Michael Agus reports on his final days in Haiti

Michael Agus Haiti flagby Michael Agus, MD, director of Children’s Medicine Critical Care Program. Agus is currently in Port-au-Prince, Haiti, where he is treating patients and sending us updates by email.

Day 10
I wasn’t supposed to work the day today because I now have to start working nights since there is a few days’ gap in the night pediatric physician coverage. But after a good night’s sleep, and with two intubated patients in the pediatric tents with no other intensivist on site, I felt like I should go for morning rounds, set a plan for the day and then sleep on the hospital grounds to rest up for the night.

At first glance, the tents seemed quiet. I, as well as the residents and nurses, wandered in and out over the next few hours and both ventilated patients were stable. I had hoped to pull the tube on the asthmatic as he was making good progress, but he clearly wasn’t quite ready. Upon re-entering the tent after one such errand, the parents urgently motioned me over to the bed of the intubated asthma patient. He was having a profound hypoxic event with seizures. I pulled his tube which turned out to be fully occluded, mask ventilated him and radioed for assistance. Paul, the other visiting intensivist quickly responded and reintubated him.

Would this event have happened in a fully monitored ICU? Probably not. Could we have transferred him to a fully monitored ICU? No, there were no beds.

Should we have waited to intubate patients until the ICU at HUEH was fully equipped and fully staffed? He would not have survived. Should I have stayed at his bedside 24/7 until extubation? Should Haiti’s hospitals have been built the first time with earthquake resistant strength?

I found a quiet spot in the old ED to nap that afternoon. Creepy but quiet.

Working in the tent overnight didn’t turn out to be too painful. There were only a handful of admissions. I was called to the OB tent to help deliver a baby since the OB residents were nowhere to be found. With several women lined up in the tent pushing, it took a moment to identify the one who needed assistance. I nervously began to assist, as 15 years had passed since my last delivery, but the resident arrived in time to complete the job. The baby arrived healthy.

Around 4 AM the asthmatic boy fully awoke and was ready for extubation. He tolerated it well. His mother was gleeful that he had made it and I was relieved. She thanked me profusely and offered to make me an honorary father in gratitude. By late morning, he was making eye contact with her and playing with his truck.

Day 11
Since the premature baby who remained intubated was extremely stable, I took the morning off and slept in. I arrived at HUEH mid-afternoon. Despite being under the watchful eye of a PIH colleague, the baby had become sicker.

Without the availability of lab tests, it was not clear what was going on. He had already required several resuscitations.

Spending nights with the residents has allowed me to get to know them even better. I continue to marvel at their ability to survive. I learned that the local name for the earthquake is “gudugudu.” It is so named because that is the sound that the shaking and falling buildings made on January 12. The other name is “douze janvier”.

As they each told me their story of survival, it struck me that there were no clear patterns. Some had survived by running outside as their house collapsed, others made it by staying inside and so avoided being struck by falling rubble from nearby buildings. All told their stories without hesitation and with no real emotion. They had all experienced profound loss and were continuing to experience severe hardships.

I did end up tasting a component of the MRE, the U.S. Army multi-course meal. A PIH colleague had come upon packaged cracker and jam. I enjoyed it but continue to be curious about the rest of the meal.

I also participated in another infrastructure upgrade. We had learned the hard way that the LTV 1200 ventilator battery lasts exactly one hour. This has come into play countless times during our trip. The problem is that the power supply to the hospital from the grid goes out almost daily.

The generator soon gets manually started but other parts of the hospital always seemed to get back online before pediatrics. We learned today that after the generator is going, a second step is still required: to flip a giant Frankenstein-like switch down the street from the pediatrics tents. This sends generator power to the Gynecology building which is where the extension cord that powers our tents is plugged in. This was a great knowledge acquisition which I shared with my HUEH colleagues and as many PIH folks as I could, so future switches could be more smooth.

Sure enough, later in the day, power went out again, the ventilator ran out of battery power again and the intubated baby’s mother calmly hand-ventilated her child again. It was dark, but I located the switch and to the surprise of onlookers I confidently flipped the giant switch. To my surprise all the lights in the Gynecology building went dark and a HUEH employee scolded me as I flipped it back on.

Apparently there was a problem with our extension cord, not the power supply. Laying across the street, it had been driven over once too often. A PIH colleague, a helpful parent and I quickly replaced the cord and hung it over the street so this one wouldn’t fail in the same way. We just need to make a sign by the socket in the hallway where it’s plugged in to discourage anyone from unplugging it.

Day 12
I started my final full day anxious to reach relative closure on some projects. The intubated baby had taken a turn for the worse. Overnight, her mother had requested that we not resuscitate again if she needed it. After further discussion that morning, she agreed that further support was futile and we disconnected the baby from the ventilator. She passed in her mother’s arms.

The interpreter fulfilled his promise from the other day and arrived with a Haitian flag in hand. With the help of a parent from the pediatrics tents we climbed up the ladder behind the structure and respectfully lowered the Swiss flag.

Initially we didn’t attract any attention. But as we raised the Haitian flag, numerous parents came out of the tents to offer their advice on how best to secure it, angle it and display it. Three boys, still at HUEH recuperating from their earthquake-related injuries, starting singing a children’s version of the Haitian National Anthem. We all – Haitians and “blancs” – allowed ourselves a moment to take in the pride that still lived among the Haitian people and those who have chosen to help them.

I raced off to retrieve the ventilator for my scheduled talk to the Pediatrics Department. After an engaging and interactive session, one of the senior residents came to the front to offer some remarks expressing the group’s appreciation for the help that our entire team had delivered and that PIH would continue to facilitate. He spoke of hopes for continued collaboration and visits to each others’ homes. When he finished, I brought the group out onto the balcony of the Gynecology building and pointed out where the Swiss flag used to be. They were delighted at the new symbol flying above the Pediatrics tents.

I was a little late getting across campus back to the old ED where I climbed back up to the roof for my third and final video chat with the South Area Solomon Schechter Day School – this time with Eytan and 7th grade. We had a great session. They were the quietest of the three classes, taking in all the details, asking insightful questions. I had to cut the session short due to a radio call about an asthmatic sounding ill.

I descended the stairs and found that someone had locked the iron gate to the stairs. I put out a call for assistance and it wasn’t long before I was set free. I found myself somewhere between hilarity and embarrassment as several Haitians noticed me and called to their friends that a “blanc” was locked in the stairwell.

The afternoon finished how the trip had started, with a flood of admissions including a 14-year old girl whom we diagnosed bedside with hematocolpus, a couple children with suspected typhoid – one of which was complicated by delirium and seizures, two with post-streptococcal glomerulonephritis due to untreated skin superinfections of scabies and chicken pox, a child with suspected retropharyngeal abscess, an 18-month old with TB peritonitis and 12-month old with malnutrition and shock.

The new PIH team from Yale, led by pediatric intensivist John Giuliano, arrived to replace us earlier in the day. They picked up the patients and the relationships we had developed exactly where we left off. Kevin and I worked to orient them until after midnight. But by then it was clear they were off and running. The residents were already coming to John to present cases. The transferability of the relationships to new people was affirming of the infrastructure that had been developed by us and our predecessors. We finished our last night with a late night team toast with local Haitian rum.

Day 13
One last job to do. PIH had arranged a head CT for a 14-year old boy whom we had admitted a few days back with a headache and bilateral abducens nerve palsies. There is a CT scanner at HUEH, but at the moment, it is sitting outside in a driveway. We located a military stretcher and brought him across campus to the waiting van. We placed the stretcher and perched it across the three rows of seats as his parents nervously joined him for the trip across town. Another story was about to unfold, but this time it would be guided by other PIH volunteers.

Kevin and I loaded our things and headed off to the airport. In the quiet car traveling through devastated yet lively streets, it was hard to be sure our work had really made a difference. But PIH has been here for 25 years and I am confident that just as we tried our best to carry forward the work of those who came in the first weeks after gudugudu, subsequent teams will carry forward ours.

PIH understands well that we were not invited to HUEH to establish an American health care delivery system. Rather, we were invited to help re-establish, support and further develop the Haitian system with Haitian attendings, residents and nurses. Only by working within their own system can we hope to achieve what has become the hopeful prayers of Haitians: to channel the massive and generous international response into rebuilding a stronger, healthier and more self-sufficient Haiti.