Patience

The following was submitted by Ben Trappey, a fourth-year medicine-pediatrics resident:

Urgence is an amazing medical hybrid: part Emergency Room, part Urgent Care. Part short stay, part inpatient unit, part NICU. It consists of one long room with a smaller area sectioned off in the back and a hallway running the length of it where another 5 to 12 patients are housed. The main room holds 15 or so stretchers, where the sickest kids, ranging in age from a few months to 13 years old, are housed. Along one wall are another 15 or so newborn babies, many of them premature. (St. Damien's has a separate NICU, but it is open only to babies born at the hospital. Those born elsewhere are initially managed in Urgence.)

Outside the Urgence department at St. Damien's Pediatric Hospital

Each patient is accompanied by a family member who sits patiently beside him/her and provides much of the nursing care. The back room is home to 8 of the more stable children. The hallway holds the overflow of children for whom there is not room in the main or back rooms.

The other American doctors (if there are any) and I start our day in the back room, and when we finish rounding there, we move on to the hallway. The hallway is full of kids who had been seen overnight and are either waiting to be sent home or to get a bed in one of the main rooms. Some, however, end up staying in the corridor for several days. Their maladies range from pneumonia to seizures to severe malnutrition, and some of them would probably qualify for ICU care in the U.S. The hallway ward is furnished with a long row of connected metal chairs, a few moveable chairs, and one padded table. The sick children sit or, if there is enough room, lie on blankets or towels in the chair next to or in the laps of their family members. The table is usually occupied by the child whom the mothers somehow seem to decide needs it the most.

Inside the Urgence department at St. Damien's Pediatric Hospital

The patience of these families is, perhaps, the thing that I've seen here that astounds me the most. Many of them sit in this hallway for days, waiting for a bed to open up, for the doctors to round on them, for the one nurse who covers both the back room and the hallway to carry out our orders, for lab results that usually do not return for at least 24 hours.

And so they sit and fan themselves and talk to each other and lean upon each other for a nap, and watch each other's children while one of them takes a bathroom break.

What they do not do, apparently, is complain. In the four days I've worked so far, I've not had one parent express concern about the wait or about being tired or hot. Two have let me know that the antibiotics have not yet been given or the fluids have not yet been hung for their child, but these were the mothers of two of the sicker children, to whom I had expressed concern and stated that we needed to move quickly to get treatment started. Neither of these mothers seemed angry or put out.

Nor did the grandmother of the very small 11 year old girl who presented three days before I got here with low-grade fever and yellow eyes. Her fevers resolved quickly, but when her blood counts returned the next day (day 2 in the hallway), she was severely anemic. Her other blood counts were normal, as were the remainder of her labs. Her grandmother had been told in the past that the child was anemic as well. The most likely cause of her anemia was sickle cell disease, which runs in their family. She received a blood transfusion the day before I arrived (day 3 in the hallway), but when I saw her the next day, her follow-up hemoglobin had actually dropped. So we ordered another transfusion and waited for the results of her sickle cell labs.

Unfortunately, St. Damien's did not have any more of her blood type in stock, and the family had to find a family member to come in to give blood for her. On the evening of the fifth day she had spent in the hallway, she finally got the blood transfusion. We repeated her hemoglobin the following day. The result, along with that of the sickle cell test, finally returned yesterday.

She'd responded well to the second transfusion, and we were able to confirm that she has sickle cell anemia and to arrange follow-up in the sickle cell clinic here. She had spent an entire week of her life in that hallway.

When I was 11 years old, a few hours of not being engaged or entertained seemed an eternity. This child sat patiently on those metal chairs for seven days, while younger children beside her cried and coughed and vomited and had diarrhea and seizures. Every day when I would see her, she would grin broadly and tell me that she felt well. I would tell her and her grandmother that we were still waiting.

And they would smile and say "dakò" and "mèsi", which means "agreed" and "thanks".

Greetings from Saint Damien's Hospital, Week #2

from John Heimerl, MD, 3rd year pediatrics resident at University of Minnesota:

Another week has passed here in Haiti. It has been a busy week.

Since my trip to Saint Damien's overlapped with the team from Brown University, I was put to work in one of the hospital wards for the week.

Initially, I was working with Dr. Vaz from Brown University.

We divided the patients up and tended to them one by one.

Seeing patients in the Orange Room on the wards at St. Damien's Hospital for Children

By the end of the week, I had developed quite a relationship with the parents and patients. A few of the children have been here for months.

The girls' room has a three year old with cardiomyopathy and TB who has been in the hospital for more than six months.

A few of the days she would sit on my lap as I worked my way through the charts.

Another girl had a right-sided empyema with a chest tube in place. After having the tube in for a week we got a CXR, and it showed no change. While the chest tube and collection system are the same we would use back home, there was no suction attached to the reservoir to assist with draining her plural fluid.

After she had had a few days of fever while on broad spectrum antibiotics and I had realized no more fluid was draining via gravity, I decided to see what I could pull out with gentle suction and a 60cc syringe.

Thirty-five mL of purulent fluid later, she was feeling much better and has actually continued to drain into the reservoir.

Following morning ward duty, I've spent afternoons assisting in the urgents (ER), where we are seeing all sorts of pathology--things I will never see in the U.S.

A few of the patients I have seen this week include a girl with CXR consistent with miliary TB as well as malnutrition of all sorts, from kwashiorkor to extreme marasmus.

One child I admitted over the weekend was 16 months old and was on breastmilk till 1 year of age, then apparently was fed cookies and juice. My interpreter made it clear to me that is was not "natural juice", which I thought was slightly humorous, as the nutrition value would still be minimal. Needless to say, this child should improve with proper nutrition, and along the way we will ensure the family receives some education.

A few patients have not made it.

On Saturday a six year old with pneumonia experienced complete respiratory failure.

I taught a Haitian medical student, who happened to have been walking by the boy's bed, to properly bag mask, then gathered the necessary intubation supplies and determined how to operate the ventilator. The intubation actually went remarkably well, however, I discovered that I had not paid enough attention to the respiratory therapists back home, and I didn't properly secure the tube.

The episode seems to have been a good learning experience, both for the med student and the nurses, though unfortunately, as expected, this child did not survive.

I did think it was a start at transitioning to the next level of care, and hopefully over the next couple of weeks, we can continue to teach the nurses.

I have had the opportunity to do a couple of day trips on my days off.

Last week I went with the Brown team to the beach.

Friday, I took a half day and was driven around the city. 

Public transportation in Haiti is called a "tap-tap".

We drove by the National Cathedral, which lays in ruins from the earthquake.

After the drive we had a wonderful, authentic Haitian lunch...

...topped off with fresh sugar cane.

Sunday I had the day off and went to the Kenscoff Orphanage for the 25th anniversary of NPFS (Nos Petit Freres et Soeurs, "Our Little Brothers and Sisters") the organization that supports St. Damien's and multiple orphanages.

Father Rick (pictured) and the archbishop attended the anniversary celebration.

Kenscoff is a breathtaking mountain retreat from the city. We made the trip with children from another orphanage that's located next to Saint Damien's.

This amazing view was taken from Kenscoff Orphanage, looking out over the adjacent hillside.

Following mass there was entertainment and dancing.

One more picture: this local artist makes these pieces out of 50-gallon steel fuel barrels.