An 11-month in respiratory failure secondary to septic shock is a tough call to be on. Having to transport that same patient in a developing country with no EMS system or ambulance service presents a whole new set of challenges. But make that same country the most impoverished nation in the western hemisphere, throw in a 7.0-magnitude earthquake, and you might think you’ve come across the worst call of your career.
Within my first two hours at the clinic I had assisted a team of physicians and nurses in wound debridement, rehydration and setting several fractured limbs. But before I even had time to take my first sip of water, a young mother with a flaccid infant in her arms was rushed to the “Acute” ward of our makeshift clinic by the triage nurse.
“I think he’s got pneumonia,” the mother explained through a translator.
The mother, her husband, and their remaining children who had not died in the earthquake, had been living under a tarp on the church grounds for nearly a week, and her young infant had been running a high fever with diarrhea for the past several days. Just from looking at the infant, it was clear to all there that if something wasn’t done for the child immediately, he would soon die.
Everything about the infant screamed “septic shock” – so much so that if you’d open your paramedic textbook to that same section, virtually every sign or symptom that is included was presenting. Aside from the 102.6º F (39º C) tympanic temp, he was breathing at 50-60/min, labored, with intercostal muscle use, retractions, see-saw breathing and nasal flaring, along with coarse rhonchi throughout his lungs. His lips were blue, his skin was dry and ashen, (and even flaking), accompanied by significant skin-tenting, and he had no purposeful movements, but only a detached, listless gaze. His pulse was weak and rapid, easily above 200bpm, though still palpable at the brachial site, and his mother said that he had not had any diarrhea or urinary output in the past day. On top of all that, it was clear that he was malnourished as his body looked more like that of a 6-month old, and his hair was thin and stringy, with a reddish-auburn tint that bordered on gray in some areas – known as hypochromotrichia, I learned, one of the signs and symptoms used to diagnose Kwashiorkor (a specific type of malnutrition lacking in protein, and common in tropical regions).
While it was clear what needed to be done, there was the ever-present problem of inadequate supplies. As with many of the treatments and procedures performed at the clinic, improvisations would have to be made. For starters, the clinic had already gotten down to its last liter of normal saline, which I had actually just discontinued from a dehydrated pediatric, clamping it off and putting it aside with only 700cc remaining. Still, the baby had no obvious veins to administer the fluids, so after several failed IV attempts, a spinal needle was placed in his lower left extremity as there were no IO needles available. After the ad hoc IO placement had been confirmed by bone marrow return, the patient was given an initial 200cc fluid bolus, and then 500mg of Ceftriaxone, which was the most suitable antibiotic available. After a second bolus of 200cc normal saline, and another round of 500mg Ceftriaxone, the baby was intubated using an uncuffed 4.0 ET tube with a 2.0 Miller blade, along with 2mg Ketamine which one of the doctors had had tucked away in his carry-on. But again, the only equipment available was far from the most optimal, and the patient had to be ventilated using an adult BVM on room air only, while the ET tube was “secured” by using a generous amount of medical tape.
Being the only paramedic at the clinic, I volunteered to transport the baby — hopefully to the Israeli Defense Forces (IDF) field hospital, which was rumored to have a pediatric “ward.” (Lidie Rondil-Gagen, a Haitian-American nurse who would play an instrumental and vital role in this mission, had previously transported a premature baby to the IDF field hospital two days earlier after an emergency c-section had been performed on one of the church benches.) But before I could transport, it was clear the patient would need to be secured to a backboard. Using another nurse’s spare hemostat, I unscrewed the backrest of a dining room chair that was at the clinic, and used the flat side to lay the patient on top. Using still more medical tape, I secured the patient’s head, lower torso, and legs, and also attached an extra piece of cardboard to the base of the board so that we could secure the patient’s left extremity and add additional stabilization for the improvised IO. We also used a roll of kerlix below the knee, as well as a small tower of 4x4s around the needle with another piece of cardboard on top of the guaze to add still more protection to the needle.
Armed with a ten-cent stethoscope and an adult ambu-bag, we found Blue, the driver of the orphanage’s Mitsubishi cargo truck, to take us six miles to where we hoped the IDF field hospital was located. But before I left, the physician handed me a syringe with another 5mg of Ketamine to give to the infant in case he started to buck the tube. “And if he doesn’t need it,” he added, “keep it for yourself because you definitely will after this is all over,” and he left with a smirk, a nod, and a pat on the back.
The first challenge proved to be even getting into the truck, and once inside it didn’t take long too realize there was no way to secure the baby and the backboard and maintain good ventilation at the same time. That was when Lidie appeard, the first of many miraculous interventions we would experience in the next several hours, who helped the patient’s mother and father into the back of the truck before getting in the front with me.
Nonetheless, treatment and packaging, as the doctor assumed, would prove to be the easiest part of the call.
The transport started out innocently enough: unpaved roads covered over with a fresh, incongruous layer of rubble and debris, and scarred by well-worn pockmarks and potholes. As any paramedic will attest to, transporting an intubated infant with an uncuffed tube can be an unnerving event, but the added road conditions while riding shotgun in the cramped, rickety truck, made every bump and jerk feel like a small bomb going off under our seat, causing great difficulties in maintaining delicate fingers around the small tube I had in my hand, only millimeters away from coming dislodged at any moment.
Once out onto the main, semi-paved road, you could see the USNS Comfort hospital ship anchored less than a mile off the coast. Of course, we immediately hit thick traffic, but what our vehicle lacked in lights and sirens, our driver made up for with a willingness to drive on the opposite side of the road while laying on the horn with equally reckless abandon. The transport continued in this fashion for nearly thirty minutes – weaving in and out of oncoming traffic while dodging pedestrians, rubble and pigs as we turned off one road for a shortcut only to come back to the main road twenty-five minutes and three blocks later. Yet even after what had felt like such a long, harrowing trip, in reality we had barely traveled two miles. All we could was manage what was in our hands: vigilantly holding the tube and making sure to reassess lung sounds after every new bump, while doing our best to match our ventilations with the patient’s own drive, or just making sure to breath every 1-2 seconds when we couldn’t distinguish between the baby’s barely visible chest rise and the bumps in the road. That was the system we formed: I would ventilate and hold the tube, as Liddie held the backboard and the baby, placing the stethoscope over the chest for me to listen as often as we could.
Though our driver did his best to keep us moving along, it was clear that we weren’t making too much progress – his horn was just like all the others (if only a bit more constant), and swerving into the opposite lane was useful only when the oncoming traffic was lighter than our own. Soon enough, however, a pickup with a Red Cross symbol on it pulled up alongside our truck filled with several Haitians in the pickup’s bed, and Liddie flagged them down and began yelling to them. Whatever she said worked, because at the next intersection both of our vehicles pulled over to have a quick roadside conference, and soon enough we were back on the road with them leading the way for us with sirens, yells and shaking fists. And when the traffic got thick, the men would jump out of the bed of the pickup and run ahead to stop cars from pulling in front of us.
But just as I was thanking God for this fortunate meeting, I whiffed an acrid scent in my nostrils, and my first (and worst) suspicions quickly became reality as I looked over to see black smoke seeping from the AC vents – the truck was overheating. But no sooner had the cab of our truck filled with smoke, and we were in the back seat of the Red Cross pickup, on our way again – as if the pickup had been sent ahead of time to meet us for exactly that.
Back on the road, Liddie became engaged with the Red Cross driver in a tense conversation about where to take us. I assumed, at least, that this was what they were talking about because I was only able make out the word “Israeli” from the Creole they spoke; and I figured that the driver was on his phone only to get directions from someone else as most of the locals had very little idea as to where any of the newly formed field hospitals had been set up.
When we finally emerged from another round of thick traffic – so thick and smoggy I was tempted to stop ventilating the patient – our driver turned onto a road that was protected by a gate. But as we passed the security guards at the gate they informed us that the IDF hospital wasn’t there, nor was there any hospital there at all. The driver went to turn back onto the main road, and as he made the U-turn, the pickup truck stalled. He tried to start it up again, but nothing happened, and after two more attempts we knew the pickup was no longer an option. Thankfully, the men in the back of the pickup understood the dire urgency of our situation, and they took it upon themselves to surround another pickup that had pulled up right behind us, kindly requesting that the driver take us to the hospital. The driver, in turn, agreed, as there had been little opportunity for him to protest, and we climbed into the bed of our now third vehicle, rechecking the tube every time we moved. Now, however, we were directly beneath the 95-degree sun, so we took the small Haitian flag Liddie had been wearing around her head, wet it down with our last bottle of water, and laid it over the baby’s body, hoping to keep him cool and protect him from the direct sunlight.
Our next destination wasn’t the IDF field hospital, however, as the driver of the Red Cross pickup had instructed our new driver that we were to be taken to a Red Cross facility, which was only fifteen minutes away. As it turned out, though, the Red Cross facility wasn’t a physician-staffed medical hospital – rather, it was a Red Cross medical supply depot, with lots of physicians walking around tall stacks of medical goods in cardboard boxes. Spotting the first Red Cross employee we came across, Liddie called out to him, and when he approached I explained to him our situation, nodding to the baby in my lap, and asked him if he could find us a doctor. He ran off and came back a few moments later accompanied by a doctor – an Austrian pediatrician – who listened to my turnover, agreed that the baby needed a hospital, and then left to find another doctor. Shortly after, a Norwegian anesthesiologist appeared, listened to my turnover, and directed a co-worker to get a vehicle to take us to a hospital. The Norwegian physician, however, was not sure of the whereabouts of the IDF field hospital, but told us that he knew how to get to the University Hospital where there was a clinic that had been set up in the courtyard. (En route to the hospital, the Norwegian doctor, named Panu Saaristo – who I later learned was a member of the International Red Cross and Red Crescent Society – informed us of the PROMESS program set up by WHO/PAHO. Originally, the PROMESS program was established to provide medical supplies to registered NGOs, but that restriction had been lifted and they were now offering supplies to anyone so long as they filled out a quick application and could verify that they were with a legitimate NGO. This helpful information would come into great use later in the week.)
Twenty minutes later, we arrived at the University Hospital in Port-au-Prince, with the tube miraculously still intact. Until then the only complications we had encountered with the tube was a right main stem placement every so often, but we were always able to correct it with slight adjustments. Our big worry, of course, was either a complete extubation (compounded by the fact that we had no laryngoscope available to re-intubate, and only an adult-sized ambu-mask to ventilate), or a pneumothorax given the adult-sized ambu-bag. Still more concerning was that by then I had taken over controlling the infant’s ventilations as his own efforts had become totally ineffective. While he was still maintaining the same heart rate, his respiratory drive was virtually non-existent, and Liddie and I agreed that if the baby were to code, we would not perform CPR, and wait until we got to the hospital to pronounce him.
Fortunately, this did not occur, as we arrived at the hospital with the baby still maintaining a good heart rate. Getting out of the car, we carried him up through the courtyard and came across a small tent that had a hand-written sign above it that read “Maternity Ward.” The tent was filled with metal cribs that had been removed from the heavily damaged hospital, and inside we spotted a woman in scrubs that was assessing a female infant in one of the cribs.
“Excuse me, ma’am,” I said to her. “Where’s the pediatric tent? And where can we got some oxygen?”
Turning around, the woman looked at the intubated baby we were carrying and her eyes grew big and her face scowled at us. “What do you want ME to do with that baby?” she barked.
It was clear to see that the woman was exhausted and under an enormous amount of stress, but so were we, and I didn’t have an answer for her, and could only ask, “Well… what do you want ME to do with this baby?”
Recognizing our dilemma she came up to us to assess the baby and I gave her a full turnover, including our original plans to get the IDF field hospital. As it turned out, she was a pediatrician that specialized in infectious diseases, and after taking a quick listen to the baby’s lungs, she pinched his skin, examined his lips, and nodded her head, saying, “Yeah, this baby is definitely septic.” We nodded our heads in agreement and asked her if there was any oxygen available as we had not had any for the entire transport.
“No, there’s no oxygen. The surgeons don’t even have any in the OR. You’ll have to keep on bagging him as you have been, but I don’t know what you can expect us to do.”
“More than the clinic we came from,” we responded.
Conceding that our situation had been more futile than hers was, she invited us to lay the baby down in one of the cribs and then asked us what the baby’s oxygen saturation was. “We don’t know.”
“Well, I’ll have someone find you one. You want to go the IDF?”
“Yes,” I answered, “or even the Comfort.”
“I’ll go see who I can contact,” and she hurried out of the tent.
About ten minutes later, two doctors wearing vests with a red Star of David printed on them approached us and asked what was going on. Recognizing their vests, we asked them if the IDF would be able to take the baby, and they told us, “No, the IDF isn’t accepting any more patients. They’re trying to find hospitals for all the patients they have because they’re trying to close the field hospital up to leave Haiti in the next couple days.”
Not long after, the pediatrician came back and told us that the Comfort wasn’t accepting any patients either. But something in the way she related the news made me think there was another way to request assistance from the Comfort – the whole country was trying to send patients to the Comfort, and it was possible that they were saying “no” to everyone. We discussed this possibility and soon agreed that she should speak with the Navy again, though this time starting the conversation by asking them if they had any “vents available for an intubated, septic infant.” Knowing that the IDF was now out of the question as well, she agreed to try again and left.
As we waited for her to return we were approached by several doctors and nurses who had been informed of our arrival, and all of them had that same exhausted, on-edge look in their faces that the pediatrician had had –- one could only imagine the countless horrors and hundreds of hopeless cases they had struggled through in the past week. Some of them, however, let this despair manifest itself in more unedited ways than others. Two doctors, an American and a Swiss, flat out reprimanded us for bringing the child to them, and told us to stop ventilating the child. “He’s going to die. Give it up,” they said, right in front of the baby’s mother (somewhere along the way we had lost the father). Fortunately, she only spoke Creole, but the anger on their face and the tone of their voice could’ve been enough to understand them. “So should I just stop?” we asked, and they brushed us off and walked away. Still, it was hard to get upset with them for being so pessimistic; Haiti was probably the last place on earth you’d hope to have such a humanitarian crisis of any magnitude, let alone this one, and there was, realistically speaking, very little hope for this child. Other doctors were more sympathetic, but no less pessimistic about our changes, and while the situation certainly seemed like a lost cause to everyone who came by, they at least tried to accommodate us while we were awaiting a response from the Comfort. One doctor tried to help us establish an IV – unsuccessfully even after multiple attempts – and then brought us a pulse oximeter. While the pulse oximeter only had an adult-sized sensor, the heart rate on the pulse oximeter matched the baby’s palpated heart rate, and the saturation read 64%. No one really knew whether to believe, or even doubt it.
A few minutes later the pediatrican returned and told us the Comfort had agreed to take the baby and we all rejoiced, letting out a collective sigh, which the mother had no trouble understanding as she began to cry, showing any emotion for the first time all trip. The catch, however, was that we’d have to wait an hour before we could be brought to the helicopter-pad. But once the pediatrician read the 64% saturation reading – whether it was accurate or not – she exclaimed, “We don’t have an hour!” and ran off again. Within mintues she was back again with a group of Army soldiers and said, “You’re leaving now – they’ll have to take you once you’re there.” So with that said, we loaded the baby onto their stretcher and walked out of the hospital, with a group of cameramen and photographers in tow who happened to be filming when we first walked in.
We loaded the baby onto an Army ambulance where an Army physician was waiting. The first question I asked was, “Do you have oxygen?” and he nodded and smiled. “Of course we do.” But after digging through the supplies he was unable to locate any oxygen tubing – this was no surprise, as it seemed by then that every time we caught a break something else was sure to get in our way. The Army physician yelled and screamed at his men, shouting orders and other obscenities as they quickly scampered out the ambulance, soon returning with some oxygen tubing from another Army ambulance.
The next leg of the transport was just as slow and bumpy as all the others had been, but we were finally headed fir definitive care, and we had oxygen on board. After another 20 minutes we arrived at a US HHS field hospital manned by a joint team of DMAT-Mass (MA-1) and IMSuRT East physicians and nurses. Once there, we turned the baby over to the medical team who quickly placed a central line and began administering more antibiotics. After stabilizing the baby as best they could, the medical team quickly got him onto a helicopter that took him and his mother out to the USNS Comfort.
After three and a half hours, five transport vehicles and three facilities, our 6-mile journey had come to a conclusion – and we never once lost the tube.
But now we were stuck in the middle of Port-au-Prince at dusk with no way to get back to our camp – and dark was not a good time to be out. Liddie, who had been trying to get a hold of her cousin all week without success, found a Haitian worker at the field hospital and borrowed his phone. After only a couple minutes she was able to get through to her cousin who informed that her that he happened to be just around the corner right then. Walking a hundred meters to the field hospital’s gates, we stepped out onto the street to find her cousin waiting at his car, waving to us with a bottle of water in his hand. Less than thirty minutes later we were back at our camp.
A week or so after returning home to San Diego, I sent an email to the flight paramedic from the DMAT team that had transported the baby to the Comfort and asked him if he knew what had happened to our patient. That same day he responded, writing, “The baby was discharged a few days ago – he made it out alright.”
In a country that had experienced more death and injury in less than a minute than most countries would ever see in a lifetime – or even in a war – it was a blessing to know that we were able to have helped at least one life. But it seems that that may have been just the beginning for that small baby – the “home” he had to return to was the same tent city that had got him into that mess to begin with.