Wednesday, January 27, 2010

Critically ill patients unable to get needed medical care in US

1530. "We need anesthesia to come intubate. Stat!" In the middle of our administrative meeting came the alarming call for a rapid response team that did not yet exist. In all of our attempts to get the hospital organized we had not formed a designated code team. Luckily we did have a code box, complete with endotracheal tubes, laryngoscope, ambu bag & code drugs. Two of four anesthesiologists available led the wound care team. And because of the need to be in communication with each other and other deptments we initially had 3 of about 7 or 8 walkie-talkies, which enabled us to respond immeidately.

We arrived to find a 19 year old, who looked to be about 13, in obvious respiratory distress, tachypneic with respiratory rate in the 40's, tachycardic with a heart rate in the 180's, and hypoxic with sats in the 60's. He was the same boy who had some sort of respiratory infection who had been making steady improvements since we arrived. We managed to get his sats from the 70's on 12 liters nonrebreather up to sats of 89 on 7 liters with daily nebulizer treatments, aggresive chest physiotherapy, and antibiotics. At 6am the pulmonologist performed a thoracentesis (lung tap) in an attempt to drain a suspected empyema. It is not clear to me whether fluid was even obtained. But by that afternoon he had decompensated severely, likely because of a collapsed lung. In hindsight perhaps this was a case where the enemy of good was better.

Perhaps he was going to decompensate anyway, but the question loomed whether tapping him was appropriate given his steady improvement. Whether to intervene using invasive measures, particularly when that intervention carries enough risk turn a stable patient into an unstable patient or set in motion a series of events that significantly decreases a patient's quality of life, is a decision we physicians face on a daily basis. Should we really be spending $150,000 or more replacing an aortic valve (major open heart surgery) on a 95 year old woman with boderline kidney function and underlying dementia who then goes on suffer another insult to her brain and ends up on dialysis? Clearly we decreased the quality of her remaining years, and utilized resources she likely would not have used had we decided such a major operation was likely to kill her sooner rather than later (actual case with which I was involved). The decision to intervene becomes even more critical in a resource poor situation such as the one we faced at Hopital Communaute.

In this case the resources in short supply were oxygen and ventilators. The one ventilator in the hospital was broken, and oxygen tanks were few. So the dilemma we faced was whether to intubate or not. As his need for oxygen became greater he was using more energy to breath, the weaker he was becoming, and the less he was able to keep up. He was fast tiring out, making intubation more iminent. But if we intubated our patient, we would be committing him to a nonexistent ventilator that used almost nonexistent oxygen. Even if there were enough oxygen, someone would have to hand ventilate him for the duration of his stay in the intensive care unit (ICU). So the decision was made to delay intubation, transfer to the ICU, and put in a chest tube.

Once the chest tube was placed his vital signs actually improved. His oxygen sats came up, and he became less tachypneic, but his heart rate was still in the 160's. So he remained on a nonrebreather as many many people began to work on trasferring him to a hospital with a ventilator. The only other hospital with a vent couldn't accept him, and the Comfort (floating US military hospital) said they were full to capacity. Finally someone was able to convince the Children's hospital at the Univ of Michigan to accept him. They found a medivac plane, complete with a critical care team, that would transfer him. And then everything fell apart.

Somehow funding became a problem, and there was no longer enough aid to cover a critical care team to fly to Michigan. So I was asked if I would be willing to help transport (and be one of a few who would help hand ventilate the boy for the duration of the journey). I deferred to another anesthesiologist who was stranded in Haiti and looking for any way he could get back to New Hampshire. At that point it looked like we had everything buttoned up and ready to go.

However, during the time it took to secure alternate funding and assemble our own transport team, the flight from Michigan lost its departure window. And to add insult to injury, we received word that the govenor of Florida was no longer willing to accept critical patients to Florida hospitals, citing the lack of federal funding and the apathy of surrounding states in sharing the load. In effect all Humanitarian visas as well as military evacuations to the US were cancelled, leaving nowhere for us to get our patient the care he desperately needed. We were all devastated, as all we could do was watch the boy slowly slip away. There were no less than half the medical staff and administration, all tied to the Hippocratic oath and intimately vested in saving each life, frantically making calls over several hours to give this boy the chance of survival he deserved. And it seemed all our efforts were for naught since effectively the message in the bottle was "we don't want you here."

Save, Secure & Support. Shouldn't that be our mission? With the overwhelming amount of devastation that occured in just 35 seconds, 150,000 dead and more amputees than there were American amputations in WWI (about 2600), there is only so muc we can do on the ground here in Haiti and aboard the Comfort. We have the means to do more, and we should do more because it's the right thing to do. So we send out the rallying call and implore other states to step up to the plate. And we petition the federal government to fully support the mission. Rather then closing our borders to the critically injured we should be leading the effort to extend a lifeline of hope to those who would otherwise die without it.

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