Sis San

I’d seen this story before.  The eighteen year old girl was carried to our clinic by her loved ones.  Rigan, a Haitian nurse who has been with CHI since before the beginning, took note of her sickly appearance and quickly ushered her back towards my room.  Why me?  She looked like death.  Or at least like death was on its way.  There was a gurney in my “office” – still in disarray because I hadn’t fully set up yet – so we laid her down.  Fortunately, we have two amazing nurses on our team that both are used to taking care of sick patients.  One rolls through a peds floor that manages CF kids with a pCO2 of over 100 (that’s not compatible with life in most instances) and the other is adult critical care trained.  Why am I the one in some semblance of charge again?  Maybe my memorization of the krebs cycle will allow me to outrank their years of practice.  #OrNot

We got vitals.  First step, easy peasy.  HR?  150ish.  I grab a manual sphygmanometer and register a BP of 90s/60s.  I was expecting lower.  She’s clearly tachypneic and is flaring, retracting…the whole bit.  In other words, she’d be using her toes if her body thought that it would help her get more oxygen in her body; she was giving it all she had.  I grab the thermometer and try to communicate to her to place it under her tongue.  I’m not sure if she’s not mentating well enough to follow commands or just doesn’t have the ability to execute.  It shows 35.8.  Not a fever.  She’s sweating.  Shivering.  And feels hot as an iron.  Let’s have another go.  Rectal?  Eh, let’s not ruin the thermometer.  Axillary it is. 

I turn my head and see Shandy, the critical care nurse, walking in with an IV starter kit.  This is why nurses rule.  I glance back and the thermometer is already to 39.  And there it is. 

I grab my stethoscope and quickly realize that I can’t clearly hear her heart sounds because of the crackles and rales in her lungs.    She’s septic.  I have a source.  But what I don’t have is everything in the “Clinical Guide to Sepsis Management”.  Should have ordered a central line with mean arterial pressure monitoring, blood cultures followed by broad spectrum IV antibiotics, and oxygen supplementation.  Instead I’m left thinking how to adjust those protocols to Haiti medicine.  Janice (peds nurse) makes short work of the shrunken veins in this girl and the fluid is flying in. 

Thankfully, Dr. Abby, the only real physician showed up to get a feel for what was going on.  I gave her the rundown, she verified the source of infection, and we started basically every antimicrobial we had.  We injected ceftriaxone and administered Bactrim and Hydroxychloroquine. Janice rigs up our nebulizer to see if we can’t get her to breathe a little better.  We check her O2 saturation and it’s 77%. 

At this point we think we ought to test for a couple of the infections we can, so run an HIV and TB test.  The HIV test is negative, but I later find out that her TB test is positive.  The breathing treatments start working and her lungs are able to open up a little more as we also give her some steroids.  All of a sudden she starts coughing up a mix of white, yellow, green and pink sputum into a plastic cup.  It honestly looked like a bunch of cake frostings layered together.  #NeverEatingCakeAgain #LiesWeTellOurselves.

We had to go about our clinic as the patients outside were piling up.  Thankfully I was just getting in the way in the patient’s room, so I had plenty reason to get out.  I popped in to get updates.  Her saturations, after 2 more breathing treatments and another dose of rocephin, climb to 80%.  She still looks like death.

Patients come and go, including some other real sickies, but our teenager is still in the room next to me.  Dr. Abby stops by my room to tell me that the decision was made to transfer her to a local hospital.  I agree with it being the best course of action.  Neither one of us are sure that she will be alive when she arrives at the hospital over an hour away.  I stare out the window as the truck pulls away, hoping that I’m wrong in thinking that I’ll never see her again. 

We completed the clinic including working through another septic pati*nt who showed the initial improvement with IV fluids and antibiotics that we never saw in our first patient.  The clinic ran us haggard and through all the struggles we still were left wondering about our patient.  The answer came later as we were all sharing a cold Prestige back at the hotel, trying to salvage such a brutally exhausting day.  Physical exhaustion and spiritual exhaustion.  Hyppolite received the phone call bearing the news we knew was coming.  Our patient was no longer alive.  We don’t know if she made it to the hospital or not before passing. 

If the history given to us by her caretakers was correct then her death was nearly two months in the making.  I didn’t learn this until later, but before sending her Dr. Abby asked if she was scared.  The patient, only an 18 year old girl, very calmly responded with, “No.  I am at peace.”  Dr. Abby said it best when she pointed out that this young girl probably had few opportunities to feel loved and cared for like she did when our entire team worked like dogs to save her.  I only hope that she saw the spiritual drive and power from a higher power working through us in our efforts. 

The phone call was not only about the loss of our patient.  Her body was now in a foreign town and the driver had felt no obligation to return her back to Les Anglais.  Apparently a two month’s salary doesn’t cover the extra hour for a round trip anymore.  And then the family was concerned about burial costs…A very important tradition in Haiti.

I’ve never discussed the passion the Haitians have for the deceased before, but it is evident by the quality of the funeral homes in every town.  If you want to find a funeral home, just look for the nicest building in the town.  Multiple stories.  Air conditioning.  Landscaping.  Any amenity that one can have in a Haitian building can be found in the funeral homes.  Tombstones and crypts are ornate expensive.  The quality of the burial situation signifies the respect and love you earned as a living individual.  Funeral processions often feature parades with music and celebration.  And without refrigeration the entire process must take place as quickly as possible #DecompositionIsNotFestive. 

The anticipated price tag for such a proceeding and burial?  Six hundred dollars.  Death is the only time a Haitian can expect to live like a king.  Seems like a cruel joke.