When I got my Haiti orientation letter, one thing I noted with trepidation was the paragraph that stated "Medical care in Haiti before the earthquake was abysmal by American standards."
And that's before people started living on rubble heaps, in tents, with poor sanitation and resources.
The same paragraph stated, "You will see people die who would not have in our country, with access to the resources we have."
One of my friends who had been to Haiti a month before said that triage in Haiti is true "black triage": it's necessary to decide who you can save before you spend the few resources available on saving them. "Of course," I remember responding. "That's the way it has to be."
What I didn't understand until I was there was how much that really sucks. There are decisions you make every day that you never thought you'd be making outside of an ethics class. There are decisions that are taken out of your hands by the failure of other people to act.
We palliated a lot of people: Severe stroke leaving the person minimally responsive? IV fluids, and wait for them to die. Sepsis not responding to antibiotics? IV fluids, morphine, wait for them to die. Sometimes we'd pass an NG tube to feed people, but they would often aspirate. IV fluids, morphine, wait for them to die. Our rule of thumb was to not intubate anyone who would need to remain on the vent for more than 24 hours. We only had one vent.
Who do you intubate? The 2-year-old in status epilepticus? Or the 39-year-old man who is status asthmaticus, gasping like a fish with an 02 sat of 55%? (We intubated the todder. She died. The man walked out the next day.)
There was a 15-year-old kid with renal failure. He was in the ICU when I got there, and I don't remember the cause of his kidney disease. He had had a dialysis catheter placed in his neck, and was doing well on dialysis, as we figured out what to do with him; there were rumors of a family member in Miami, and we were trying to think of how to get him there. Then the catheter failed. He was only able to get about an hour and a half's worth of dialysis one day. Surgery was called to either fix the catheter or insert a new one; after two days of waiting and wrangling, and as he became more and more unstable due to fluid overload, a new catheter was placed in his groin. We were so happy! He could go for dialysis the next day!
Or so we thought. The next day was Saturday. The dialysis area in the hospital was not staffed on Saturday, we were told when we brought the kid over for treatment. Even if it was, there's no electricity today. I pointed out that the World Cup was on--right on that TV over there! So there has to be electricity! No, no electricity. Sorry. The kid's doctor pointed out that he could die without treatment, please, is there any way? No, sorry. Also the last shipment of artificial kidneys was sold to a different hospital. What if we got one, we asked, what if we bought one from somewhere? No, sorry, no dialysis today. Sorry.
We took the boy back to the ICU and our coordinator began calling the other organizations in the area to see if they had access to dialysis anywhere, or supplies, or anything.
That night the kid coded. The night staff intubated him and got a pulse and blood pressure back, but brain death was confirmed the next morning by our staff, even though he was still breathing a little on his own.
So we decided to extubate the boy, and put him in the back of his parents' car, so they could drive him the twelve hours to their tiny farm in the mountains. He would die there, or on the way there, and this way the family would not have to pay the $25 that the hospital would charge to get the boy's body out of the morgue. Twenty-five dollars is about two or three weeks' wages. To get a child out of the morgue who would not have died had the hospital provided dialysis.
Did the boy's relatives scream and cry? Did they call down hellfire and the wrath of many lawyers on the hospital that basically contributed to the death of their child? Did they scream at us?
No. They took his body and thanked us. And that was the worst part.
It just illustrated how cheap life is when you have nothing.