It is also not uncommon to get "transfers" from other hospitals or clinics without much regard for our capacity or environment. Some other medical NGO's will not send us patients in an ambulance with a note in French stating need to be admitted for surgery or oncology care without any understanding that at the time our surgeons happened to be on strike (well not sure you can say they are on strike since they have not been paid for months many not since the earthquake. Is that called being on strike or is it just not having a job?). Anyway this movement of patients from hospital to hospital is a totally a common occurrence in the US and it is amazing to me that our ED and the overall health care delivery system has some of the same problems we see in the US. The good things are that we can transfer patients to higher level of care for some things, for example women who need a C-section. I recently got a patient of mine with burns over 50% of her body transferred to a hospital that specializes in burns.

Anyway, things here are progressing -- most would agree that the state of emergency health care here has never been better (at least for the poor in urban Port-au-Prince). The challenge is how to maintain it in a sustainable, local manner.

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Monday, May 10, 2010

"Survived the first night shift."

Dr. Mark Courtney is from Northwestern University and is representing the Chicago Medical response team with International Medical Corps in Haiti. We'll be posting his updates from the field over the next week.

OK. Survived the first night shift.

It's now day 6 in Haiti. Kirk and I were the night doctors and overall had an outstanding experience. We resuscitated a CHF patient who otherwise would have died -- as of this morning they were giving us the thumbs up sign. The usual machete wounds to the scalp were a bit more common at night. There was a case of diphtheria, which is minimal risk to us but maximal risk to Haitians with almost no vaccinations.

Yesterday we saw a kid with a leg fracture happy to be splinted and another standard shoulder dislocation. Unfortunately there was a very sick septic baby who may or may not make it but there is an unbelievable team of pediatricians here from Partners in Health -- many are from Boston Children’s Hospital. Bottom line is there is incredible talent here.

There are plenty more crazy medical stories but I've now really connected with the people here, which is perhaps equally rewarding. For example, our translators are young Haitians hired by International Medical Corps. Many of them live in tents. They speak Creole, French, Spanish and English and most are self taught. One guy is looking for an English slang dictionary to hone his skills. One is working 12 hours nights with us and then is in school during the day and is only 18. They are smart as can be and the hardest working people in hospital. We rely on them massively.

In medicine, without CT scans and blood tests, the history a patient tells you becomes all the more critical. I'm really looking at the positives. There are plenty of kids in school uniforms going to school every morning who are healthy. They hold hands and smile at each other like other kids. Things are clearly better than in the past and better than they could be. I'm just trying to add a bit to that. Sometimes just talking and listening to people is as helpful as medicine and high levels of US style care.

It's raining cats and dogs right now but cooling things off.....

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Friday, May 7, 2010

Figuring it Out

Dr. Mark Courtney is from Northwestern University and is representing the Chicago Medical response team with International Medical Corps in Haiti. We'll be posting his updates from the field over the next week.

Starting day three. Yesterday I worked triage. This was challenging; due to the very limited resources you really have to figure out if you should bring people back.

There is no CT scan -- the chest X-ray is reserved only for the most sick patients. We’ve been seeing lots of cerebral malaria but they get better pretty quickly after an IV of quinine. Bottom line is patients with symptoms that at home that would mean a hospital stay, like mild chest pain that could be early heart attack, sky high blood pressure, or moderate pneumonia, in Haiti are treated with some pills and returned to their home-tent. They almost have to be in some respiratory distress, altered mental status, or high fever. Almost everyone else gets sent out or treated in a triage chair.

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