May 2nd, 2017
Today, we’re leaving Haiti. Yesterday was by far the busiest and most traumatic day of the entire deployment; it was also the last day.
A truck rolled in with three trauma patients. One had an obvious head injury with a large scalp laceration, was combative, lying on the ground, and getting everyone’s attention. George and the Haitian E.R. doc, Dr. Charles, were taking care of him, and he managed to roll off the narrow stretcher in his anguished agitation. While that was going on, our paramedic, Lorna told me that there was someone lying in the back of the truck. I went to look, and saw an elderly women lying on her left side facing way from us on the floor of the empty trailer.
I got some help to move her into the ER, and tried to assess her. It was difficult, because everyone was looking after the young man with the head injury. Fortunately, I had Kim and Lorna to help. The patient was very quiet, which worried me, but she was still a GCS 13-14 and she was protecting her airway. She had some facial lacerations and left facial swelling, but seemed neurologically intact. She denied any shortness of breath, chest pain, belly pain, or back pain, but complained of hip pain, and I was worried about a hip fracture. I put her in a c-spine collar, because I was worried about a c-spine injury as well as a possible closed head injury with her facial swelling and her altered level of consciousness. I was reasonably hopeful that she didn’t have an unstable pelvic fracture, because she was hemodynamically stable, and seemed reasonably comfortable, especially after we put a Foley catheter in, but it was still a consideration and I was anxious for her to get imaging done.
Meanwhile, the other docs had decided to intubate the other patient, which they did with impressive skill, considering how big he was, and how he needed in-line neck stabilization. I tried to assist by providing BURP. George did a FAST, and the patient had a slip of free fluid in the RUQ. I also ultrasounded his belly and chest. He had no pneumothorax, and it appeared that there was no interval change in the free fluid around the liver.
The patient I was looking after remained stable, but she had a couple of facial lacerations, including one on her lip, and one on her left eyelid that required closure. Her left eye was also full of gravel, which we flushed out with normal saline. The hours dragged on, without the requested CT head, c-spine, and pelvis X-Ray getting done.
The other patient was going to be given blood, and needed it urgently, but Dr. Charles explained that an HIV test needed to be done on the patient first. If the test was positive, then the family wouldn’t be able to say later that the patient had received tainted blood, and sue the hospital. Apparently, this has happened before. What about drawing the blood for HIV testing, and then doing the transfusion while awaiting the results? This would help minimize delay. No, explained Dr. Charles. The results of the test must be reported to the family before the transfusion is given. There must be no way that family can later say that their loved one received blood in hospital and is now HIV positive as a result. I can understand this, but it causes a delay that can be life-threatening in a trauma patient with blood in his belly, and a deep scalp laceration.
Eventually, the patient went to CT and X-ray, four hours after arrival in the ER. There was much commotion and tight spaces, and heavy lifting, getting this patient who was intubated, and must have weighed over 100kg, on and off the stretcher for his CT. The scan showed what looked like poor differentiation between the brain’s grey and white matter, suggesting swelling and injury, as well as some trace subarachnoid blood. Afterward, his chest X-ray confirmed the placement of his endotracheal tube, showed what looked like a big heart, and likely some right-sided pulmonary contusions.
He went from X-ray to the ICU, where we were getting him settled when he suddenly went bradycardic as I was trying to scan his heart and look for a pericardial effusion as Ana had requested. His heart rate came up a bit, and then he developed PVC’s and went into Ventricular tachycardia (VT), and finally ventricular fibrillation. CPR was started, and an attempt at defibrillation was attempted, without success. CPR and pulse checks continued. He was given several 1 mg ampules of epinephrine. His lab results were available, and showed that he was very acidotic, so bicarbonate was given. Calcium chloride was requested too, but too slow to arrive, needing to be retrieved from the pharmacy. As an EMT went to get it, I believe he was initially refused, and in retrospect, if a doctor had gone, it might have been more quickly procured. Eventually, we got a pulse and we were about to start him on norepinephrine. We weren’t sure why he arrested. Did he have a pericardial effusion, thus explaining why his heart looked so big on X-ray? Did he have a cardiac contusion? His heart looked very hypokinetic on ultrasound, but I didn’t see a pericardial effusion.
Despite the return of circulation (ROSC), the patient arrested again, and after more rounds of CPR and epinephrine for his PEA (Pulseless Electrical Activity) he couldn’t be resuscitated. The code was called, after lasting almost an hour. On hearing of the patient’s death, I could hear family members in the compound outside of the ICU wailing and screaming with grief.
The final CT report available after, showed that the patient had massive brain swelling with a traumatic subarachnoid hemorrhage and uncal herniation, his brain pressing on the brainstem and disrupting the primitive regulation of his basic bodily functions, such as respiration and cardiac activity. There is no coming back from that.
I know Dr. Charles was upset with the outcome and we wondered, if things could have happened faster, maybe the brain swelling could have been identified on a CT done earlier, but there wasn’t much that we could do. We couldn’t give him mannitol to decrease the brain swelling, because his blood pressure was so low. These are difficult conditions to work in, with limited resources, and a slow pace of execution.
We can only try our best, and not become angry or frustrated at the way things are done. We’re not there to show people how to do things the right way. If anything, we’re there to learn how to make do with less. In an era of increased scarcity of medical resources, we may be forced to learn these lessons anyway.
My lady with the hip fracture had by now been in the ER six hours. I accompanied her to the CT scanner, and saw that her head was fine, and c-spine intact. Her facial bones were not broken. She only had a lot of soft tissue swelling and the lacerations that I sewed up.i was expecting her to go to the X-ray after her CT, and found much to my surprise that it had already been done while I was away with the other patient. So it is that my expectations had been lowered. A critically important X-ray that I would expect being done within minutes of her arrival had not been done for several hours. Still, it had already been done, and I had already resigned myself to it not having been done, so I didn’t even bother to check. The X-ray showed an unstable pelvic fracture, the worst I’ve ever seen. I can’t believe she wasn’t in more pain. She seemed comfortable with morphine. It’s lucky that she didn’t bleed out into her pelvis. We tied a sheet around her to act as a binder. I left her with a plan to admit to ortho, as our orthopedist suggested, so that she could have an external fixation of her fracture. I’ll have to find out what happened with her.
George saw a third patient in the accident who had a broken thumb, and needed only stitches and a splint. The spectrum of disease from a single accident ranged from the life ending brain injury, to the life-threatening pelvic fracture, to the most minor injury.