Haiti update from Michael Agus, MD: Days 4-6

Michael Agusby Michael Agus, MD – director of Children’s Medicine Critical Care Program

Day 4

The day started with a proud smile and high five from the HUEH resident who wryly bragged, “I told you I wouldn’t need all that airway equipment.” The child had been safely transported and the surgeon had successfully removed the pebble from her trachea.

The routine has begun to set in at this point, but admissions were few on this Sunday. The weather, which had until now been in the 70s with scattered rain, hit the 80s with strong sun. With this change, the temperature in the interior of the medical tents rose to above 100F with extremely high humidity. Slight fevers are no longer clinically significant, standard intravenous fluid calculations no longer apply. Thanks to the NGOs, drinking water is plentiful and those patients, who are capable, work hard to maintain adequate hydration. The rest are dependent upon IVs or attentive family members to keep them hydrated.

Two children were doing well after their overnight emergency surgeries for perforated ileum due to typhoid and an incarcerated hernia. Their weary parents stood at their bedsides, calming them, cleaning them, cooling them and advocating for an exam or an IV check whenever possible. I stumbled upon several pediatric endotracheal tubes while searching through internationally donated supplies. These may become useful in the days to come.

I ended the day with a video chat with my three boys. They were equally interested in the child who had the pebble successful removed as in the curiosity of taking a freezing cold shower in a boiling hot country.

Day 5

Michael Agus Haiti When I arrived the hospital campus was packed with of hundreds lined up at the adult and pediatric triage tents. After several hours in line in the hot sun, the visitors would finally get attended to by the hospital staff. The hospital hands out food trays and food tickets to those waiting in lines, which inevitably causes a stir, and sometimes a bit more, especially when the tickets run out.

I was invited to attend the HUEH pediatric faculty meeting where I met with the chair of pediatrics and her fellow pediatricians. We discussed what resources PIH might be able to provide HUEH on an ongoing basis.  The pediatric chair and staff expressed their desire for intermittent visits by various pediatric subspecialists who are often difficult to locate in Haiti. They also expressed their deep appreciation for the assistance that they have already received. We discussed the prospects for continuing to elevate the level of care provided in the pediatric tents. The pediatric office building had been condemned shortly after the quake and all remaining equipment that had survived had since disappeared.

As I rounded with the residents in the afternoon to get updated on the admissions for the day, I met two more boys with typhoid fever, one with sickle cell crisis and acute chest syndrome, and one with delirium thought due to typhoid, but which turned out to be due to carbon monoxide poisoning due to burning trash in his tent village. Although the level was high enough (29 percent) to warrant entry into a high-tech hyperbaric chamber for treatment, we instead maximized oxygen delivery with the resources at hand, using oxygen shared evenly between him, a baby with TB and the child with acute chest syndrome.

I signed out to Kevin and his night colleagues to keep an eye on all three. Just before I rolled out, a worried father carried in his 10-year old lethargic son, covered in hundreds of pox – chicken pox. We quickly rushed him back out of the tent and brought him to the isolation tent, transferring the girl with resolving diphtheria back into one of the main tents.

This was the first 24 hour period without losing a patient, though several had decompensated. The discussions about long term support for the hospital are very rewarding.  A busy day, and judging by my headache, one when I should have drunk even more than I did.

Day 6

Michael Agus HaitiI awoke to another beautiful day in Haiti, though now I knew enough to understand that this would inevitably lead to unbearable heat inside the Pediatrics tents by midday. I decided today would be an infrastructure day. I found a roll of duct tape and together with my interpreter we secured all the key plugs into their connecting power strips on the web of extension cords that powered the one or two fans in each tent. We made sure all the canvas flaps were off the windows. But it wasn’t enough – later in the day a premature baby in one of the incubators in the NICU reached near fatal temperatures as his plastic, insulated home absorbed all the heat in the tent. He was rescued in time, however, by HUEH staff. A staff member estimated temperatures in the tents at over 100F.

I also had a disappointing food related moment during the day. I have been enjoying delicious rice and beans for breakfast and dinner, and eating energy bars for lunch. I admit that I have been eyeing the MREs, or US military prepared “Meal, Ready to Eat”, that another NGO working at HUEH often have. They appear to be multi-course meals in a bag with bread, main course and dessert. I have yet to get my hands on one. When I was wandering through their storage area in search of medication burettes, a commodity in these parts, I came upon a group of volunteers with more than 20 Domino’s pizzas. It looked like they were still hot. I secretly got on the walkie-talkie to alert my PIH colleagues that there was pizza to be had, and one immediately pointed out over the radio that secrets aren’t very well kept when they are announced over a walkie talkie. I moved quickly back to the pizza area before anyone changed their mind only to find that there were no vegetarian pizzas – all meat. For a Kosher guy, this was a low moment.

The day ended with a significant step forward for the pediatrics tents. In concert with PIH and HUEH pediatric physicians and nurses, we implemented a medication administration record for the bedside chart. Though not computer charting, it provides a safe, reliable method to know at a glance what medications the patient is on, and when they are due.

Stay tuned for more coverage of Agus’s time in Haiti.