Sunday, November 14, 2010

Haiti, Part 1

Touching down in Port-Au-Prince, I had very little idea what to expect. My sister (Rachel) talked me into coming down for a week and, while I knew I would have a transformative experience, I knew little more than where I was staying. During Rachel’s first trip to Haiti she met the crew at MMRC Global, led by Paul Sebring (Big Paul) and Paul Waggoner (Little Paul). After arriving in Haiti following the earthquake, the Pauls met while doing heavy volunteer work at a hospital. Since then, they have both relocated their lives to PAP in order to set up and run an NGO that provides medical supplies, services, and personnel to areas of need. Both are absolutely incredible in their energy and ability to get things done. More on that later. After picking up myself and another person coming to work for MMRC, Big Paul took us back to the MMRC compound where I settled in. Rachel came back from her day of work at the TB clinic and we sat around talking with the incredible group of people.

On Sunday morning, Rachel offered to take me with her to Lopital General for a day on the TB ward. We walked the mile to the hospital accompanied by Billy, a Haitian MMRC employee/friend/translator/etc. As he took us through the middle of a tent city, I couldn’t help but gape. Thanks to the utter lack of government or infrastructure, the general situation in PAP has not changed much. Haiti’s streets are still strewn with rubble, her people are still without homes, the palace still lies in ruins, and poverty abounds. It's almost beyond belief. Since the TB clinic is neither run by the hospital nor particularly well tolerated by the hospital, the lead doc (Megan Coffee) not only cares for patients the hospital won’t care for, but also brings in food, sources the medication she gives away (again with help from MMRC), and buys bottles of oxygen out of her own pocket. The generosity of outsiders is a common theme throughout this trip. So I got to meet the interesting collection of patients that have kept Rachel busy for the last month. From a delightful man handcuffed to his bed thanks to a strange imprisonment in which he didn’t commit a crime to a slippery patient with diabetes, TB, and AIDS who doesn’t take care of himself and has to be forced to eat, it’s quite the assortment. Between watching Rachel do thoracenteses and keeping an eye on patients, daylight passed quickly.

We returned to the compound after dark to learn that the Pauls received a call for help at the Northwest Haiti Christian Mission in St. Louis du Nord. The clinic there was treating a cholera outbreak with help from several other NGOs and was about to be short in both care and supplies. By the time we walked upstairs, the gang had a plan in place to charter a plane the following morning to take a team and 1,300 lbs of supplies up to the mission. MMRC is agile, relentless, and dedicated. These guys just get it done without having to worry about filtering through layers. We woke Monday and assembled our team: Big Paul, Little Paul, Rachel (as our only M.D.), Micaela and Jeanne (two nurses), Yvette, Billy, Riaan (a US Marine and EMT), and myself. We even picked up another nurse, Carol, at the airport to head up with us. After some nonsense with Tortug Air, we had our flight and headed north.

Grant from the Northwest Haiti Christian Mission picked us up at the airport in Port de Paix and shuttled us the 8km to the mission where we dropped off our supplies and gear, ate, and quickly slipped into scrubs to staff the 7pm to 7am shift. The clinic is broken into a main treatment area for sicker patients and an oral rehydration room for patients no longer vomiting and in reasonable condition. It’s worth noting that Rachel was in her element and on her game, in addition to whatever other clich├ęs describe that sort of thing. After her earlier outing to fight an upwelling of cholera at St. Marc, she had first-hand experience to back up the WHO guidelines and MSF protocols for cholera. On account of her experience, we hit the ground running. As it turns out, cholera isn’t particularly tricky to treat. Other than antibiotics where appropriate and the rare antiemetic, patients need liters upon liters of fluids. To compensate for the vast quantity of fluid lost to diarrhea and vomiting, patients get bag after bag of IV Ringer's Lactate until vomiting ceases and they can hydrate orally. Several patients needed more than 10 liters of IV fluids. A few even required epinephrine to buy Rachel and the nurses a few minutes in the hunt for a vein and many more received intraosseous lines. Heck, I even placed my first IV. Whatever it took to get fluids into people. Honestly, convincing the patients and their families that drinking Oral Rehydration Salts solution is the same as getting an IV was the most vexing task. If it doesn't come in a bag and drip into the catheter in your arm, it apparently isn't medicine. The job becomes even more difficult when the families of the patients wait to bring them in. Families that live a reasonable distance away can't walk to the clinic in the dark and so the crowing of roosters is a warning bell for impending mayhem. At sunrise, new patients began pouring in. Thanks to a continued push from a tired but energetic team and timely relief from the next shift, we finished out and handed off to the next team in time to grab some decontamination and breakfast.

Coordination of the teams and materials was a joint effort between Grant from NWHCM, Les from Grass Roots United, Ted from Medical Teams International, and the Pauls. Our stay at the mission overlapped with two other incredible groups from Open Hands and Medical Teams International. Thanks to the extreme conditions and nature of the people involved, our stay at the mission was not unlike summer camp: Dorms with bunks, a paucity of sleep, and a common interest. And cholera. Lots and lots of cholera. In downtime between shifts, we’d sit around and shoot the breeze. You won't find a more dedicated, energetic, or friendly group, all of which made the difficult moments better.

The first night wasn't all sunshine and lollipops and copious watery diarrhea. We lost a few patients. The first passed away a few minutes into our shift. A woman died on the floor of the clinic after her family carried her in face up, aspirating her own vomit. Not even the best efforts of our team were enough; those were difficult minutes, made more difficult by the fact that the family was right behind us. Since it was my first real experience with death, it took a toll. Thankfully, Riann the Marine had some perspective to share as the two of us carried the body out of the clinic and followed decontamination guidelines to prepare the body for the family.

The second night was similar to the first. We took our handoff after dinner and ran with it, completing a very productive night in terms of patient care. According to the stats as reported by Ted, our collective groups held mortality well below the average for treated cases of cholera despite somewhat limited resources and long hours. Thanks to more incoming help, including two more awesome MMRC-affiliated nurses (Bridget and Liz), we schemed to start running three 8 hour shifts at the mission clinic to take effect after our Tuesday night 12 wrapped. Since we were also trying to help the hospital at La Pointe, halfway between Port de Paix and the mission, we sent two people a night over there for 7pm to 7am shifts. On Wednesday night, those two people were myself and Jeanne, a nurse just out of school. Knowing that it'd be simply the two of us with extremely limited resources, a hospital that refused to give patients meds or fluids unless they bought them from the pharmacy, sporadic electricity, and only three Haitian nurses, I had every right to be nervous.

Jeanne and I were dropped at La Pointe and set off to get acclimated with our charge for the evening. With around 75 patients and their family members packed into the cholera area and a tent just outside, our shift carried the promise of a busy night. After making our first rounds and getting a thorough handoff from the Haitian doc on duty, we settled in. Between convincing each room of patients to have community "parties" once an hour to wake the patients up and get them to drink and dealing with the lack of available IV fluids and potable water, we stayed busy. The responsibility of taking the reigns was liberating, however. With the help of an incredible local translator, Moise, we stayed on top of our patients and even had the wherewithal to transfer a young child out of the cholera area after deciphering that she had only one case of vomiting six hours prior with no diarrhea and was therefore not likely to have cholera. As one of our patients was still cold to the touch with a thready pulse after 9 liters and complaining of left flank pain along with developing tachypnea (~55 breaths per minute. Yikes.), we got phone consults from Rachel on her clinic shift and a Haitian doc at home in bed. After the Haitian nurses administered the suggested antibiotics and dexamethasone, he made progress*. As daylight broke, we sat exhausted on the desk in the makeshift clinic office with rain falling on the tin roof. Out of nowhere, the women in the room next to us started singing in chorus. Surreal.

*He looked a lot better 24 hours later.

Daybreak also brought in a flood of patients, several critical. One 75 year old man, carried in by family members, lacked a carotid pulse. As Jeanne and a Haitian nurse each worked furiously by headlamp to try to get IVs down, I raced to the pharmacy to get epinephrine. They didn't have it and we made an ultimately futile effort at CPR, my first such attempt. Amazing how training kicks in without thought in dire situations. After standing stunned for a few moments and, despite frustration with our lack of ability to do anything thanks to a patient too far gone and no resources, we turned to face a new stream of patients. The diligence of Jeanne and the Haitian nurses allowed for quick placement of IVs in a handful of patients while I briefed Les and Ted, who had shown up to take us back to the mission. Both were crucial in helping with crowd control, bringing in some much needed drinking water, and calming the situation (and myself) down tremendously. As we chopped down the very rough road back to the mission, it occurred to me just how rare an experience I'd just had.

I'll break it up here as this is already becoming a novel and I'd like to catch some sleep before class starts tomorrow. The rest of my account of the trip will be up within two days.

3 comments:

  1. wow, powerful stuff. looking forward to the rest and catching up when you get some more time.

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  2. Aron, what an amazing experience and how wonderful that you could provide direct lifesaving care. Hope it serves as an inspiration for the years ahead!

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  3. Glad you had an opportunity to do such amazing work (and with your sister too!). I'm sure it's the tip of the iceberg for the future. Let's catch up soon.

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