There was a buzz around the hospital this morning that Hillary Clinton might visit, though it did not turn out to be true. It was an interesting process to consider what would be my answer to her obvious question: What one thing could the US do to make things better? My own answer would have been: nurses. Despite my tendency to focus on the physician side of the equation, it is nurses that make a hospital run. And HUEH needs more. They need more of 5,000 things, but mostly they need more nurses.
Nobody yet knows exactly how many staff were killed in the earthquake. But it’s absolutely clear what percentage had their lives destroyed in one way or another: 100%. During an informal moment with a half dozen pediatrics residents, they shared with me that all but one of them is sleeping in a tent or their car. Showering, washing clothes, finding clothes, commuting and eating all became hardships on January 12. As if residency is not difficult enough. And yet several of them came to the hospital today for the sole purpose of hearing a talk on DKA by some foreign doctor.
After the DKA talk, several opted to stay for an additional teaching session at the bedside of an intubated adolescent in the adult ICU tent. A couple of others took advantage of the mentoring by placing lines and intubating a patient in the Pediatrics tent for their first time since the quake. In fairness, even as the residents were using me for backup, I was doing the same by sharing rapid fire emails back and forth with my Children’s Hospital Respiratory Therapy colleagues.
Patients in the tents took a turn for the worse last night. One premature baby with sepsis passed away, and two more new admissions didn’t make it to the morning – one had died by the time his parents brought him into the tent.
But one sick, malnourished, 2 year-old orphaned girl with TB was adopted this morning, in a completely legal and documented fashion, I might add, by a Peruvian family now living in Haiti for over 20 years. Another orphan, called “abandonné” in Creole, is being fed by her neighbor in one of the tents until her social situation can be sorted out. I think the neighbor is growing attached to her.
92 degrees in the shade today. Inside the Pediatrics tents it was simply brutal. To be able to sweat this much without developing an electrolyte abnormality is a tribute to the body’s ability to maintain homeostasis in the face of significant physiologic challenges. And yet neither the child we intubated last night nor the 18 year-old I helped manage in the adult ICU could overcome their insults: one sepsis in the setting of malnutrition, the other traumatic brain injury from a motorcycle accident. Later in the day, it was surreal to present a talk about management of sepsis to the Pediatrics Department and discuss the use of catheters, physiologic measurements and medications to which physicians at HUEH simply have no current access. Could either patient have been saved in a different setting? This is a haunting, almost debilitating, question.
The triumph of the day, and perhaps my most significant contribution to the rebuilding of the healthcare system of Haiti, had nothing to do with my years of school, residency and fellowships. It was the setting up of a second supply cabinet in the acute pediatrics tent. My interpreter and I “borrowed” a tall metal cabinet from the abandoned Emergency Department (it is now functioning out of a series of tents) and rolled it two blocks across the campus to the Pediatrics tent. A roaming ED nurse stopped us early in our journey and made us write “Emergency Department” on the cabinet so that it could be returned once both buildings are rebuilt, but then she let us go. After narrowly avoiding an extremely low speed collision with the humvee of the 82nd Airborne (US Army), we made it to the tent. Along with a visiting intensivist from Phoenix, Dr. Paul Bakerman, we worked for six hours cleaning, organizing and labeling. The quiet, heartfelt, articulate thank you we received from one of the residents in the tent made the entire sweatfest worthwhile.
The other highlight of the day was a video chat I was able to arrange with my 1st grader’s class – the ones that had sent me with stuffed animals and drawings. Speaking to them from the roof of the old ED building I was able to show them with the webcam the beauty of the nearby mountains as well as the devastation in many of the city’s buildings. The most excitement was generated when a UN helicopter flew within a hundred feet of the camera. After the chat, Kobe’s teacher described the warmth and smiles amongst the kids as they heard first-hand that their donations had, in fact, been delivered and that they had made some sad kids just a little bit happier.
My weather app on my BlackBerry keeps predicting that the next day will be cloudy and not as hot. I wonder where it’s getting its data from. Today’s prediction of cloudy and 80 turned out to be sunny and 95 – and that’s before you enter the pediatric tents. It finally occurred to me that we could take apart one side of the tent and open the whole side to the remainder of the road. It detracts slightly from privacy, but of the scant amount that remains in this place, it seemed a worthwhile tradeoff. The parents seemed to agree with their applause when the temperature plummeted closer to 95, and several smiled and said “merci beaucoups, Blanc.” “Blanc” is used as a non-pejorative term for all non-Haitians.
We reluctantly intubated a 16 month-old boy with asthma who presented with hypoxia and associated seizures. Asthmatics are notoriously difficult to manage with a mechanical ventilator. But he simply could not reliably maintain a normal oxygen level, so our hand was forced. After a rocky start, he seemed to be doing well going into the night. Suctioning through the endotracheal tube has been difficult as he developed copious secretions as well as a high fever. We added therapy for pneumonia, as well. This one could be a straightforward “save”. His mother was disappointed to learn that she could not breastfeed while he was on the ventilator.
After chatting with several HUEH pediatric attendings on a balcony overlooking the pediatrics tents, I pointed out the Swiss flag that is hanging above the area. The attendings recalled that as soon as a country arrived after the earthquake with its equipment and tents, the first thing each did was plant their flag. He marveled at the number of flags that were flying at one point. He hadn’t noticed that the Haitian flag was nowhere to be seen. He and the other attendings liked the idea of replacing the Swiss flag with a Haitian one. I asked one of our interpreters to try to pick one up. I gave him $5, a day’s pay – that ought to buy a nice flag.
Once again I was able to video chat with a class at my kids’ school – this time Noah’s class, the 5th grade. It was Noah’s 11th birthday and I got to sing to him along with his class from my perch on top of the old HUEH Emergency Department. Noah made sure that I told his class about the responsibility of the parents in the tents, both to participate heavily in their child’s care and to step up and be equally involved if another child’s parents are absent. He seems impressed with this level of community responsibility.