International Emergency Medicine – A Reflection on Haiti
(Or, as it really was, an unforgettable, life-changing experience)
Author: Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)
Editor: Alex Koyfman, MD (@EMHighAK)
As emergency medicine physicians, we love the undifferentiated sick patient. We all have those shifts where we see back pain after back pain, or headache, or the medication refill, or low risk chest pain. These shifts sometimes are the most tiring. However the patients we live and practice for include the ones where we can truly make a difference: the crashing hypoxic patient, the septic shock patient, the trauma patient requiring emergent airway and procedures, the mottled and febrile newborn, and even the patient with no access to healthcare.
International medicine has made large advances in recent years, with fellowship and elective opportunities attracting many physicians. This last month a team from my residency program, consisting of a staff EM physician (Michael Barakat), a nurse practitioner (Mallory Barakat), and two senior EM residents (Andrew Amack and myself) traveled to Port-au-Prince, Haiti, for a two week elective in Hospital Bernard Mevs with Project Medishare (http://www.projectmedishare.org). Our goals were to provide assistance to patients in need, practice in an international environment, and help educate the staff presently at the hospital in emergency medicine topics including resuscitation, trauma, airway, and sepsis. This post will give you a journal-like reflection on the first several days at the hospital, interesting cases evaluated, and an overview of Hospital Bernard Mevs and its goals.
Arrival Day: After arriving at the airport, we had a quick ride to the hospital through traffic, while observing the lack of helmets on motorcycle drivers (which will come into play on our shifts). The team received a quick introduction to the hospital including the triage/emergency room, which consisted of two beds, a cot next to a wall, two chairs in a corner, and several stools. The ED was truly a room. One nurse is on at all times, with several medics and a translator. The ED possesses an older Sonosite US machine. The ICU consisted of 4 beds. The hospital ward is broken into two areas: Med/Surg A and B. The pediatric ward can care for 12 patients, with a PICU across the small path and NICU as well; each can care for approximately 3-4 patients. The hospital contains four ventilators, which is the total for the city. The hospital has one of the only CT scanners in the city, which is 16-slice. We had laboratory capabilities and Xray. Available medications include midazolam, succinylcholine, morphine, Tylenol, ibuprofen, metoclopramide, and ondansetron. The hospital has streptokinase, but no other thrombolytics. Antibiotics included ceftriaxone, clindamycin, amoxicillin, penicillin, Bactrim, and Augmentin. Blood supply included up to ten units on site (usually whole blood), and if a patient required multiple units, family needed to find donators (often themselves). This hospital is vital in the city, as it truly is the only trauma center/ critical care unit in the country and only ED in the city.
Hospital Bernard Mevs
Triage/ER at Hospital Bernard Mevs
Perhaps most importantly, we also received an introduction to Haiti healthcare. Many of the Haitians and the healthcare system have recovered after the earthquake, but the vast majority of patients possess no primary care. Most patients must wait until they are very ill, as to receive any care the patient or family must pay. The patients are very stoic due to the living conditions and what they see daily going on around them. Poverty is rampant and every day can be a fight to survive. However, many of the Haitians truly care for and are passionate about their country.
View of Port-au-Prince skyline and street from hospital rooftop
That night after dinner (the night before our first shift) we were asked to come to the ED for a failed intubation. We found an obese patient being bagged, hypoxic in the 40% range, and were told she was unresponsive at home after a thyroidectomy two days prior. She was barely breathing on her own, so the current physician attempted several intubations, but was unable to complete them. After some extensive suction, a tube was passed by Dr. Barakat through an anterior, edematous airway with the help of bimanual pressure. We decided to use ventilator number 4 for her (the last ventilator in the hospital and city). We then went to bed, anxious for the next day and our “first shift.”
Day 1: The Eye Opener
Needless to say, with the ED setup described above and staff present, you can be quickly overrun and must learn how to triage quickly. We received multiple assaults with rocks to the head and motorbike accident patients, as well as a gunshot victim. Because the hospital was full, we had no admission beds and were forced to transfer patients needing admission. One 71 year old male with diabetes presented with a foot infection, brought on the back of a motorcycle by two others. His initial GCS was 7, RR 32, BP 100/55, HR 105, T 102.4F, and SpO2 94% on RA. We quickly obtained IV access and gave him a fluid bolus. All of the ventilators were taken, so we decided to monitor his airway status and intubate/bag if needed. Due to limited antibiotics, he was given clindamycin and ceftriaxone. His foot once exposed demonstrated two necrotic toes (4th and 5th), with poor perfusion up to the ankle and a “mushy” feeling on palpation of the foot. His mental status and RR improved after a second liter. We transferred him due to lack of beds.
Necrotic foot with dry gangrene
A second patient was a two day old female, born prematurely at home. She presented with aunt and the neighbor, as the mom was sick at home. The baby was pale and mottled, with little responsiveness to stimulation. The pediatric team evaluates the majority of pediatric patients who present to the ED. The baby preceded to lose pulses and was taken to the PICU, and the ED staff took control of the resuscitation. After roughly twenty minutes of chest compressions, a dose of epinephrine, an umbilical line, and an established airway, we were unable to obtain ROSC, and we declared the patient dead.
We also cared for a 27 year old male who had come in during the night and was intubated after a motorcycle accident, with a negative initial FAST. His injuries included severe head trauma with frontal lobe contusion and bleeding, pneumocephalus, and an open right tib/fib fracture. The following morning his blood pressure was decreasing and ventilator alarming for high pressures (due to high PIP). His abdomen felt tense, so we repeated the FAST, which was markedly positive in all windows except the pericardial window. We called the general surgeon, who took him to the OR and found large amounts of free, clear fluid in the abdomen, but no blood. After his return, he was much easier to ventilate, with much improved vital signs as well. The clinical picture was consistent with abdominal compartment syndrome, though we did not check pressures. All of the physicians who had worked night and day shifts were in awe of the patient acuity and resuscitations completed during the first 24 hours.
Day 2: Forget “GCS 8 = Intubate.” In Haiti, GCS 5 = Staying Alive.
The day started with several pediatric patients with severe malnutrition, including a five year old male with classic pellagra (diarrhea and dermatitis). This patient was found in a ditch and brought to an orphanage. He was transferred to a malnutrition center in the city for further care.
And just like in EM, one minute it’s quiet and then it explodes. All of a sudden a family brought a lady found unresponsive at home to us with history of prior stroke one year ago. We had no bed, so we placed her on the cot next to the wall. Her initial GCS was 3, but she was breathing on her own. Exam showed right-sided hemiplegia with eye deviation. We performed jaw thrust and were able to obtain access via the external jugular vein. At that time she seized and her saturation rapidly dropped to 50%. We proceeded with intubation using midazolam and succinylcholine, passed the ET tube with no difficulty, and then had one of our medics bag her, as we had no ventilators available. Just as we finish the intubation, the 27 year old male with head trauma who went for exploratory laparotomy woke from sedation and self-extubated, despite his restraints. You see, drips are difficult to work in this environment, so most of the medications are done by push. He was receiving 4 mg midazolam pushes with 2mg morphine roughly every 2 to 3 hours. With him extubated, he was breathing 24 times per minute with saturations around 95%. This freed a ventilator. However, within ten minutes his respiratory rate slowed and his saturations dropped to 60%, so we reintubated him and placed him on the ventilator.
That night a 5 year old male presented with severe dyspnea, stridor, and retractions. The family believed he had swallowed something, but they were not sure. Breath sounds were diminished on the right base with inspiratory and expiratory stridor. His retractions included everything up to suprasternal retractions, with his sternum caving inward due to his work of breathing. He soon stopped breathing, but Andrew Amack made a tremendous save and intubated him on first pass. He was taken to the PICU and ultimately needed several reintubations due to mucous plugging. He underwent bronchoschopy several days later, which revealed a small piece of cell phone lodged in the right bronchus.
Plastic cell phone piece from bronchoscopy
Day 3: An Everyday Occurrence – Tough Decisions and Ethical Dilemmas
One patient presented after suffering trauma to his face from a shovel. His wife brought part of his lip and nose in a plastic bag. Unfortunately she could not pay, so she went home (with the lip in her purse) to get money before we could obtain the lip/nose. Due to his injury, we consulted ENT, who stated he required OMFS evaluation. Unfortunately, OMFS would not be able to operate until the next day, so we were in a predicament. General surgery did not want to repair the lip, so the ER staff decided to attempt repair. Unfortunately, his wife came back with the lip in a bag of water, and the lip was black and necrotic. At that point, we spoke with the patient and his wife about his options, and they elected transfer to another hospital for OMFS.
Our team was then called to Med/Surg A for a patient with advanced AIDS and TB not on current treatment, as he refused it. His saturations were in the low 30% range. We placed him on non-rebreather and nasal cannula and blasted oxygen, with saturations improving to 88%. His mental status also significantly improved. He then started to swipe at his mask, which resulted in his saturations again dropping. The hospital has limited ketamine supply but access to morphine, and with 0.1mg IV morphine and close observation, he stopped hitting his mask and his breathing pattern and respirations improved. The BiPAP machine finally arrived, and after placing settings, his saturation improved to 95%. He was kept in Med/Surg A, as there were no open ICU beds and the ED was full.
That night after dinner all of the EM physicians worked in the ED for several hours, as it was overrun with a sudden bolus of patients with head trauma, motorbike accidents, stroke, and lacerations. One patient brought by family had been seen at an outside hospital four days prior for a decreased responsiveness and vomiting and found to have a subdural hematoma, but family did not recall any trauma. They were discharged, but brought him to our hospital for further care. His GCS fluctuated between 6-8, but he was breathing on his own. We again had no ventilators. His head CT revealed 2cm of midline shift with a 3.7cm subdural hematoma, uncal herniation, and subfalcine herniation. He was taken to the OR with neurosurgery the following day.
Large left acute subdural, 2 cm midline shift, with herniation
A second patient had been hit in the head with a large rock, resulting in a boggy left parietal/temporal hematoma with crepitus. He had vomited several times. His CT showed an impressive depressed skull fracture. His neuro exam was normal (minus gait), despite a GCS of 5. Intubation was withheld, and we elected to closely monitor his airway.
Large depressed skull fracture in Patient with GCS 5
Another night a 36 year old male presented with sudden onset right sided paralysis while playing basketball. He had no past medical history and no sickle cell disease. Exam revealed complete right sided paralysis, right facial droop, intact sensation, and classic Broca’s aphasia. Unfortunately, the CT scanner was closed for repair. He presented 3 hours after onset of weakness, but without CT scanner, we could not rule out hemorrhagic infarct. Thrombolytics were withheld.
Surprising Acuity and Pathology
On the evening of our fifth day, a male walked to the hospital gate carrying a small plastic bag. The guard immediately let him in the gates, as he was carrying his small infant in the sealed bag. Michael Barakat immediately carried the infant to the NICU while doing compressions. We started the resuscitation with the standard 3:1 compressions to breaths. An umbilical line was placed by Dr. Angela Zamarripa, a Peds EM fellow, and fluid bolus provided. We were able to obtain return of pulses. We discovered the male was born at 28 weeks with a twin, who had passed away earlier at the OB hospital. Unfortunately, despite the initial save, the 28 week old male died two days later.
Later in our second week, a 26 year old G1P1 female presented four weeks after delivery with dyspnea and lower extremity swelling. She was diagnosed with preeclampsia during pregnancy and had been placed on nifedipine and lisinopril by her OB. Her initial vital signs included RR 45, BP 138/105, HR 114, SpO2 98% RA, and T 37.2C. US revealed an ejection fraction of 10% with LV dilation, normal RV with no strain, dilated IVC, and greater than 3 B lines in multiple lung fields. She was started on magnesium, nitroglycerin, and furosemide. Her respiratory status improved, and she was admitted to Med/Surg B. With the exam and US, we were concerned about peripartum cardiomyopathy, and PE did not seem likely. During our first weekwe had a patient with similar presentation with EF of 5%, ascites, low urine output, and a liver that extended down to her suprapubic region. She died despite our best efforts, so with this second patient, we viewed this as a chance for redemption. On the day of our departure, our second patient with peripartum cardiomyopathy had improved and was breathing comfortably.
Chest xray of peripartum cardiomyopathy patient.
Haitian Heroism and Ingenuity at Hospital Bernard Mevs
Despite all of the stress and acuity, we saw many episodes of love, heroism, and comaraderie. Hospital Bernard Mevs and its volunteers and employees are truly doing something that no other organization is providing in Haiti currently.
A five year old male who fell from a roof presented with a right femoral shaft fracture and bilateral frontal lobe contusions and right hemorrhagic contusion. With some ingenuity, a traction device with splint was applied using nasal cannula, IV fluids, plaster, and an ACE wrap. This patient’s 7 year old brother remained with him the entire time, comforting him and caring for him.
Almost every patient had family who cared deeply for them, and we saw this multiple times every shift. Family would repeatedly bring soap with water and towels and lovingly clean individual patients from head to toe. They would clean up vomit and urine, daily change the bedding, and often carefully feed their family member.
The vast majority of the Haitian workers desire to learn as much as they can, and they constantly ask thoughtful questions with the goal of improving their care. They particularly love to learn about the ventilator, intubation procedures (setup, preparation, techniques), antibiotics, and sepsis.
Hospital Bernard Mevs and Project Medishare consistently need and desire volunteers (especially ER and ICU physicians, nurses, respiratory therapists, and EMT’s) and supplies. This hospital provides care that no other institution can do in the city. They readily welcome volunteers and supplies. If you volunteer, you will have a life-changing experience. Our team volunteered for two weeks, but the hospital asks for at least one week of service. Supplies that could be used range from extra ventilators to even small items like boxes of gloves, hand sanitizer, and linens.
This elective and service opportunity was ultimately one of the greatest learning experiences I have had in residency. Nowhere have I seen such acuity with resources that demand improvisation (with the same opinion coming from staff physician Dr. Michael Barakat with several overseas deployments). We made decisions based on resource availability. Many of the permanent staff love learning, and teaching these care providers will have tremendous long term benefits with a goal of self sufficiency for the hospital and the Haitian people.