(this is a cross post from Rahul’s blog found here)
What We’re Doing in Haiti – Again-
In retrospect, this is what was said by a member of our team regarding what we’re doing:
We are on a fact-finding mission and while we are there, let’s try to help, wherever we can, but first do not destroy what has already been built. Remember, this is a long term journey for this ER, hospital, city, and country.
A few months ago, the Israeli Ministry of Health built a new Critical Care Unit (CCU). As you know, the Israelis know a lot about trauma and resuscitation. It’s unfortunate they have had to become the leaders in this filed, but they are now educating and building units that will help other people.
The Israeli Ministry of Health agreed to build this CCU, however, they did not wish to supervise and overlook how it is used, so they asked a partner of theirs, Jewish Healthcare International (JHI) to do the education and operations portion of the CCU. To bridge the Israeli Ministry of Health and JHI, they sent Shirley, an Israeli to the newly built unit to ensure it is used properly and that there is an infrastructure for its continued use after she leaves. JHI sent 4 of us, in order to gather facts and come back and report to them what we think it needs to survive. Shirley was extremely helpful in explaining what she had already done and we began understanding what was needed for future success. Shirley is a Pediatric Intensive Care Nurse in Tel Aviv. She was sent to Cap Haitian for 8 months and used her managerial skills to organize the CCU, building an inventory, staffing the newly built CCU, and writing the order protocols which includes who gets in the CCU (must be sick, but cannot be too sick). Most importantly, she got buy-in from the hospital administration. She is the last resource the Israelis will be giving to the hospital for this CCU and now JHI will take over. As I said, we are here on a fact-finding mission, and our team will help determine what resources JHI can give the hospital.
The Critical Care Unit
The CCU is like no other part of the Justinian University Hospital. It looks like a long skinny rectangle, as if someone attached 2 trailer homes linked together by the ends. When you walk in the only door, you feel this rush of cold air and cleanliness. It is the only place, other than the operating rooms, with central air conditioning. There is a waiting room with 2 rooms next to it where a patient can be triaged, then a second door leads you to a long hallway lined with clean beds. To the left is a room that looks like our trauma/resuscitation bay at Northwestern Memorial Hospital. There’s a monitor, cart for emergent procedures, medication cart, suction, in-wall oxygen, and enough room for multiple people to work on the patient. Down the hall was another room, filled with 6 beds, separated by curtains and a nursing desk. The CCU is staffed by 1 MD for 12 hours shifts. There are 5 MDs that rotate covering the CCU 24 hours a day. Although there are many doctors, only a handful has bought into this early resuscitation and the whole art of emergency medicine. These physicians understand trauma and critical care. They move fast and have advanced knowledge in emergency medicine.
This CCU is beautiful. It is the opposite of what the ER is like, which is located about a 30 second walk from the CCU. Let me describe the ER:
First off, it’s in the middle of the hospital campus. You see registration first and pay the required admission fee (less than 3$), then patient line up and are seen by interns (Haitian doctors who are just out of medical school). Patients are seen on a first come, first serve basis. There is no triage. The attendings are internal medicine doctors without any emergency medicine training. In a word, the ER is: chaotic. It is also dirty, extremely smelly, not sanitary (no easily accessible running water and no easily accessible gloves), and because there are no supplies and RN assignments, it’s disorganized and inefficient. Let’s say this, I’m an ER doctor and I did not like going there.
Okay, that’s the background of what the ER is… The CCU vs. the ER was like heaven vs. Hell of hospitals.
Our goal… To make sure that the CCU is used correctly and is well-run. Also, while we were there, not to take over control of the ER (because we’ll be gone in a week and we all know that it’ll go right back to where it was prior to our arrival). So we needed to educate, and with the MDs in the ER and CCU, to help them see and understand how different operational changes can really make an effective change. The ER nurse who was leading my group, Leanna, with the help of the leading resident, helped develop a triage protocol, waiting space, and mentality of sending patients who did not need the ER to their required areas quickly. It was amazing what the place turned into: an efficient, almost wait-free ER. We did notice, that when we left, it quickly slipped back to what it had been prior to us being there… And that’s the fear we all have.
So What Did We Do?
After 2 days of us observing and talking with the residents, attending physicians, nurses, and others, we got a good sense of what was going on. I witnessed many, many different kinds of cases. I worked along side the resident (there were two who essentially ran the entire ER and CCU). In the CCU, I participated in a trauma case where a pickup truck with 5 people in the back of the pickup rolled over. All came to us. I witnessed how they triaged 2 to the CCU and three to the ER. It was a beautiful scene, as Haiti does not have a triage system or a trauma center mentality. Since it was during the day, there were four physicians in the CCU.
The first patient, a 30-year-old female was placed in trauma bay #2. She was lifeless and she had no pulse. The resident looked up and said to me, “She has no pulse!” I asked him what he wanted to do, and he looked at me and said, “she’s dead.” Now, for us in the US, this is our protocol, as a traumatic arrest is pronounced dead. We are done, it’s pretty easy, but in Haiti it’s a bit harder culturally. It made me relieved that he was so decisive. He went over to the next patient where she suffered major facial trauma, forehead hematoma, nasal fractures, and at least 6 upper and 4 lower teeth fractures. A c-collar was place appropriately, a primary assessment was done and then a secondary assessment. There were multiple physicians, buy it was not chaotic. The nurses simultaneously placed two large bore IVs and the patient was placed on the cardiac monitor. I thought to myself – there is NO way this would have happened in the ER. This CCU is a success, as it saves lives, and it must be continued.
This patient did very well. She was transferred a day later to the surgery ward, which is a room with over twenty patients in gurneys without curtains, lying side-by-side where family members do 75% of the nursing care. Where if the orders say wound changes three times-a-day, IV fluids, and Ancef every 8 hours, then the family member goes to the pharmacy, purchases wound care materials, IV fluids, and Ancef for the nurses to use for that day.
Later on that day, the senior resident came to me and asked me if I’ve ever seen a dislocated jaw. I smiled and said I had. I asked him, is it a young girl who could not close her mouth after yawning? With wild eyes, he said, “Yes! How did you know?!” Funny, the things you see as a resident in Emergency Medicine. I told him to put her in the CCU where we could mildly sedate her and reduce it. He was very excited. We gave her 5mg Valium IM, and 15 minutes later I taped up his thumbs (you sometimes get an accidental snap of the jaw, causing the patient to clench down on your thumbs) and he mostly reduced her jaw by himself. It was a fun, very gratifying procedure. The patient was extremely happy.
We had other patients, and although there weren’t many actual findings, we discussed the workups and treatments of syncope (passing out), head injury, calcium channel blocker overdose, and vague abdominal pain (without the use of CT scan).
Health care is different here. It would be difficult for me to be here, but on one hand, I could see myself loving it. Here’s an example:
With the resident, I saw the next patient. It was quite bizarre… The patient was a 70-year-old female who had purple colored lesions all over, including on the bottom of her foot, palate, arms, and had a rock hard non-tender abdomen. She was emaciated, and only a bit uncomfortable. I had no idea what it was. The resident wasn’t sure either. The other internal medicine physician came over, and took a look. He looked it over for 15 seconds and turned to us and said, “She has Kaposi Sarcoma and probably AIDS.” Ah… I’ve seen pictures of this, and I’ve read about this, but I’ve never seen it. It was impressive. The internal medicine doctor talked with the patient for about 10 minutes and then the patient started leaving with the help of her family. I asked the resident what was going on, so he talked with the doctor and discovered that the family had a feeling that this is what it was, but just needed a confirmation. They told us that she was old, and it was her time, that she had lived a good life. We offered admission to see the internal medicine doctors, but the patient would like to go home, where her family was.
How beautiful is that? That mentality rarely exists here in the states. I’m unsure why. Why are we brainwashed to think dying at the hospital is the best place to dye? Let me tell you… It’s not, and it’s one of the worse places to die. I have a few stories like the one above in all my visits to Haiti. The Haitians seem to understand the bigger picture.
So, in Conclusion
We taught, we observed, we made some diagnoses, gave some treatments, and we are going back to JHI where we will advise them on what they can do with their funders’ money to ensure the continued use of this CCU which the Israelis built. How often should a group be sent to the hospital? Who should come? What should they do? What education should be taught while there? In the next few weeks I’ll be writing up my report. The week I had was very insightful. The physicians and patients in Haiti are amazing people. Their stories pre- and post- earthquake make me remember why I initially came. Their resilience is why I continue to come back.