Note: The first post in this series can be found here.
(EDITED TO ADD: I'm having problems posting pictures how I'd like to; the next post will feature photos and captions!)
The next morning at the ungodly hour of six am, I got up, shoved a breakfast of bananas, fruity pebbles, and one teeny tiny cup of weird coffee down my gullet. We got on the bus to drive the five blocks to the hospital, passing more rubble and tents on the way.
When we got to our headquarters at the hospital campus, I learned to my surprise that I would not be working in the ED, but in the ICU. I was a little disappointed, because I knew that the ED staff would be seeing a lot of great stuff--sad, funny, interesting--and that the nurses from our group in the ED were very independent practitioners, diagnosing, treating, and discharging the simple patients from triage ("fais mal"? Here's some ranitidine. Bye! Vaginal discharge for a year? Here's a scrip for the GYN clinic). They often did sutures, and occasionally were allowed to tap a lung with a physician supervising. I had been looking forward to all of this.
The ED was very similar to the ones we know--in character. Tons of people for whom it was the only access to medical care, a lot of BS complaints--and a lot of not BS. It became obvious that when a patient came up to triage, screaming "Mes amis!! MES AMIS!!" (which literally means "my friends" but in a vernacular sense means, "lookie here, I'm freaking out, please help me") that they were not that sick--so much so that it became a triage designation: Emergent, urgent, less urgent, and "mes amis." However, there was a lot of TB, a lot of typhoid, a lot of malaria, and--tetanus! There were treatment guidelines posted everywhere: "See Stroke, seizure, eclampsia, HELLP: think MALARIA and treat with 600 mg IV Quinine in D5NS over 4 hours. See fever + diarrhea OR constipation OR abdominal pain AND/OR perforation, THINK TYPHOID; give ceftriaxone 2gm IV or IM or Cipro 500 po/400 IV BID or Azithromycin; consider steroids for shock."
Anyway, despite my disappointment not to be placed in the ED, I realized I was there to help out in any way I could, and headed into the ICU (an extension of the main ED) to learn the ropes. Fortunately I had the fantastic Ms M, RN to show me. She is a nurse from Chicago who had grown up in Haiti until she was 13. It was great to have a nurse who spoke the language--we had translators everywhere, but none of them were medically trained, and so sometimes things got lost in translation.
I can't even describe the feelings I had on getting report and seeing what actually went on in this "ICU"--the first and only one in a Haitian hospital. It was a large, dark room filled with 19 low mesh cots. There were a few windows on the far end of the room--windows that had no glass, just badly damaged screens to keep out the mosquitoes. A 100-pound oxygen tank stood in the middle of the room; it had eight or ten regulators coming off of it and extension tubing was running all over the room, strung up from pipes hanging down off the ceiling. No IV pumps, no cardiac monitors. No running water. Intermittent electricity. One sharps container. One or two anemic fans that blew the sticky, stinky air around. (Florence Nightingale was rolling over in her grave!) My heart sank. This was no ICU--it was less than a med-surg unit back home! My first thought was, "Ugh, floor nursing! I'm going to be a medication waitress in Haiti! Oh, no, two weeks of this? Oh boy."
Then I realized how stupid I was being and decided to throw myself into the work, for better or for worse; all I could do was the best I could do and by golly, I was going to be the best I could be.
For my first day, the two other ICU nurses went easy on me and gave me six patients. I had "the twins": two 28-year-old women, not related to each other, but both with the same problems: HIV, encephalopathy, bedsores. One had an NG tube, and one didn't; that was how I told them apart. They had been there for months, slowly recovering. I had an older man who had suffered a stroke: aphasic, dysphagic, unresponsive. His plan of care? Palliation and waiting for him to die. I had a few young people with TB. I honestly don't remember a lot of the patients that first day.
I busied myself doing vital signs (I had bought a tiny pulse oximeter for the trip and MAN it came in handy), assessments, and giving morning meds, something I hadn't done for years. All the HIV and TB patients had a zillion pills to take, everyone was on Ceftriaxone 2gms IV BID--and we had no piggybacks! And hardly any NS! (Ceftriaxone can't be mixed in LR.) I ended up mixing it in a 10-cc flush and then pushing a little at a time over 15-30 minutes. It became almost a game: assess, push a little ceftriaxone on everyone; chart, push a little ceftriaxone; prepare some other meds, push some more ceftriaxone. And so on down the line.
Fortunately, most of the patients had their families with them. The family brought linens, washed and dressed the patients, brought food and fed them, helped them with toileting (usually squatting over a bucket on the floor), and would administer meds and tube feeds as provided by the nurse. The care these people gave their loved ones was inspiring and amazing. They worked in shifts; at night they would sleep on cardboard under the patients' beds. They were all eager to help in any way possible, and were so grateful for what little we could do for their relatives. What was even more moving was when a patient had no family, or their family was far away, the relatives of the patient in the next bed would try to help as much as possible. All of us nurses pitched in with the patients with no family: we'd bring them food from our headquarters, give them half of our lunches, try to get them out for a shower or at least a bed bath, and the translators would shave the men's faces and heads for them. The families would pray for each other; during resuscitations or codes they would gather belongings and try to stay out of the way. Once during a terrible code on a young woman with postpartum cardiomyopathy (something I'll write more about later), the tiny portable vent/c-pap machine kept tipping off the bed; there just were not enough hands as we struggled to get a line in her swollen body, and hang dobutamine without a pump, just counting drops the old fashioned way. I became aware of hands beside me, holding the vent in place--when I looked, I saw it was the young man with TB/HIV from the next bed, standing up, holding the vent up with one hand and the young woman's IV bag with the other. The generosity and community that these people showed with one another was remarkable.
Occasionally a patient would be discharged or transferred out to the medicine ward--the "catacombs." This was a huge ward of cots where patients could languish for weeks--even months. Dark, hardly any windows, a doctor would come by a couple of times a week. No nursing staff at night, and barely any during the day. (We found out that the nurses had not been paid since OCTOBER but would show up occasionally to keep from being fired so they could still collect their back pay--whenever that might happen.) Then another patient from the ED would come to take their place.
Up next: Photos, followed by vignettes from the ICU.