66

Last night, at the close of clinic I was alerted to a critical patient that had just been sat down in the floor of our treatment room.  She actually couldn't get past registration and had to be dragged/carried behind a wall where our makeshift treatment room was set-up.  She was wheezing.  That word does not carry the morbid connotations that are necessary to describe how this woman looked and sounded.  It sounded like she was drowning as she was sitting in the middle of a desert.  She was unable to support her head even as she leaned against the wooden planks of our wall and sat on our dusty, concrete floor.  Her frantic family was hovering on either side of her, clearly distraught, and unsure of what to do.  Try as they might to find confidence in our faces, they probably failed at that as well.  We learned through our translator that she had a history of bad heart and probably suffered a heart attack about 8 months ago.  She had just visited her normal doctor this morning and her medicines were changed.  These symptoms struck out of the blue.  Our primary survey was complete and IV access was gained.  Her blood pressure was sky high at 180s/110s, her heart rate was tachy to 115, her shallow respirations were tachy to 30, and her oxygen saturation was %66.  Sixty-six percent of her hemoglobin in her blood was filled by an oxygen molecule.  We didn't believe the number, so naturally we tried it on ourselves (equipment has a funny way of malfunctioning in Haiti).  %99.  Normal.  Replaced it on the patient...%66.  We went to work.  She clearly had V/Q mismatch.  We dilated her bronchioles with an inhaler.  We threw all the IV diuretics we had at her.  Her lungs still sounded wet.  You couldn't hear her heart over the sounds of the fluid in her lungs.  Her eyes opened but the stare was empty.  One of our team members was already trying to arrange transfer to a facility better equipped to care for someone in as critical a condition as she was in.  And then, genius pointed out our early error.  We had administered a diuretic, but the woman was in no position or condition to pee.  So we scooted, reclined, and supported her body into a position better suited to place a urinary catheter.  The catheter was threaded on the count of "urinary sepsis."  A crude comment made to point to the insanity of the situation and the unrealistic concern that she would develop urinary sepsis.  %72.  She's climbing.  She's diuresing.  Her posture is such that she can open up some of those upper airways.  Her breathing is slowing, although still appears labored and sounds flooded.  Her heart is easing into a more comfortable rate.  The truck to take us to the hospital is on the way.  Things are pointed upwards.  We tend to a pair of other procedures in the same room that we had temporarily postponed when this patient showed up on our front step.  Our flashlights have to dart from the abscess being drained to the patient against the wall, a mere 8 feet away.  %80.  She's getting better.  She still doesn't talk.  She just rests.  She is our lone patient now.  She has produced over 400 mL of urine in under half an hour.  'Hopefully that came straight out of her lungs', we all think.  We decide to take shifts eating supper and keeping an eye on the patient.  %82.  The truck is here.  Both doctors, the pharmacist, the ER nurses, and a translator jump in the 'tap-tap' with the patient and her family to take them to the hospital.  There is no doctor there.  There are no nurses.  There is just a closed facility waiting to accept our patient, and our personnel.  She is started on a positive pressure airway.  The machine doesn't work so pressure must be manually created by our staff.  Let me emphasize manual again.  She is gradually tapered from a non-rebreathing oxygen mask to nasal cannula by the morning.  %99.  Dawn has broken.  The team was up all night in shifts.  At one facility a once-sick patient is walking through the front door and into a tap-tap with her family.  At another, a crew anxiously waits the return of their only physicians and news about the patient who most certainly had to have died overnight, or at the very least remains ventilated and on pressers.  Her saturation was %66...  For what seemed hours while she sat on our floor.  Death was likely.  Brain damage was an absolute certainty.  She needed to be ventilated or else she didn't stand a chance to survive.  But she wasn't and she's alive, with baseline cognitive function and was never intubated.  From %66 to %100.  Impossible.  Amazing.  Lucky.  Miraculous.  #Blessed.  Loved.  That was our patient.
As an addendum, she decided to come back and visit our clinic with her two sons, very well dressed Haitian business men.  She smiled.  Her lungs were CLEAR.  She walked with very little assistance.  She thanked us.  We thanked her.  And at that moment, we knew for sure that what we were doing was good.