ED

As the sun rises in Port au Prince, rays pierce the otherwise dim field hospital tent and make me squint as I survey the scene. A little boy lies in the exhaustion that follows a seizure, while a young man breathes quietly through a tube in his throat. His mother stands beside him, keeping the flies off his head. It's been an eventful evening.

TJ and I got the night shift at the ED (emergency department) after talking to an Indian doctor serving there, and hearing that they were understaffed at night. Our team leader ok'd it, but only if we'd work the day before and after--a 36 hour shift. Upon hearing our plans, our pediatric ED MD decided to join us.

We arrive at the ED just before shift change. It's located in the compound behind the presidential palace, set up by a medical non-profit. It is comprised of two MASH-style tents set up on the asphalt, without floors. There is no ventilation or A/C. Beds are green mesh collapsable cots, with buckets under them as commodes.  Storage boxes and an old desk outside the first tent comprise a rough triage area. Inside, medications and supplies are strewn between a couple of folding tables and some rolling shelves. The dimly lit interior smells of old urine and dried blood.

The staff for the night is seven strong. There is an emergency physician from California, an ACNP from New York, two nurses, the peds ER doc (Dr. M), TJ and me. There are no labs available, and X-rays are hit and miss. The most valuable staff member in the ED is the portable ultrasound machine.

The night starts off slow. There are a few patients with relatively easy dispositions. One patient had three liters of fluid drained from his bladder. Another father was concerned because his soon was pooping crayons. To quote Dr. M, "As we speak, kids all over the world are eating crayons." A couple of minor wounds come to be patched up and are on their way. I'm wondering where this chaos is that people mentioned.

Soon, a lone man comes staggering up to triage. He is soaking wet, wearing only a baggy t-shirt and smelling of feces and urine. And booze. It turns out he was riding his motorcycle and wrecked it, then walked an untold distance to the ED. No one knows if he lost his pants or if he ever had them. He gets paper scrubs and is bundled off to X-ray. My initial thought was, "ah, now it feels like an ED!" but in reality, we see very few inebriated patients.

In the midst of caring for a few minor patients, we hear the squeal of tires outside. I walk out the front to see a dusty pickup out front, with a couple of people sitting in the back staring at us. In the bed of the truck lays an unconscious man. At first glance I thought he was dead. The NP and I grabbed a stretcher (think MASH) and manhandled the patient on to it, who was guppy breathing (really, think of how a guppy breathes out of water). Once inside, he was found to have a severely low blood pressure and blood sugar--hypovolemia and hypoglycemia. Obtaining a peripheral IV was a near impossible task, and an internal jugular line was finally established with the assistance of the ultrasound. Fluids and sugar were started, while the MD worked on a diagnosis. Our patient looked like a cast member of Outbreak--red, sunken eyes and flaking skin.

From there, we treated a patient with catatonic schizophrenia, two minor asthmatics, a UTI and an elbow relocation. Most disturbing was the woman with metastasized breast cancer--our only possible treatment were to give comfort analgesics and release her.

A father rushes in, carrying his limp infant son. They came from a nearby clinic, unable to care of the child. He's been having trouble breathing, and quickly draws the attention of all of us. We grab the ED's only oxygen tank and start the child on a nebulizer. At almost the same time another pickup rolls up out front. Another unconscious male. Another double take to make sure he's not dead.

It's an asthmatic this time. His lungs are so tight he's not moving any air. He is intubated on the floor of the ED, among the flies and buckets serving as toilets. As he is moved to a bed we are alternately bagging him (breathing for him) and squirting an asthma rescue inhaler down his tube--we're out of other asthma medications. He does get steroids through an IV line. He's been sedated, and still can't breath on his own. There's no ventilator in the ED either, and there is the sick infant still. The nurses give the family instructions on how to use the bag valve mask to breath for their loved one.

Amidst the infant, now seizing, and the family bagging the asthmatic, another patient arrives. A boy of no more than fifteen comes in heavily bandaged and accompanied by his father. He has been beaten by a crowd, and treated at an outlying clinic. The lacerations covering his face and head were rudimentarily sutured. Slowly, we remove the bandages covering his eye. Under it is a bloody mess. It looks like hamburger--I'm not even sure the eyeball is intact. He has lacerations to his upper and lower eyelids, such that they split apart and overlap each other. The doc brainstorms at the best way to repair his eye.

Meanwhile, the infant boy continues to struggle. It is lucky that we have the pediatric ED doc with us tonight. He watches over us as we work on stopping his seizures, and improving his breathing. There is only one oxygen tank for the now two patients that need it. TJ disappears, and returns sometime later lugging another oxygen tank that he "liberated" from the ICU. The infant has stopped seizing, for now, but we still need to get an IV in him for medications.

The family of the asthmatic isn't doing an adequate job bagging him. We move him next to the infant, and will take turns the rest of the evening breathing for him. Keeping him alive. I take the first shift.

In another stroke of luck, an ophthalmological surgeon arrived in our camp that morning. Technology helps us to save the boys eye. An iphone picture to the camp gives the surgeon an idea of what we have. He relays back that he can fix it. From there, he wakes up the head doctor of the clinic, who in turn rouses the chief of the special forces for an escort--the streets of Port au Prince aren't safe after dark. Soon, the surgeon arrives at our ED. I help sedate the patient while we scrounge up a suture kit. We assisted and watched as this amazing surgeon pieced an eyelid back together. It turns out the eyeball is intact, and the damage is to the tissue around it. Stitch by stitch, a perfect pair of eyelids reappear. Soon, the boy is resting quietly. Hopefully, he'll have few scars and full eyesight.

The infant boy, on the other hand, was getting worse. He was in status seizure now--a seizure that doesn't stop. His brain was slowly cooking. No one was able to get an IV in him--EJ, peripheral, femoral, nothing was working. His legs were blistered from a previous clinics IM administration, and our ED was out of rectal benzos.  With much resignation, the decision for an IO--a needle directly into the boen--was made. The concern was of osteomyelitis, a bone infection. For now, that was secondary to the seizures. There were only two realistic places on this patient for an IO--the tibial plateau of each leg. Too low and the bone may crack. Too high, and the risk is run of fracturing the growth plate. The doctor made his drill....and missed it. The drill was passed to TJ, with one chance left to get an IV in order to stop the seizures in this infant. I'm proud and happy to say that TJ got the IO in successfully. Medication was given, and the seizures were stopped. He needed more definitive care, but the only NICU in the region wasn't accepting patients.

The asthmatic patient is still not breathing on his own. Worse yet, he is exhibiting deceberate posturing--a sign of serious brain injury. The MD and NP discuss discontinuing ventilation and providing palliative care--allowing the patient to die. They are worried that the lack of oxygen injured the brain beyond repair. For the moment, we continue bagging him.

Around 3 AM, the infant was resting somewhat quietly. The sickly patient with the low blood sugar was starting to come around after three liters of fluid and 3 administrations of sugar. Suddenly, gunshots shatter the silence outside, reminding us of where we are. Surprisingly, no trauma comes of it.

As the first rays of sunshine begin to penetrate the plaza, amazing things begin to happen with the asthmatic. His lungs continue to clear. His posturing stops. As his sedation wears off, he even begins to fight the tube. As he wakes up, he is even able to follow basic commands! This is a patient we feared was brain dead. As a further test, we give him the chance to breath on his own, albiet through the tube.

Our drunk wanders through the sleepy ED, having slept through the night's chaos on a cot on the floor. He smiles at us, clutching the X-ray of his bruised, but unbroken arm. X-ray in hand, he wanders out the front door and into the sun.

The shift is coming to an end, and it is full of mixed feelings. The asthmatic is breathing on his own, and should be discharged soon. The first comatose patient will likely remain in the hospital for observation, but is now up and taking the first shaking steps on his own. His suspected diagnosis is end-stage AIDS. The boy with the eye laceration has gone home with his father. Our only loose end is the infant. It remains to seen if his seizures will continue to be controlled. His lungs are clearing at least. He will remain in the ED, outcome unknown.

For us, it is time for us to rejoin the sunshine. Clinic starts soon, and there are many patients to see.