Children's and Project Medishare: reflections from the ICU

Elizabeth Robertshaw, RN, BSN, CCRN, 7 south MSICU
Elizabeth Robertshaw, RN, BSN, CCRN, 7 south MSICU

From April 10 to 18, Children’s Hospital Boston sent a group of 26 clinicians to a field hospital in Haiti. Here, those who staffed the ICU reflect on their experience.

Elizabeth Robertshaw, RN, BSN, CCRN, 7 south MSICU

Where to begin? How do you write on paper a whole country’s suffering? How do you show their faith, courage, and thankfulness through words? It has been so difficult to express all the emotions I have experienced in the past few weeks. Highs and lows. Coming home I feel guilty for how good my life is, how much I have and how fortunate I am. Simple pleasures such as a sheet to sleep on, a warm blanket at night, hot water to bathe in and a toothbrush are all considered a luxury.

From the moment I entered the airport, I could see the needs of the people. Devastation and poverty everywhere. The community has yet to even begin to rebuild. It must feel nearly impossible with all your neighbors suffering, sick, starving and homeless. The hospital is chaos. Supplies everywhere, some organization to it but nobody really sure where everything is. No code carts, no ambu bags readily available, monitors are shared between each ICU patient, pumps that don’t work or that do work but no syringes that will fit on the pump. Electrical cords criss crossing across the floor in all directions. Water seeping through the cracks in the tent while the rain thunders down. Whole families sleeping on one cot…mother, father daughter, patient, using towels as blankets. No funerals for families. No moneys for funerals. No comfort room and no privacy.

Patients turned over from ICU to floor to discharge at a rate unknown to the USA. The patient to nurse ratio is unacceptable. One nurse for every sixteen adult or pediatric patient.

The army, physical therapists, anesthesiologists and psychologists all volunteering to feed the preemies. The translator helping me change diapers and turn my patient. Parents emptying urinals, helping the patient next to them vomit, or get up to the commode. Every four hours vital signs are a dream. Keeping IVs patent a concern. No D5NS use D5LR, no NS use LR, no nitric oxide use viagra. The list goes on. Patients we could have saved at home expired because of limited resources.

Working for Children’s, standard of care is something so important to each of us as individuals. We all work so hard to provide the best we can for our patients. We all want the best for our patients. I felt we were challenged to do the best we could due to lack of people, supplies and resources. We provided good care to many patients. We clearly made a difference in the hospital. We worked great as a team. We were supportive to each other. We helped each other in each different department. Pediatric nurses working on the adult floor, in the OR, in the adult ICU. The strength and confidence of the hospital was evident in the atmosphere. We built equipment from the supplies we had. We made due with what we had. The Haitians trusted us.

The strength of the people was remarkable. Patients who were ventilated and septic up and walking 3 days later. Each family supporting and helping each other. Staff sharing food, water, love and clothes. Courage was remarkable. The experience was worse then I expected and better than I expected. We made a difference. It was exhausting, trying and rewarding. They need us. No human should be left to suffer.

We need to continue to help them develop their health care system. The needs of the Haitians have barely been met. Speaking to the local workers tragedy is everywhere. They are trying to rebuild their country. They are young and hoping for a new world. They work long hours and have endless strength and hope for their future. Always having kind words for their neighbor.

Gina Miano, RN, 11 South, MICU on left, with Brittany Crush, RN.
Gina Miano, RN, 11 South, MICU on left, with Brittany Crush, RN.

Gina Miano, RN, 11 South, MICU

Working as a nurse in Haiti was the single most important thing I’ve ever done. It was challenging in every aspect. It put every ounce of my abilities and capabilities to the test both personally and professionally. The PICU at Project Medishare is a very busy unit. We took care of the sickest children in Haiti. At times we were an OR, a NICU, an adult ICU, a burn unit, a PACU, an ER at night, or a trauma service. As a team, we were able to care for critically ill children with a wide variety of conditions. I learned how to step out of my comfort zone in nursing and into whatever role was needed at that time. I worked harder than I have ever worked before and for longer hours with more patients than I am used to. It was painful to know that each family had their own story of loss as a result of the earthquake, and that most children have never been seen by a doctor. Although the outcome wasn’t always positive, I know that we gave each child a chance, and that more children would have died had we not been there. We worked well as a team, helping each other, relying on each, and learning to laugh or cry with each other. I didn’t realize that we stood out in that way, until people who had been there for multiple weeks brought it to our attention. It just seemed natural to have a good attitude and help anyone and everyone in any way that you could. None of us knew each other, but we functioned like we had worked together for years, and it became apparent that the Children’s group was different in that way. Going on this trip and having this experience has made me a stronger nurse and a stronger person. I learned a lot about myself and about life. I am amazed at the courage and strength of the people of Haiti and I wonder if our culture’s spirit and pride would remain as alive as theirs. I was always humbled by the singing at night. I am grateful to have had this opportunity, and to be apart of such an amazing group. It is something I’d like to do again. It was obvious that the need for medical relief will be ongoing and probably permanent, and I feel strongly that Children’s Hospital continue sending medical and nursing staff for as long as possible. Without the volunteers of these relief efforts, Haiti would not have a healthcare system.

Loren Wolfe, RN, holding a baby in the Pediatric ICU. To her left, Brittany Crush, RN; on her right, Tyler Hartman, MD.
Loren Wolfe, RN, holding a baby in the Pediatric ICU. To her left, Brittany Crush, RN; on her right, Tyler Hartman, MD.

Loren Wolfe, RN

It was during the early days in January that I first became aware of the tragic devastation which struck Haiti and people living there in the form of a massive earthquake. Some of those images that flashed across the screen of the television on CNN and the Today Show captured my heart. I saw photos of the crying children, dirty and bloody, in desperate need of medical care. One image particularly caught my attention. It was of a child, soiled and dirty, receiving surgery under a tarp in the middle of the city with a reporter stating that there were not enough medical personnel on the grounds to deal with all of the Haitians who were injured and wounded in the city. It was at this moment that I knew I wanted to help the country of Haiti by providing my time and medical skills to their children.

Two months later, I was granted my wish. I was given the opportunity to travel to Haiti with 25 of my colleagues of Children’s Hospital Boston for seven days. My colleagues and I were to work and reside at Project Medishare, a tent-based field hospital located at the airport in Port-au-Prince, Haiti’s capital. I was ready…or so I thought.

In the early morning hours of April 10th, with trembling hands and a racing heart, I stepped out into the suffocating heat and humidity of Haiti with a backpack strapped tightly to my back. After walking precariously down a flight of stairs onto the hot tarmac with my colleagues, I took a deep breath as I stood beside my co-workers. This is what I had come to do, to help the children of Haiti, to help stop the suffering that I continued to see on the news each evening and I was finally here, anxious and ready to get to work.

Once the customs officials understood that our team was comprised of medical personnel, we were quickly cleared through customs, and we were ushered through and placed in line to board trucks and jeeps that would bring us to our base camp; a tent city that we would call home for the next seven days. As we were driven the short distance from the airport to the field hospital, we left the barbed wire and gates of the airport. It was during these brief minutes that I was able to take in the sheer magnitude of the poverty that the people of Haiti were living in. Tents and tarps were erected alongside the roads in makeshift small communities. A small market sold mangos, and young children were knocking on the windows of the jeeps asking for food or money. In less then a mile traveled, we entered our compound, an oasis of organized activity, hope, and caring, surrounded by gates, barbed wires, and armed guards.

As I pulled my backpack full of medical equipment and powerbars out of the jeep, I took in the field hospital. Three large tents stood tall. I followed my colleagues into the first tent on the right and discovered our sleeping quarters for the next week. I found my luxury accommodations – a military cot in the middle of the tent dormitory – and spent the next half hour laughing with my new friends as I struggled to figure out how to rig up and hang my mosquito netting. After settling in, we were given a quick tour of the grounds.

I found out that the dozen or so tents that were on the left of our sleeping quarters housed the key long term logistic members that ran the hospital and the grounds. My mood quickly grew somber as I began to be aware of the large number of sick and injured patients and I was reminded exactly why I was here. Another tent housed the adult medical-surgical facilities. We were given a quick tour of the medical-surgical facilities and the images that I had seen splashed across the news over the past months quickly became my new reality. Rows upon rows of patients lay on military cots, IV fluid hanging from ropes above them. Against all generally accepted medical practices applicable to normal hospitals, these patients had been positioned very close to one another in order to house as many patients as possible under the protection afforded by the huge tent. There was no privacy of any sort, as male and females were crowded next to one another, using commodes and bedpans. Walkers, wheelchairs and crutches crowded the small aisle. Family members often stayed with the patients and the lucky ones slept on pieces of discarded cardboard next to their loved ones, while the not so lucky ones slept on the ground or even shared cots with the patients. A makeshift x-ray room had been set up in small corner of the tent. A small line of people patiently waited their turn in line. A pharmacy was set up in the front of the tent, somewhat organized by classification of drugs. Row after row of medications stretched out on long tables and carts.

Next to the adult tent stood the pediatric tent. Walking in was similar vision to that of the adult tent, military cots filled every corner and inch, children of all ages played quietly with their families and with one another. The back of this tent housed a three patient adult intensive care unit, operating room and post operative four bed PACU. This tent also housed where I would be spending most of my time in Haiti, the pediatric and neonatal intensive care unit.

After our quick orientation we were given our assignments, and the Children’s team pitched right in to help. Our team staffed all areas of the hospital due to our range of knowledge and expertise. Children’s members were assigned to the OR, PACU, ED, the entire pediatric tent as well as the ICUs and the adult medical-surgical tent. The pharmacies were run by our own pharmacist, who quickly organized and arranged our drugs in the tents. Our team seamlessly integrated with the other teams and organizations that were already hard at work. The pace was set for us after arriving, within hours our teams were in the OR delivering babies and performing surgeries in an orderly form of mass chaos.

We worked that way for seven days, some 16-18 hour shifts, with our patients and their suffering sometimes consuming us. An attempt was made to save every person that was brought through the gates of the compound. Not everyone was a survivor given our resources. The highest level of care that we were able to maintain was delivered to each patient.

projectmedishareOne night, a small baby was brought into the compound in the back of a pickup truck, his mother closely holding the baby swaddled in her dirty clothing. Through the help of a translator, we were able to gather information from mom stating that the baby was two months old and she thought that maybe something was wrong with the baby’s breathing. After a quick assessment of the baby, it was noted by our medical team that the baby was clearly in both cardiac and respiratory distress. Not quick to intubate the baby because of the limited number of vents, our team became creative and constructed a CPAP machine out of oxygen tubing and a bottle of water. After stabilizing the patient a decision was made that an x-ray would be our best option of determining what was medically wrong with the baby. Cradling the baby, carefully not to dislodge the makeshift CPAP machine, Dr. Dave (while lugging an O2 tank) and I (cradling both the patient and our CPAP) braved the elements of the rainy season and rushed the patient over to the adult tent for use of the x-ray room. An x-ray confirmed Dr. Dave’s preliminary diagnosis of an enlarged heart.

After returning to the NICU/PICU with the patient, a decision was made that clinically the patient would need to be intubated due to her declining respiratory status. Once the patient was stabilized and intubated, we were able to explain to the mother medically what was happening to her child through the translator. Forty-eight hours later, while our patient’s health rapidly declining, I found myself again in the rain at four am. Flashlight in hand, I shined the flashlight on each face until I could find the Chaplin’s cot. After bobbing my light around in his face for thirty seconds and hoping it was the right person, I quickly shook him awake and explained the situation. He dressed quickly and followed me back to the NICU/PICU. He held the patient’s mother’s hand as she stoically watched our failing attempt to save her child’s life. She lifted her arms and began to sing praises and prayers quietly. Suddenly, the Chaplin’s face lit up in recognition. As she sang a song in French-Creole, the Chaplin softly sang the same song in English. It was at that moment that my own faith was renewed and I was able to remember why I was there.

Every baby and child were truly heartbreaking, some affecting me more then others. Among the devastation, as life was ending for some patients and families, life was beginning for others. Several babies were born the week we spent there. Seeing life being born among the devastation was truly miraculous. And among those who died, there were the ones we saved. In the wee hours of one of the mornings, in walked two volunteer paramedics from an outside clinic. In a small cardboard box laid a blue baby, unresponsive and lethargic. Attached to a small monitor a oxygen level alarmed at a mere 66%. After receiving report from the transport team that our baby was born breach and was a difficult delivery for this estimated full term infant, our team quickly got to work. My heart began to race as the baby turned a deeper shade of blue and then blacker despite all our efforts. Unable to obtain IV access on the baby after several tries, an ETT tube was dropped and a round of epinephrine was given. Unable to keep the ETT tube in place, chest compressions were started as we bagged the seemingly lifeless child. I stood there wide-eyed as I thought to myself, another loss for these people, another death. Suddenly, the dark baby began to pink up and after another moment, the baby began fighting the bagging. Our team began to fight harder with renewed effort to save the child. We held off on re-intubating the baby, instead choosing to bag-mask ventilate. As IV access was obtained through the umbilical line and fluids administered, the baby began to regain color and life. Within an hour, the baby was stabilized. As I placed the baby in an incubator, wrapped in a soft donated blanket, large tears slid down my face. Finally, a save amid all this despair. And I couldn’t be more proud that it was done by my team, my colleagues from Boston.

My final hours in Haiti were my hardest. As I held a baby with a diagnosis of hydrocephalus, feeding her orally though a syringe, post operative from a VP shunt placement, I wondered if she would be difficult to sneak through customs. Thoughts were running through my head. If shunt placements have a high infection rate in the United States, under sterile OR environments, I could only wonder what was to happen to her in the next days, months or if she would even live another year. She looked at me with her sweet brown eyes, and my only hope was that the next group of medical professionals that came though the tents would care for her and love her as much as I did. Tears running down my face, I placed her back under her warmers and swaddled her softly. I placed the 60cc syringes that I had filled with hot water bedside her, it was the only makeshift hot water bottle I could create in the chaos. I had to remind myself as I walked out the tent doors that she was in the safest place possible for her right now, receiving medical care, shelter and love by the people working and volunteering at Project Medishare.

I worked closely with four other Children’s nurses during my night shifts and two of our intensive care unit fellows. I couldn’t have asked for a better team or support during those long shifts. As healthcare providers, we were all faced with dealing with burned children, fresh and old amputees, traumas rolling through the doors at all hours, premature babies, tetanus and malaria. Never would I have been exposed to a shift with all those diagnosis at a hospital in Boston. Never have I had to work and run a code without all the medications and supplies needed. Never have I felt so much emotion and pride while working as a nurse.

I am so proud to say that I work at an institution that has allowed me to experience mission work. I am so thankful to my family, friends and workplace for providing me with the support and strength to help the people of Haiti. I am forever thankful for being able to experience Project Medishare with my colleagues. I am so proud to say that each and every person from CHB worked so hard and well together. As we all return to our daily lives, I hope to see all my fellow colleagues around the hospital as it will bring a smile to both my face and my heart. I anxiously await my return to help the people of Haiti. I can only wish to experience it with such giving people again.

David Kantor, MD
David Kantor, MD

David Kantor MD, Critical Care Fellow

I’m still trying to process everything that happened during the trip to Haiti, but I can say definitively that the group from Children’s made a significant difference in the lives of the many many patients we saw during the week.   From the ED, to the OR, to the ICUs, to the wards, providers from Children’s worked incredibly hard to care for patients under difficult conditions.  Many people commented on our teamwork and how well the group from Children’s meshed with all the other providers in the compound.  When I stopped to look around, I was struck by how this humble group from Boston was pitching in to help at nearly every level of the operation, and it really made me smile.