Hypothermia part 1

The untreated water washes the blood off my hands and down the drain.  My brow is still dripping with sweat.  I don’t know why I think ‘still’ when I know our job is far from done.  I walk back downstairs in the ServeHaiti clinic to see our patient lying still under the x-ray machine.  All I can think about is how lucky we are that the rest of the group left this morning. 

Two nights ago, Rachel and I arrived to a mission in Gran Bois.  Gran Bois has a clinic sponsored by an NGO called ServeHaiti.  ServeHaiti has a large contingent of Iowa members including some of Rachel’s neighbors.  They have been active in Haiti for over ten years and this clinic shows the payoff of hard work and a serious financial commitment.  They are able to employ two fulltime Haitian docs to staff this place.  Our arrival was met with much fanfare as they really didn’t know when to expect us.  We spent one day with the whole team, but this morning we waved goodbye as they loaded up into the three vehicles and set off to return to the U.S.  And thank goodness.

Our patient was carried through our front door on a stretcher just as we were departing for a five hour hike into the mountains to visit another clinic site.  To think, if he had come five minutes later we may have never seen him.  He was shivering and far from responsive.  The story we got was that he had been missing for two days and they found him on the ground.  They carried him back to the post-partum room where our only empty bed is and we get to work #TraumaActivation.    

His airway is intact and appears to be midline.  He’s tachypneic over 50.  I auscultate with my stethoscope.  No breath sounds on his right lower area, but faint sounds up top.  I’m concerned about a pneumothorax.  I check for neck veins.  None.  I percuss his chest.  It’s tympanic.  Well, shit.  Now what?  As I continue with my primary survey, he starts to come to and suddenly becomes very active #NotAGoodTime.  I guess it’s safe to assume he is neurologically intact.  His distal pulses were regular, so even though we didn’t have a blood pressure cuff available I knew his numbers to be good enough to perfuse his fingers and toes, so it must be good enough to perfuse his brain and heart.

The nurses and Dr. Leo were trying to set up the EKG leads, blood pressure cuff and O2 saturation monitor.  I ran to grab a thermometer.  I shove it under his armpit. . . . 92.3 F.  Blankets.  We need lots of blankets.  We finally get the monitor running and Rachel squeezes the finger clip on his index finger to measure his oxygen saturation. . . . 80%.  We’re in for a long night.

We ask Dr. Leo to grab the oxygen machine.  We tell the nurse that we need a couple IVs running fluid.  I start the secondary survey.  He’s dirty.  His pupils are equal and reactive to light.  Dr. Leo brings back the oxygen machine and we drag around some extension cords to hook it up.  He tells us to look at the patient’s scalp.  I run my hands over his head and his skin scalp spreads apart.  He has a full thickness laceration about 6 cm long over the crown of his head.  There is no blood, so I missed it during my survey.  That’s not a good sign.  Scalp injuries bleed like crazy.  This was a major scalp injury and it had stopped bleeding without any medical attention.  He must have lost a lot of blood.  Dr. Leo tells me to wash his head off so I grab some water and soap and begin scrubbing.

Oh shit.  I find a second laceration longer than the first.  I palpate the depth only to feel a rough irregularity in his skull.  My stomach drops.  This man had been struck by a machete, twice.  That’s the only thing that makes sense.  Rachel points out some odd scratches on his hands that we couldn’t place before, but now we know them to be the characteristic defensive wounds when someone is being beat.  I tell Dr. Leo we need to go ahead and get chest xrays to see what’s going on. 

The patient is still making purposeful movements in that he’s trying to fight us at every step.  He’s got an IV in both arms.  He continually tries to pull them out, pull off his oxygen, and take off his monitors.  We get him in a wheel chair and maneuver him into the main room of the clinic.  Dr. Leo already has the x ray machine set up so we just have to lie him down.  Thankfully the father of the newborn baby sharing a room with our patient is helping us or else we’d be struggling to have enough hands.  We lie him down and get him comfortable.  There are no IV poles to hang his fluid and antibiotics that we started.  I take one for the team.  We have to move forward.  Everyone clears the room while I hold his hands to the side and the IV bags up in the air.  Maybe if I cross my legs my junk will get less radiation?  He shoots the image and takes the film back to load it onto the computer.  Yes, digital imaging.  Rachel comes out to tell me that he does have a pneumothorax and significant mediastinal shift.

Midclavicular line, second intercostal space.  That’s the board response for any patient with a tension pneumothorax, which I’m not convinced this patient had.  He just had a significant pneumothorax that was compromising his respiratory status.  I need a 14G needle with a stopcock valve.  We have an 18G used to put in an IV catheter.  Okay then.  #AlwaysSettle.  “Do you feel comfortable with this, Dr. Leo?”  “Oh yeah.”  Okay, that makes me feel better.  Cause I’m terrified.  Rachel offers me some sound reassurance and I pierce.

The whoosh of air and faint spray of his blood that returns through the needle onto my face is actually a relief.  He’s still tachypneic.  I listen and he has breath sounds on the right side.  They sound like shit, but they’re there.  I let myself get nuked again for a repeat image and see that his heart and mediastinum are relieved.  We also see an extremely clouded right lung.

I steal away from the hubbub to clear my head.  I head into the restroom.  I stare into the mirror trying to comprehend what we’re doing at this clinic.  Dr. Leo just told Rachel and I in between images that this man was found at the base of a seventy foot pit with his hands tied behind his back.  He was the unfortunate prisoner of some monster, or monsters.  And to make matters worse, he was one of the gardeners that helped Dr. Leo with the garden.  I wash the blood off my hands.