Thursday, January 28, 2010
Wednesday, January 27, 2010
Today was actually my first day in the operating room due to the departure on a pedi anesthesiologist and a nurse anesthetist. Most of our general cases are done with ketamine & versed because oxygen is in very short supply, and the only working anesthesia machine is in OR one, which also happens to have an EKG monitor. So in OR's two, three, and four our only monitors are a blood pressure machine and a portable sat monitor, which are difficult to use because patients are often cold or we are amputing the one extremity where we can pick up a sat (no ear probes available).
According to the anesthesiologist doing her case, they had just ligated the sciatic nerve when he got a low blood pressure reading. A short time later he lost her sat reading. He checked a carotid pulse and found she had none. At this point they started chest compressions and began to bag mask her with room air.
I was next door and had just finished helping the nurse anesthetist put in a spinal on a woman having a caesarian section, when Dr. Garcia bursts through the door in search of oxygen. Thinking our 19 year old in the ICU was decompensating again I was surprised when he said the patient next door was "in trouble."
I rushed next door find the orthopedic surgeon on a stool performing chest compressions and began administering cardiac resuscitative drugs. Epinephrine and atropine were in no short supply. We even had amps of calcium and plenty of lidocaine. Chest compressions to circulate the epi were sufficient enough to generate systolic pressures in the 70's and diastolic pressures in the 40's at one point, but to no avail. We had to call it. Time of death: 19:35.
There was no sustained drone of a flatline like on tv, for we had no EKG monitor in this room. There was only the deafening silence of our profound sense of sadness that not everyone we lay on our operating table will rise again. Given the acute demise of our patient I suspected she suffered a massive pulmonary embolism due to a blood clot that very likely would have developed in her badly fractured leg. As we began the work of sewing her leg back together and cleaning her up for her family, we each went to that objective place we all go that allows to cope with the extent of the loss of life and limb. But for one of us, a general surgical intern who was first assist in the case and one of the wound care team members who encouraged her to have the amputation, the day's stresses proved to be too overwhelming, and the woman's death took him to his emotional breaking point. We allowed him to shed tears for all of us, as this particular death--the first intraoperative death at our hospital--is undoubtedly poignantly and indelibly etched on the tableau of our experience here in Haiti.
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.
Tuesday, January 26, 2010
CNN was here at Hopital Dela Communaute Hatienne today. The 82nd Airborne thought this hospital was destroyed. A few days ago they began patrolling the area. Apparently word has gotten around about the care we are provinding here. I have no idea how many hundreds of patients are here,but yesterday our wound care team saw upwards of 70 patients, both in the morning and again in the evening. We are mainly still dealing with amputees, but have seen a few gunshot victims, women who have been protracted labour. There are teams from Sweden, France, South Korea, Jamaica, and several other countries, all of whom have committed to being here for the next 6 mo or more. I hope the response continues to be as strong, as this country mends itself.
2300. Finally back at the house in Boutelliers. Our hosts, Linda & Ben & their daughter, Terry Boucard, have been absolutely awesome. They have opened their home & their hearts & availed themselves of their time & talents. A turkey dinner was much appreciated after being on our feet (or on our knees as in my case, as I was often giving anesthesia on the floor) all day and half the night. I would estimate our wound team treated 60 patients today. Off to bed to do it all again in the morning...luckily we're all exhausted enough to sleep through whatever aftershocks occur in the night (yes there have been two since we got here).
Monday, January 25, 2010
Up early this am. Arrived at Hopital Dela Communaute Hatienne this morning. Operating rooms are well equipped so most patients having amputations under general anesthesia. Things are finally getting organized but finding have found situations whereby we have surgeons amuptating and no one doing wound care. Lots and lots of wound care to be done...I come bearing all the good stuff: ketamine, morphine, percocet, tylenol #3...acute pain service at it's finest!
It's been years since I've used ketamine without versed so the hallucinations my patients are having are something else. I've been maman to every other patient, the last in particular was quite upset when I went to the next patient after she told me to stay by her side until she finished flying in outer space.
Working with a great team of PA's from New Hamshire via St. Thomas. Tommy, Amanda, & Tiffany.
Sunday, January 24, 2010
The first pic is a view of the propellers as we were landing in Port-au-Prince.
The second pic is a shot of the missions airport exit, which is currently being controlled by the Marines and the United Nations peace keeping forces.
The 3rd, 4th, & 5th pic show the way various houses feel, like pancakes, to the ground during the 35 seconds of pure terror the Haitian people experienced that fateful day.
The last pic is of the first hospital we visited--Hope Hospital. Many patients are outside, some out of fear of the aftershocks (which I'm told have not occurred for 24 hours), but most out of lack of space inside.
After two hours of sleep, we are making the one hour journey to Ft. Pierce. With the strict weight instructions imposed on us I'm guessing the plane is going to be of the size & type where a xanax (or several) would be helpful. Having nothing of the sort in my luggage I'm going to rely on extreme sleep deprivation as my anxiolytic.