Alright –on the first plane heading home. Final thoughts...
When traveling internationally – particularly from an
airport such as the one in Haiti – if it is only $80 more for business class on
the way home, you take it. Seriously best 80 bucks I've ever spent, and I’m
still on the ground in Port-Au-Prince. I also imagine this will feel nice come
tomorrow morning, as I land in Seattle just after midnight, and have class at
8:30 in the morning. Nothing quite like hitting the ground running, right? I would also like to take this time to thank whoever
it was who invented the air vent on airplanes.
In other news, I think we figured out what that strange “rooster”
noise was… My new guess is a screech owl. I wasn't able to completely confirm,
but a quick Google search at the hospital yesterday showed that screech owls do
in fact reside (or have at some point) in Haiti. In my half asleep state the
other night, I almost made a recording of whatever noises were occurring at
some point in the night, and now I wish that I had. Oh well, something to come
back for.
Our last class was Monday. In general I feel they went well.
There was a definite “education gap” between the students, with some being
incredibly well trained and still sharp when it came to EMT-level knowledge of
diseases and disease processes, while others struggled to recall some pretty
basic stuff. I think the gap stems from initial training. It turns out EMPACT
is not the only organization that offered EMT training after 2010, but
education wise it was by far the best. The other gap was between those EMT’s
who worked in hospital or pre-hospital setting and those who weren't currently
using their certifications, but this is a more normal delineation. Again, I
stress that they went well for everybody involved, although I again found
myself wishing I spoke the language. Claudel and Saul, our translators, were
incredible (EMPACT EMT’s themselves), but it meant that all information had to
funnel through them, which always alters my natural flow.
---Break in the action: Just spotted a whale as we were
climbing from the airport! The water looked funny, and when the plane tilted a
bit the light changed just enough to see the shadowy outline. ---
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| Triage! |
Yesterday, our last day at Bernard Mevs/Project Medishare
(the hospital), was a full day spent in triage. I didn't really explain how the
hospital works before, so here goes. When a patient comes to the hospital, they
simply come and knock on the front gate, right off the street – imagine going
to visit your rich uncle Mr. Burns – same style of gate, just pink, and with
the hospital name on it. They are greeted by two big security guards, one
holding a loaded 12-gauge shotgun (good fun). Depending on the nature of the person’s
request, they are allowed to pass (routine appointments, visiting another
patient, etc), or, if the person is requesting to be seen by the emergency
department, the security guard gruffly shouts “EMT!” in the general direction
of anyone standing in the triage area, which happens to be the closest section
of the hospital to the gate. One of the Creole speaking EMT’s will then go and
quickly interview the patient, or in cases of more obvious emergencies (GSW’s,
stabbings, severe respiratory distress, etc.) the EMT will just wave the person
in, or in some cases, wave in the vehicle transporting the patient (car,
Tap-Tap, Land Rover, motorcycle, or other) to the triage area.
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| Looking toward the gate/street. On the left is where the patients sit, the ramp on the right is triage. |
Now, let’s be clear – HBMPM has one entrance and one
entrance only. This means that not only are all patients, both coming and
going, walking/wheelchaired/or vehicled, are passing through this gate, but
also all cargo, all administration vehicles, and the occasional ambulance
transferring a patient from an outside hospital to use the CT scanner (that is,
when there is power. Electricity is typically lost sometime around three or
four in the
afternoon, and while the majority of the hospital is on a generator,
the big portable CT scanner is not). It is a very, very busy gate, and all
traffic goes right through the middle of the triage area. Think about it like
this (adding pictures for help clarify): all patients sit on one side of the
thoroughfare, and the one bed, one bench, on chair triage area is on the other
side. Patients come from the gate, sit on the wooden bench under the shade
flowers on one side, and wait to be checked in/triaged. We typically come over
from the triage area itself, interview them, determine the nature of their
complaint, and advise accordingly. It is absolutely up to the EMT’s to
determine who needs to be seen now and who can wait, which was really fun. The
role we played was absolutely critical to the proper functioning of the
organized chaos that was hospital triage. Side note - why shouldn't the
patients cross the “road?” Because they may not make it to the other side. It
wasn't as if cars were moving quickly through there – probably only 3 to 5 miles
per hour, but it seriously felt like the world’s slowest game of Frogger at times.
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| Nicole and a paramedic whose name I cant remember outside triage - if you look at the curtains and then find them in the picture above of the inside of triage, it will give you a good idea of size... |
Once a patient was evaluated by an EMT, they were
registered, and waited for the doctor. Few patient’s would go directly to the
ED, as it only had in the neighborhood of 8 beds, and the ICU 3 or 4. Doesn't
allow for much leeway or patient surges (for example, a triple shooting).
Anyway, back to the bench. The patient’s sit on the wooden bench, when the
doctor has a chance to finally evaluate them, he/she writes some quick notes,
orders either an IV of normal saline (most people are dehydrated as it is, can’t
go wrong with a little fluid), labs, an x-ray, pain meds, or a small sampling
of other preliminary treatments/tests. The patient, or more commonly a family
member, must then go and pay for these treatments and pick them up from the pharmacy,
then bring them back to triage where they have the medication administered.
This is the general process.
Highlights from yesterday included a neat-o distal femur
fracture, some routine trauma (girl hit in the head with a rock, a girl thrown
from back of Tap-Tap who ended up having a small subdural, and a broken arm),
routine medical (I don’t feel well, on again off again toe infection for the
last three years, abdominal pain that’s probably food poisoning), and a 25
minute span that wasn’t so routine. It started out with an “ambulance” coming
through the gate and parking directly in front of triage, effectively blocking
off all traffic from going anywhere. This naturally led all the available EMT’s,
nurses, and a couple of docs to investigate, to find a gentleman prone on the gurney
(on his stomach), with a very clean stab injury to his lower lumbar region,
almost DIRECTLY over his spine. Imagine a spinal tap gone terribly, terribly
wrong. The patient was quite stable – great vitals, full range of motion in all
extremities, no bleeding. Nonetheless, one of the docs climbed in to the
ambulance to figure all this out while we all watched and waited. About 15
minutes in to this, a very angry/emotionally upset young male started shouting
at security/anyone who would listen, very near the back of the still parked
ambulance. After a few minutes of shouting, he was led down toward the
administration building, reasons unknown.
Picture Break! (get it?)
Distal femoral shaft fracture. Elderly female, non ambulatory for the last several years, fell out of her chair the day before. Totally stoic - not even a grimace (femur fractures are notoriously painful).
Another one of our favorites - patient being discharged with a recently cast leg. This is how I recommend how people should travel with a cast.
Returning to our story.... We all continue watching the doctor evaluate the stab wound.
Given that the patient was stable, compounded by the lack of beds in the ED,
the patient was granted the sole triage bed, until further notice. Easy peasy,
get him out of the ambulance, transfer him over, get vitals, start a new bag of
fluids running.
Enter Kate, RN, head of hospital logistics (She’s super
cool, from Seattle – I recognized her from the Seattle Children’s ED actually –
her and her significant other Scott have been at the hospital for over a year
now), very calmly attempting to collect details on the patient who coded (died)
outside the hospital gates.
Patient who coded? Say what now?
The four EMT’s, two nurses, and doctor all in
triage at the time sort of look around at one another, hoping someone knew
more. After several minutes of confusion, a story finally emerged. While everyone was
gathered around the stab injury in the ambulance, which was of course blocking
the gate, another car with a patient either in, or about to enter cardiac arrest (still
unclear why, possibly another stab injury) pulled up. The security guards,
hollering “EMT,” managed to get one of the Haitian EMT’s to break away and come
check what was up. The EMT found a patient in cardiac arrest, with what we like
to call “injuries not compatible with life.” Or so the story goes. At any rate,
sounds like the guy wouldn't have been long for this world, even if he had made
it through the gates. But, as Kate
calmly explained (I mean this literally – I was really impressed with how she
managed the situation) to the EMT, if you find a patient who needs immediate resuscitation - even if it is clear they aren't going to make it - right
outside the gates, you don’t turn them away, or tell them as such.
Her words were something along the lines of, “that gentleman,” (the aforementioned
angry one) “will forever remember that his friend died outside the gate. He got
all the way here, only to die while he waited to get in the hospital. At the front gates." Which, when you think about it, would feel brutal. Personally I relate it to what they teach EMT's regarding SIDS. Should you find a lifeless newborn, you never ever "call it" inside the house, even if it's obvious. At that point you are treating the family. Morbid, but it makes good sense if you think about it logically.
At any rate, the rest of the day seemed to past rather quickly, and aside from riding home in the back of an all metal Tap-Tap during a thunder storm, passed without incident. I am now sitting in Miami International Airport, I just ate fresh fruit (a catch up post needs to be dedicated to the dietary trials and tribulations of the past nine days), and this post is incredibly long. I DID manage to capture some decent footage of the mean streets of Port-Au-Prince, so I'll see about uploading those when I get home.
That's all for now - thanks to all who have kept up, and especially to those of you who managed to make it to the end of this post!
Cheers,
Nick
