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.

Dlo Twa

Water can be the source of so much joy all while it can be the source of so much strife.  Yesterday we ran through our second trauma in as many days.  A six-year-old girl had fallen into the river and was pulled out after an unknown amount of time.  She was carried into our clinic floppy.  Her eyes were shut and his muscles relaxed.  It became #GoTime.  I grabbed her and set her on our exam table.  She was groaning and tachypneic.  Rachel and I rolled her on her side to see if we could discern breath sounds.  Crackles all along the right side, but she was moving air.  Rachel got vitals while I checked for neurologic status.  Her eyes were closed and she was sluggish to open them for pain.  She had sounds coming from her mouth, but would not respond to questions or use words.  I pinched her arm.  Nothing.  I pinched the skin over her ribs.  Nothing.  I pinched her leg.  Maybe a muscle response.  GCS is not good.  “She needs to be intubated.  If only we had a pulse ox to see how she is oxygenating.”  PERRL.  Heart sounds are good.  No signs of trauma from the fall.

Our interpreters are fiendishly translating four different women giving their accounts of the events, yet none of them witnessed it.  We continue to stimulate her by firmly rubbing her sternum and speaking to her.  Slowly we see more life coming out of her.  Her eyes open with more purpose.  She mutters a few words.  Eventually we get her to give us a ‘thumbs up’ with each thumb.  She’s sleepy, but appears to be improving without intervention.

We call Dr. Buresh for guidance as we tell Guirlene to work on getting a tap tap to take her to the hospital #TwoInTwoDays.  I give him the 30 second presentation and ask his opinion.  We don’t have oxygen.  We can’t ventilate her.  We can’t even monitor her.  She needs broad spectrum, IV antibiotics, which we do not have.  Her lungs sound full of water and she’s doing a pretty terrible job of replacing the water with air on her own.  He reminds us to maintain her c-spine because of the unknown fall history. 

Guirlene reports that no taptaps are available.  Mahalia volunteers her car.  I drive it around so we can load and go.  We log roll her and slide her onto the folding chair just like before.  I think I need to patent this.  We take her out to the car and carefully load her into the backseat.  Rachel rides alongside her to maintain c-spine.  Thankfully the girl continues to improve clinically and even flashes a smile.  I navigate the SUV out the gate through the throng of community members that had followed the child over.  I head down the road.  Potholes are the least of my concern.  Large ravines have been carved through the dirt road from the storms.  Maintaining c-spine precautions won’t be easy.  I cringe with every bump and turn, but the girl is a trooper.

We arrive at the local hospital and I take John in to find a collar for our patient.  The nurse immediately diverts us to the doctor who is in the back administering an IV injection.  She finishes up and quickly says she can’t speak English.  #JohnToTheRescue.  I explain that we need a collar to protect our patient’s neck.  She tells the nurse to call for the Cuban doctor on call.  The front exam table is vacated so John and I head back out to bring in the girl.  I crawl through the back seat and push her out the other side so Rachel can maintain c-spine.  We get her onto the exam table as the Cuban doctor walks into the “ER”. 

He starts speaking… in Spanish.  #RachelToTheRescue.  She’s been trying to speak Spanish this entire trip and now she finally gets her shot.  She shines.  We tell the doctor that the little girl was brought to us after falling into the river from an unknown height and was submerged for an unknown time.  She was somnolent when she was brought to us, but has slowly improved.  Her lungs sound crappy on the right side.  And we’ve been doing our best to maintain c-spine precautions. 

They accept the transfer.  However they also do not have any breathing assistance machines or xrays.  She’ll have to be sent to another hospital.  They notify the ambulance drivers while the Cuban physician places an IV.  The Haitian physician begins writing transfer papers.  We wait for her to be loaded into the back of the ambulance and are even hit up to help pay for gas.  But, we had every confidence that the little girl was going to make it to St. Damien’s http://saintdamienhospital.nph.org/ and not incur a single cost for her treatment.

Dlo De

The hurricane’s rains brought more than the obvious destruction.  Haiti has been struggling with an outbreak of diarrheal illnesses ever since the last set of natural disasters.  When infrastructure is devastated the incidence of disease grows.  Makes sense though, right?  The rural poor of Haiti already can’t afford to build latrines and don’t pay to treat their water.  Or at least that’s what my limited personal experience has shown.  Cholera ravaged the country during the last rainy season and I think we encountered our first patient after this storm.

He was a sixty year old man and by the time he got to our clinic at nine in the morning he had already had five stools.  It took him a little over an hour to reach our clinic.  I try to not think about where he would have defecated along the route.  He has crampy abdominal pain along with his watery, clearish diarrhea.  No one else in his family has it, but he reports with an ominous tone, “They will be struck soon.” 

His blood pressure is 90/60 but he is not tachycardic.  His oral cavity carries a terrible odor and his four teeth look like petrified wood #FossilMouth.  However, it was still moist.  I perform my abdominal exam and note that his aorta is fairly obvious.  His pain is worst in the mid upper epigastric region.  His lower quadrants are relatively benign.  No guarding.  No rebound.  Otherwise normal exam.  I discuss with Rachel the advantage of treating him for severe cholera.  He can tolerate PO, so that should remain the crux of his therapy.  We teach he and his a wife how to prepare ORS and prepare a liter for him.  He lives far away and it has been our practice – and others before us – to over treat especially when someone lives far away.  So we opt to give him the 300 mg Doxycycline recommended for moderate to severe cholera infections.  We ask him about dehydration symptoms.  Chest pain?  Dizziness?  Light headedness?  Syncope?  Weakness?  Yes.  Yes.  Yes.  No.  Yes.  Of course.  Just like everyone in Haiti.  #OverTreat  #OverTreat I keep telling myself.  I get the equipment ready and Rachel places an 18 Ga needle in his left arm.  We run in a liter of fluid wide open.

He says he feels “much better” but we still give him a  tortilla with peanut butter to help him with a little more strength for his long journey.  Mr. Matay, our translator for this patient encounter, has to remind him to say thank you for us helping him out.  It’s okay.  A lot of patients who should be saying thank you in the United States certainly don’t either. 

He waves back as he leaves the compound and promises to come back and see us.  He kinda missed the counseling about us leaving the country in a couple days.  Raymond quickly seizes the opportunity to plug that we should relocate here permanently because there is such a need.  “Did you not hear?  I am starting a residency program here!  The paperwork should be finished just in time for you guys to be the first class!”

#PeaceOutERAS

Dlo Youn

The families in the Northeast know exactly how devastating this disease can be.  Hurricane Sandy, after having passed through the Caribbean, touched down in NYC and ruined Mayor Bloomberg’s plans to hold the NYC marathon.  People are displaced and living in the many NYC hotel rooms.  Disaster relief is pouring in but people are still being forced to ration gas, food, and power.  Sounds like another day in Haiti.

The storm was its own disaster in little Haiti.  While the area where I am staying was largely spared, the Lower Peninsula had extensive storm damage.  Arcahaie lost its bridge connecting itself to Port-au-Prince, but the bridge that was washed away in Les Anglais completely separated families from their homes.  Four lives were lost when that bridge gave way.  Days passed and mothers and fathers were still unable to reach their homes and children.  The river was powerful and no one was foolish enough to challenge it.  One of my classmates, @AlexHubbell, was down there at the time and witnessed the devastation first hand.  I know it got him fired up.

However, I found the rain a welcome relief from the days without water to bathe in.  While the clinic team was here we would often run out of water in the cistern supplying the showers.  My showers were brief and unsatisfying.  Once I resorted to the bucket method.  Hurricane Sandy brought downpours that offered a salvation.  I lathered up outside and caught the runoff from the tin roof.  I can’t take full credit for the idea, for Dr. Bybee was out dancing around under the runoff before I made the decision.  I just provided the soap.  The water was chilly, but nearly unlimited.  By the time the drops slowed we had gathered a small crowd of bathers and a greater number of gawking onlookers.

 As the rain continued unabated over the next days I had to turn to other methods of entertainment.  Always the scientist, I decided to conduct a study to determine exactly how well my @FroggTogg would work given the conditions.  I donned a set of green scrubs and put on my @FroggTogg.  By design, my scrub pants would get soaked while my shirt would be spared.  The fabric was the same and I would perform different movements to ensure that there were no leaks.  The experiment was a wild success.  After nearly an hour “playing in the rain” I finally surmised that enough time had passed to call the study good.  I went under cover and removed my jacket.  Sure enough, the only part of my shirt that was wet was where it was tucked into my pants.  The water had soaked up through the fabric exposed beneath my @FroggTogg.  Hey, @FroggTogg, how’s that for an ad campaign?  #IllKeepYouDryInAHurricane.  

Wouj

The Red Zone.  In Iowa they call it the “Case-IH” Red Zone.  Can you tell that we play our sports in the middle of a cornfield?  #FieldOfDreamsReference.  I’ve been going through crazy football withdrawal since I’ve been down here.  Here’s hoping my fantasy teams survive and my return will inspire them to a playoff run!  In keeping with my fantasy football theme, I’m going to borrow a bit from @MatthewBerryTMR and do a love/hate on the color red.

Things I love about the color red:  According to Will Smith in Wild Wild West red is strong, it is the color of passion #DidIReallyJustReferenceWildWildWest.  Studies show that red is the color that girls wear when they are on the prowl.  And Rachel looks pretty dang good in red if I do say so myself.  I would be remised if I failed to mention the STL Redbirds #12in13?  And in Haiti that Digicel sign in bright red can often be a welcome sign when you need to charge up your phone.  But that’s about all that is positive about the color red in Haiti.

I learned during my first trip down here that wearing red is a fashion faux pas.  It’s not like the people I’m working with have a very expansive wardrobe, but the color red is intentionally avoided (unless you’re Digicel).  If you wear red then you are telling other people that you are in mourning.  You are saying that within the past year you lost a member of your family.  Needless to say, an NGO can experience a big problem if they try and dress their employees in the wrong color.  So whenever I see red I see it in a different light now.  As a medical person, I often wonder what the past medical history of the decedent was.  I wonder if they were a victim of the social adversities that plague this country.  I wonder if there were treatments or medicines that would have gave them a second chance at life.  I wonder if the family attributes death to Earthly causes or if they assume it was a voodoo curse.  Basically I think too much.  But at this point you almost have to because this culture has made a point to make the color red something sacred.  In the U.S. you wear black to a funeral for fear of having color display something other than a somber mood.  Even though we should be celebrating their life and praying for their life eternal we choose to don black clothes and walk in silence to pay our final respects.  And after that, you may carry the grief of death in your heart and mind, but we don’t announce our grief for the rest of the world to see.  Some keep it bottled up deep down inside so that it never crops up again.  Such a stark difference.

#ChangingGears During a teaching lesson shortly after the big clinic had arrived I had the unfortunate opportunity to talk about a little girl with reddish hair.  Now, I didn’t perform any epidemiological studies or genetic testing, but I don’t think that there has been too much Irish DNA injected into the gene pool down here.  The red hair you see is often brittle and more coarse than normal.  It’s a sign of disease.  I take a peak in the little girl’s mouth and it too is a fire engine red.  The tongue almost appears irritated.  The gums weepy.  The corners of the mouth cracking.  Red dominated above her shoulders.

I grabbed a MUAC tape and wrapped it around her arm.  She was a tad older than 6, so technically it was no longer sensitive or specific for malnutrition, but it was important to do for the sake of teaching.  The mid-upper arm circumference is the best measurement for detecting malnutrition in kids and pregnant ladies.  It’s quick, cheap, and easy #TheseAreAFewOfMyFavoriteThings.  And it has solid sensitivity and specificity for a screening tool. 

She was at the bottom of the green.  According to the color lesson, she was not malnourished, but per her exam she was suffering.  Her age might indicate that she is malnourished as her arm should be expected to be larger than a younger child’s.  A few times we have had kids who measured in the red zone of the MUAC.  Not near as exciting as when your favorite team enters the red zone.  But certainly a million more times significant. 

Fortunately for us working in Haiti there is an awesome resource located in the mountains near Casale.  The hospital turns no one away and they even have inpatient treatment available for children suffering from severe malnutrition.  They are pretty rockin and have been extremely helpful during my time here.  I have complete confidence that they will do everything possible when presented with a child who is malnourished.  I know I've mentioned them in previous posts, but @RealHopeForHaiti (http://www.realhopeforhaiti.org/) do some amazing things.  When they get a kid that's in the red zone, they don't fumble.