Black Triage part II

That's a picture of a CT scan. Please excuse the box labels you can see through it; and the florescent lights behind it.

That's the neck of a 20-year-old man with a huge mass in his neck from the bottom of his jaw to the top of his collarbone; his airway is at the upper left of the picture--and that's at it's widest point. At its narrowest, it was about the width of a coin slot.

He came to the ICU from the "Catacombs"; the medicine ward where he had been languishing for months. He had a PEG tube through which he was fed, but was having a lot of pain and his airway was obviously diminishing--you could hear the stridor from across the room. The tumor was starting to come through the skin of his neck.

We had no hopes of doing anything for this guy; we were waiting for an obligatory consult from ENT--for a week. We were in the process of shutting down the ICU because the hospital management had decided to take back control of their facility; we had already pulled out of the ED, leaving it to the Haitian doctors and nurses. Hospital administration stated that they didn't have the staff or the desire to keep the ICU, and so we stopped taking admissions. This young man was one of our last three patients left.

We gave him IV fluids--he was convinced that there was some "medicine" in there that prevented pain, so we ran fluids slowly, continuously. His family fed him gruel through his PEG.

It was obvious that this kid was going to die. So over dinner we had the most macabre conversation I have ever had in my career: What are we going to do when his airway finally fails, or a blood vessel in that vascular tumor bursts? What do we do to help this kid for the five or so minutes until he dies?

This was not a hypothetical question.

One nurse who worked in ENT and had seen this sort of thing before suggested Versed, which was nixed because we didn't have a lot of Versed, and we couldn't waste the little we had on this. Morphine? No. So what we finally decided on was Etomidate, 20 milligrams. Sort of like a Rapid Sequence Intubation without the intubation part. The next morning we taped a vial of the etomidate and a syringe next to the bed.

Because we were closing down the ICU, there was no need for all of us to hang out there; people were needed to pack up our headquarters and redistribute our supplies. We took turns sitting with this kid and his family. When it was my turn, I listened to his every breath whistling in and out of they tiny opening that was his airway and prayed that that eensy slot would hold up. Would I be strong enough to do what had to be done when the time came? I was pretty sure I was--but I've never had to face this before, at least not with a human.

At last, the ENT surgeon came to evaluate the patient, and of course, after seeing the CT, declared that it was hopeless. Even in the United States, a tumor that bad would be inoperable--but it would have been caught long before it became inoperable.

So this was another one we sent home.

Black Triage part I

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."

Abysmal.

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.

Pictures of Haiti

And now a brief tour of the hospital:

The gated entrance to the hospital campus, from the inside












The outside of our headquarters at the hospital; it used to be the "pavillion des internes," or the living quarters for the interns.











The lab. Labs had to be walked over, and woe betide the person who didn't get a number: no results could be received without it! There were no stat labs; mostly you had to wait for the next day. We had two I-Stat machines, but as you probably are aware, they don't work well in 100-degree heat. We kept it in a cooler, and then had to dry it off and gently warm it up, and even then it often didn't work.





The radiology department.













The medicine ward--or the "catacombs."













The TB clinic; outpatients would come here for their daily meds. The inpatient TB tents are just behind it.











One of the three TB tents.













Part of the ICU--the "higher acuity" beds that were just across from the med room/nurses' station. The guy in the first bed was unresponsive and febrile--he was seizure vs cva vs meningitis; I think he died. The young girl in the next bed had severe TB empyema; got a chest tube, convalesced, and actually recovered enough to be discharged to an outpatient TB clinic. The woman in the far bed had kidney failure; she was dialyzed a few times and was transferred to the medicine ward, only to come back in severe distress and die.


One of our two little vents.













The crazy oxygen setup. That 100-lb tank was supplying 02 to the entire ICU. The man in the cap in the background is a translator--he was the guru of the oxygen. Anytime we needed 02 strung to a bed, we yelled for him and he would make it work. The tank would run out a couple of times a day--usually we'd notice when the girl with the chest tube (two pictures above) would desat to 65, and point to her oxygen mask. We'd have to radio for the oxygen guy to bring us another tank. Nothing ever happens fast in Haiti.



More pictures and stories to come!

Haiti II

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.

Haiti I

When I left for this trip I swore I would keep notes and write up the events of every day just as they occurred. Of course, that didn't happen.

What I'm left with is a series of vignettes and impressions, some sweet, some sad, and some infuriating. My intention is to serve them up to you.

My two friends/coworkers and I arrived in Port-au-Prince at around noon and met our contact in the airport at baggage claim. And I use the term "baggage claim" loosely--there were boxes stuffed with fruit, plastic bags, crates, and all sorts of stuff rotating around the conveyor in the warehouse that was the terminal. The place was hot--107F hot--dusty, and smelly. Those three words would define the rest of my stay in Haiti.

We also met another volunteer: G, from Wisconsin via Boston, an adult nurse practitioner who works in a neurosurgery practice. She ended up being my roommate, for which I will eternally be grateful: I couldn't have asked for a better roomie!

Looking out the window of the minivan on the way to the hotel, we saw the rubble and devastation remaining after the earthquake nearly six months before. Tent cities filled with makeshift dwellings filled every open public space. One of the other volunteers who grew up in Port-au-Prince later told us of the former beauty of the public parks that surrounded the Presidential Palace and the hotel--a place to stroll with your family, eat ice cream on Sunday after church, and have picnics. All of these spaces have disappeared, covered with shanties and shacks and tents. People sell food from charcoal grills set up along the road; vendors hawk their wares from shacks labeled with what they are selling: cell phones, clothing, ice cream. Adults and children bathe in the street. Port-a-Potties are everywhere.


We headed to Hotel Le Plaza on Rue Capois. It was behind high cement walls with armed guards. We were left to our own devices until the crew returned from the hospital for the evening meeting. We were strictly admonished NOT to leave the hotel grounds for any reason; there had been a kidnapping of volunteers from another organization a few months before, and our organization was not taking any chances with our safety. So essentially, we were to be prisoners in a gilded cage for the next two weeks--shuttled between the hotel and the hospital every day. We were fortunate to have such a nice place to stay. Other organizations had their volunteers sleeping at the hospital in unused buildings, eating in tents and not showering for days.

We set up in the ballroom and waited for the others to return: we claimed our mattresses, changed out of our hot travel clothes, and unpacked a little. We strung up mosquito netting. I brought my own pillow and boy was I glad to have it.




We swam in the pool, ate a Haitian club sandwich (chicken, cheese, fried egg, bacon, lettuce, tomato) in the bar, had a beer, and then it was time to meet our compatriots for the next two weeks.

We spent the first night in the ballroom, enjoying the air-conditioning. We were up at 6 am the next morning, ready for our assignments and to spend our first day at the hospital.