Where I usually work, we have a triage system for the everyday emergency room flow of cases, and a triage system for disasters. A general triage system prioritizes the sickest and gathers all resources to tackle the illness in the acute situation at hand. When in disaster mode, the priority triage population is, who is the most likely to be saved. So how do you prioritize care and limited equipment when every day is disaster mode? Do we prioritize our sickest? Or do we prioritize those with a survivable prognosis. Who do you give the ventilator to when you have one vent and two people? This is no rhetoric question, in Haiti this is the reality of another Thursday, more specifically my reality one Thursday.
The patient is deteriorating, his oxygen levels are dropping, he is status post motor vehicle accident, and he has a brain bleed. We are bagging the patient and call our on call volunteer respiratory therapist, we need to intubate the patient STAT. She informs us that we have no ventilators in the hospital available, all are being used by patients. She runs across the street to the hospital warehouse to check if we had any ventilators, however old they might be, in there. No luck.
We are still bagging. He is still struggling to breath. His work of breathing increasing, despite our bagging efforts. One ER resident goes to the ICU to speak with the ICU attending. We have reached the point of who can survive without a ventilator, or who even has a chance to live? Who can we extubate so that we can intubate this new patient? We find our patient, she had a spinal cord injury, and she is doing well today. The doctor says that she is stable enough to be extubated, and so we extubate. We gather our equipment, wheel it across the courtyard to the emergency room. Our patient is extubated, he is stable for now. Our other girl is extubated also stable for now.
We are still bagging. He is still struggling to breath. His work of breathing increasing, despite our bagging efforts. One ER resident goes to the ICU to speak with the ICU attending. We have reached the point of who can survive without a ventilator, or who even has a chance to live? Who can we extubate so that we can intubate this new patient? We find our patient, she had a spinal cord injury, and she is doing well today. The doctor says that she is stable enough to be extubated, and so we extubate. We gather our equipment, wheel it across the courtyard to the emergency room. Our patient is extubated, he is stable for now. Our other girl is extubated also stable for now.
In our mad rush to gather equipment, it only dawned on me much later what extreme levels of triage, prioritization, and critical thinking are needed at every moment in such an environment; as well as the challenge its is to maintain a life here in Haiti. In my usual area of work, a patient deteriorates, I make a call and I have the equipment needed to save a life. Here it is so much more.
The next day we got a patient in respiratory distress again, he was brought to the ER by bystanders via hanging off the back of a motorcycle, the usual culprit of our most severe cases. He was responsive, large bloody lacerations, and in severe respiratory distress. We bag him and prepare for intubation. The attending is about to intubate, but remembers that there is one ventilator available at this point. What if we use it and his family does not want it? Here in Haiti this is not so much a moral dilemma as much as a practical one as well. If we intubate and the family does not want it, we have just used our scarce intubation equipment for no reason, and what if something else come through the door and they absolute want those extreme lifesaving measures? At first I internally and silently judged the team for the delay in making the decision to intubate, I was also getting hand cramps from bagging this patient for over an hour while decisions were being made. However, medicine,triage and lifesaving, has a completely different thought process and level of prioritization, especially when you don't know what will come in next and what you will need to have available to deal with it. And so I continued to bag, respectfully awaiting to hear back from the family and the physician regarding the next steps.
Back to the girl with the spinal cord injury; Dorisca is her name, she is 15 years old and her favorite singer is Shakira, who is also a victim of a motorcycle accident, and who was extubated to intubate that 8th patient with the 7th ventilator. She is doing well; in fact we bonded during nighgt shift, as I was her nurse in the ICU. By night number two, together in the ICU, she was calling my name, giving me hugs as her arms were now able to move, and she even caught on to some of the lyrics of the music I played on my iPad for her during my shift taking care of her.
However, sometimes fate has its way despite our best efforts to direct it in our own direction. Ironically, patient #8 who used ventilator #7, died the night he was intubated. Sometimes we make decisions and hope to save the life that can be saved, and sometimes fate has its way and makes the decision for us, regardless of the extremes we take to make it on our own.
Me and the patient; sweet 15 year old.
Vintage vetilator;comodity though, in Haiti!
The injury of the causing for the occupation of the 7th ventilator.
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