Children's and Project Medishare: Reflections from the pediatric wards

Grace Chan, MD, with two patients on the Pediatric floor.
Grace Chan, MD, with two patients on the Pediatric floor.

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 pediatric wards reflect on their experience.

Grace Chan MD, Boston Combined Residency Program

On our first day, a young woman came in with new onset seizures.  She presented with all the signs of increased cranial pressure that I learned about as a medical student – obtunded, signs of cushings triad – bradycardia and hypertension.   We gave mannitol, steroids, hypertonic saline.   I didn’t think she would survive.   Did she have meningitis, cerebral malaria, a tumor?  We don’t know, but several days later she was walking, talking and close to baseline.  Here, diagnosis isn’t as important as management.

One day, we had the brilliant idea to deworm the pediatric ward, all 35 kiddos with one dose of abendazole.  The next day, early in the morning, David our 10kg 2 year old admitted for 1st degree genital scalded burns, passed a stool full of worms – big, small, all moving!   Mom screamed and nearly ran out of the tent.  Success – high fives all around!  Hm… maybe I could use a dose on my way out.

Pediatric ward team meals were another highlight…  It’s a great big deal, parents often wait well after discharge for that late afternoon meal so they can feed their child one more time before leaving.  Rice, beans, and a small piece of meat.   Mm-mmmm.  I had seen lots of mangoes starting to ripen on the way in and contemplated how I was to climb one of those trees to get one.  My dream came true when Erly Matthieu gave us a big, ripe, mango.  That afternoon we were in bliss, our mouths full of sweetness.   It helps to have connections with people in high places…

If I thought I worked hard, those nighttime nurses did that and more.  Children’s brought 15 plus nurses, the centerpiece in keeping a hospital functioning.   Our ever-so-talented pediatric nurses even staffed adult tents…4 nurses for 75 adult patients?!  Wow, that’s like one nurse per floor at Children’s.

We saw lots of kids with hydrocephalus…word got out, Dr. George, the neurosurgeon was in town and kids with big heads just started showing up on our front door.   One was a 6 day old already with signs of sundowning (eye deviation).  I watched in amazement as Dr. G drew off 60ml of CSF in the ED, and the baby’s eyes returned to midline and started moving. He preformed two VP shunts in our field hospital and referred the less acute cases to a neurosurgical team coming in two weeks.  In addition to neurosurgery, there was an awesome surgical team composed of orthopedic, plastic, general surgeons, and ob/gyn physicians.  The level of care provided was similar to developed world standards, much higher than the hospitals I’ve visited in sub-saharan Africa, Indonesia, India, and Bangladesh.

Saturday morning came sooner than expected and I left with a small ping of sadness…I knew I was going back to Boston, where I would be sheltered and safe, sleep on my comfy bed, breathe clean air, eat three meals a day from more than two food groups.  It was hard to leave, but we were comforted knowing that everyone will be well-cared for by capable hands (hi haylene!).

Here’s two cents about what I learned and areas for future work, specifically focusing on prevention and training local health care staff.

Prevention:

1)    Malaria – Our first code was a girl with malaria; she didn’t survive.  An older woman was intubated in the ICU with cerebral malaria; two other children were hospitalized while we were there.   We slept in cots under mosquito nets, but next door the kids slept in cots in the open.  Do we have resources to distribute bed nets?  Someone call Jeff Sachs.

2)    Nutrition – Most kids we saw were chronically malnourished.    We were at an acute facility, making it difficult to treat chronic problems.  We didn’t have refeeding formulas, micronutrient supplementation, etc.   One 11 mo F was admitted for failure to thrive, our less-than satisfying solution was NG feeds for a day.   There are chronic malnutrition facilities in Haiti for referral.

3)    Burns – One third of our cases were burns.  Hot water, perfume flames.  Burns and malnutrition made for a poor healing combination.    We learned that kids cook at a young age, homes are heated with flames…

Training:

The magnitude of health workers lost after the quake is not clear.  Haitian health workers were scarce at the hospital, a few nurses, pharmacists, and specialist physicians.   Yet, there’s so much young talent and ambition.   A young, bright interpreter we met, Marc-Junior, wants to be a doctor.  Let’s find a way to train him.

Kasia Stabach, RN
Kasia Stabach, RN

Kasia Stabach, RN, BSN,CPN ICP/MICU

This mission to Haiti meant a number of things to me both personally and professionally. Personally, I was empowered by the people of Haiti and by the teamwork of the CHB group. I was challenged physically, mentally, and emotionally on a daily basis by the work demands, the heat, and also by hearing the tragic stories of orphans, broken bones, tent cities and living on the street, PTSD, malaria, illness and poverty. These are real struggles the people of Haiti face daily. They continue to need help

Professionally, I wasn’t quite prepared for what I would see or what I did as a nurse in Haiti; however I tried to embrace the experience as it was. From the beginning it was apparent we would be challenged, but we were ready as a team. The first night two woman arrived at the hospital in the back of a pick-up truck ready to deliver babies. The babies were delivered successfully via c-section; and the mothers did fine as well. The week continued to be busy with Motor vehicle accidents, trauma, malaria, emergencies, sick people and children, rehab for broken legs, wound care, burns, amputations, and physical therapy. We were considered one of the best hospitals in the country at that time.

I was working on the pediatric ward, and we were at maximum capacity. The nurse patient ratio was 1:11, the work was busy and the days were long. Despite our lack of supplies at times, we did our best; making med-fusion tubing from a secondary set to run dopamine, making IV arm boards from tongue depressors, we were creative when we needed to be. Through frustrations, laughter and tears, we saved some lives and lost some too. But, we gave people hope.

Considering the circumstances of life for the Haitian people, every night you could hear the singing of prayer coming from patient tents, the children had contagious smiles and bright spirits. Our presence meant something for the people of Haiti but also for us. I am proud to have been part of this mission and hope that our work has continued on since our departure. I only wish that I had more time to work with the Haitian nurses to teach them to effectively carry on our work without us.  J

Stefanie Caldwell, RN
Stefanie Caldwell, RN

Stefanie Caldwell RN, BSN,CPN  Staff Nurse Cardiology

One particular memory continues to hold such freshness and power in my mind…a tiny girl wrapped her fragile arms around my neck and squeezed so tightly as she whispered in my ear ” I will never forget you.” I looked at her beautiful smile and big bright eyes; I instantly felt the tears begin to well. I was so humbled by her courage, strength and perseverance. At such a young age she had experienced incredible pain, witnessed complete devastation and just as I was feeling so insignificant she reminded me that my presence alone provided her comfort.  Her smile, her words, and her life all incredible examples of the hope Project Medishare continues to provide for the Haitian community.  I don’t think anyone who has experienced Haiti could ever forget, and that’s what makes me confident it is not a question of whether I will go back, but when.

Ann Cooper, RN
Ann Cooper, RN

Ann Cooper RN CPN,  8 East

My experience in Haiti was truly life changing for me and I am so thankful to CHB for the opportunity. I went in with very few expectations. The facilities were better than I expected while the poverty and resiliency of the Haitian people was what really struck me. It will always stay with me in the moments I am tempted to complain about irrelevant things. We saw a lot of growth in the Haitian nurses working with us over the week we were there, and I think that will be a lasting contribution to the Hospital. I feel unable to still really express fully what the experience meant to me, but I feel very bonded to the great group of people that went and also to the institution as a whole for their leadership in sending staff to Haiti and the experience it afforded me, for which I will be forever grateful.

Jonathan Hausmann, MD
Jonathan Hausmann, MD

Jonathan Hausmann, MD Med/ Peds Boston Combined Residency Program

When I told my parents that I wanted to spend my spring break volunteering in a clinic in Haiti, my dad thought I was nuts.  “Don’t you work enough during the week?  Do you really need to spend your vacation working as well?”  Good point.  But I became a physician to help those that need it most.  And although I’d like to think that I help patients at Children’s Hospital every day,  the resources available to each patient is so great that it seems my contribution makes less of a difference.  I wanted to dive into the other extreme, where the need for healthcare providers is so great that it almost overwhelms the system.

There were more than 200,000 people killed in the earthquake that took place in Haiti on January 12, 2010.  Those that survived were left homeless, orphaned, hungry, injured.  There were only a handful of hospitals in Port-au-Prince before the earthquake, and all of them were left in ruins.  To try to fill this void, the United Nations and several international NGOs attempted to set up clinics to treat the wounded.  Project Medishare, a non-profit organization from of the University of Miami, quickly set up a hospital in a tent inside the airport of Port-au-Prince, complete with operating room, air conditioning, and even a child life center.

We arrived early on Saturday morning and were welcomed by the hot haitian sun.  Without much introduction or fanfare, we were immediately put in charge of caring for the twenty children in the inpatient ward.  The place had the feel of a shelter. Children that weren’t orphaned had parents, brothers, sisters, staying with them, often sharing their cots or sleeping on the floor.  The medical problems we encountered were remarkably varied–from congenital malformations such as hydrocephalus, broken bones and wounds from the earthquake that had not healed or had became infected, tropical diseases such as malaria and typhoid, burns, motor vehicle collisions, meningitis, congenital heart disease.  Complicating all of these medical problems was severe malnutrition, which did not allow wounds to heal and made our patients extremely vulnerable to pressure ulcers.

Although the hospital was originally designed to treat trauma and the acute problems that arose from the earthquake, it had evolved to become one of the premiere healthcare centers in Port-au-Prince for a wide variety of illnesses.  It had the only neonatal and pediatric intensive care units in all of Haiti, something which did not exist before the earthquake.  Project Medishare had become one of the largest referral hospitals in Port-au-Prince, serving a similar function to that which Children’s Hospital serves in Boston.  Children’s Hospital nurses, pharmacists, and physicians, in addition to other healthcare professionals from across the United States, worked tirelessly to care for these patients.  Everybody was pushed to their limits–nurses caring for more patients than they ever had before, general sugeons performing cesarian sections, orthopedic surgeons drilling holes into a patient’s skull, neonatologists treating the elderly.

Nevertheless, the hospital was not designed to provide the continuity of care that most of our patients needed.  I did not know how my patients would fare after they left.  Who would follow my heart failure patient to adjust the dose of her diuretics?  Although I was able to provide her with a limited supply of medicines, where could she turn for a refill?  She had been receiving two meals a day while she was in the hospital, but how would she receive her next meal?

The trip also made me question my role as a physician in confronting these global issues.  Am I doing enough by volunteering one week a year to do clinical work in places like Haiti?  Should I instead dedicate my life to help set up healthcare systems in developing countries?  Would it be better for me to specialize and help improve the life of a few patients, or become a generalist and help as many people as possible?  Do I want to practice medicine in a setting where I have every diagnostic tool at my disposal, or should I help bring these tools to places where they are desperately needed?  I don’t have answers to any of these questions, but at least now I know what the questions are.

Erly Mathieu, RN, BSN, CPN Intermediate Care Program 11S

What a difference our presence made in Haiti.  Talking to many of the families, including the local Haitian employees, they have let me know, that out of all the groups who have been to Haiti, our team had a special touch. It is true that we made it to Haiti few weeks after the earthquake;  but the job is still immense, the need still great, yet there are not enough hands to achieve it.  It was a challenging job, yet I feel great to be able to  give my best, in exchange for a thankful smile.  It feel good to share some of our blessings with the less fortunate  in Haiti.  Will  I do it again?  In a heartbeat.  Thank you all for letting me share this experience with such an extraordinary team.