Lukesmission.files.wordpress.com

Chapter 11
Angeline
Each day brought with it its own challenges. As much as I would like to think that the day before would allow some of those challenges to be easier to deal with, new ones crop up almost every moment. I reported to the Watermelon room when we arrived the next morning. Within the first three hours I had started three IV’s, hung blood, received a patient who was having seizures and was on an IV infusion of Dilantin--strong anti seizure medication. I was beginning to feel like things were getting out of control. I was hanging a blood transfusion on Adeline, the little girl with the two broken legs and spika cast. From the corner of my eye, I saw two young men come in with a young girl on a stretcher. We were never told when a new patient was to arrive. They just showed up. She was put in the one empty bed that I had. I hadn’t really noticed her because I was concentrating on getting the blood in the IV running. It took several minutes for me to get to her but once I came within 20 feet of her bed space it was clear what the problem was. The smell of gangrene is not one that you can forget. It was definitely there. I knew she had it before I even laid eyes on her. No one told me anything about her and there was only a short paragraph written on a paper that lay on the end of her bed from the makeshift ER. It stated that she was dropped off at the ER with no parents. They weren’t able to get her complete name. Apparently someone had found her-now 12 days after the earthquake-and simply brought her to the ER. How she survived in the meantime is a miracle in itself. An alias Haitian name was written on the top of the sheet. The Emergency room note stated that she had gangrene in her left leg and severe lacerations and wounds on her right leg and hip. The note indicated that they wanted and “ortho consult in the AM”. That was written at 10 PM the night before with no signature and nothing else except that she had received two antibiotics. It was now 1:00 PM-- the following day. I quickly looked her over. I couldn’t see all of the toes on her left foot because of her dressing but the ones I could see clearly were gangrenous. Her leg was bandaged up to her thigh; there was a large amount of drainage, which also smelled. Her right leg was heavily bandaged on her thigh. She also had heavy bandages on both of her legs and buttocks I estimated she was about 4 years old. She had an IV in which was running well. She wasn’t fully awake but did arouse easily. I knew this little girl had a very serious problem. I was concerned that no one in the ER had taken the initiative to see that someone from Ortho had seen her sooner. It was this kind of thing that I think had the potential to happen often—someone falling through the cracks. Likely the shift had changed after that note had been written, other patients had come in which took the attention of the staff away from Angeline for the night, and then when the morning group came on, they simple transferred her out of the ER because newer patients commanded their attention at that time. Even though her condition was quite serious, it was easy to get lost in the shuffle—especially since she was alone and had no parent to advocate for her or at least keep her in the forefront of the relief worker’s attention. She had gangrene that was at least into her foot and lower leg and from the smell likely was well up into her leg. She was now 12 days out from the injury and had had no care in that amount of time. She was dehydrated and malnourished along with everything else. It was quite possible that the infection had spread to her blood stream making it life threatening. Gangrene is a complication ofdeath characterized by the decay ofwhich become black (and/or green) and malodorous. The smell of gangrene is very distinct. Once you have smelled it, you won’t forget it. We had to act fast to save her life and I knew it. I did a quick assessment, grabbed her chart and ran down to the special procedure room where Phil was working. I told him about the child. Sensing that it was serious, I told him I was going to send her for x-rays to see what was actually broken and then would return with the their results. But I wanted him to have a heads up about her. I thought she would need to go to the OR as soon as possible. He agreed and told me to let him know when the x-rays were completed. I stopped by the x-ray room on my way back upstairs. I needed to expedite getting her x-rays so she could get to the OR. This was my first experience with x-ray’s at St. Damien’s. I quickly found the lab from directions someone in the hall way gave me. The door was locked so I knocked. When the door opened I was surprised at what I saw. First of all, I could feel the air bathing my skin like a cool shower. This room was air conditioned. What a relief- especially since I was now dripping with perspiration-it was mid day in Haiti-and I had been running around all over the hospital trying to get Angeline the care she needed. The room contained a state of the art digital x-ray system. It had one x-ray table and x-ray machine. On the counter were two computer screens and a keyboard. These were used to order and display the x-rays. Digital x-rays are displayed directly on a computer screen instead of the x-ray films which are developed like film in a camera. Digital films can be magnified, rotated and edited in other ways to make viewing them much easier for the physicians doing it. I was really surprised to see this modern and very expensive piece of equipment in this hospital. Fortunately the x-ray technician spoke English. I quickly told him the story-we had a seriously injured girl who needed plain films of her legs and pelvis before she went to surgery. It was an urgent case. He was very helpful as he said could do her right away and would send a transporter up to the Watermelon room to get her. I quickly returned to the Watermelon room to get her ready. When I returned, I made sure her IV was working well and that she was continuing to respond when I aroused her. Getting x-rays wasn’t a problem but getting someone to take her there was. When 15 minutes had gone by and no transporter had arrived, I decided I couldn’t wait any longer. She was oozing from all of her wounds. I found three of the absorbent underpads that we put on the beds under patients to protect the sheets. I had Eddy help me tuck them into my scrubs around my neck and waist. Donning a pair of gloves, wrapped her in the sheet which she was laying on. I grabbed her up in my arms and started out the door. I was going to take her to x-ray myself. I just couldn’t wait any longer. With Eddy holding her IV bag, we walked quickly down to x-ray. This wasn’t an easy task. We had to maneuver down the stairs since there were no elevators. In my mind’s eye, I felt like this looked like one of those scenes I had seen in medical shows or movies that I always think is ultra dramatic-and that rarely, if ever, represent reality in medical situations. But here I was, experiencing it in real life. When we got to the x-ray room, the technician was waiting for us. He asked me to lay her on the table. At this point Angeline was whimpering quietly, likely in pain from the movement of the serious wounds on her tiny body-now 12 days old and filled with life threatening infection. He asked me what her name was so he could enter it in to the computer. I told him that we didn’t know because she was alone. They had put a Haitian name down but it wasn’t her own. Over the next 5 minutes or so, this young man quietly and calmly worked with Angeline by speaking to her in her own language in a manner that allowed her to trust him. He comforted her and got her to tell him her name. Through his patient and calm approach, he came back to the control area and said she had told him her name. It was Angeline Pierre. I was grateful for the moment to sit down and soak up some of the air conditioning while I had a chance. It was a blessing that I was conscious of. Even with the chaos and sense of urgency around me, I was able to notice the small things-a chance to stop and smell the roses in post earthquake Haiti-if there was such a thing. It took about 15 minutes to do the x-rays. I was worried that she wouldn’t lie still for them but she did. The technician was masterful at positioning her without causing her undue pain. I had never seen a Haitian trained x-ray technician. I never got this young man’s name but his work is engraved in my mind-even now as I write these words-7 weeks after this experience. His compassion and skill literally gave us the information needed that would go on to save this little girl’s life and he did it with such grace, poise and professionalism. He was one of the hero’s of the disaster relief effort in my mind. The great thing about digital x-rays is that they are ready immediately. The screen pans across digitally bringing each row of pixels up as they are transmitted to the machine immediately upon doing the x-ray. I watched as the x-ray picture was composed, row by row on the computer screen. Once the front view was completed, I couldn’t see anything that obviously looked like a fracture of her legs. Her pelvis showed two definite gaps in the hip bone areas in the same place on both sides. On someone else, this might have indicated bilateral pelvic fractures. But on a four year old, I thought it likely indicated her growth plate-normal separation in the bones of small children which grow together over time. As the second view of her legs and pelvis was coming up, I decided to run down to the special procedures room to tell Phil that the x-rays were ready for him to view. He was finishing up on a case and said he would be right down to look at them I told him that we had found out her real name. I wrote it down on a post it note and stuck it to the wall near where he was working so he could look her up in the computer system. The x-ray viewing computers were located in a small room adjacent to the room where the x-rays were actually taken. Doctors would go into the viewing room, type in the patient’s name and pull the x-rays up to view them right there on the screen. This same procedure was happening at the same time in multiple areas in the hospital where I worked at home-in the Unites States-even as it was here, in the middle of the worst natural disaster in modern history. Eddy and I carried Angeline back upstairs to wait until Phil looked at the x-rays and decided what the rest of the day would hold for her. I placed her gently back in the bed. She was crying quietly again, the result of pain due to movement. I hadn’t given her any pain medication at that point and decided she might benefit from some. I wanted to be cautious knowing she would soon be undergoing general anesthesia but I felt she still needed something to help with her pain. Since this was the first day I was at St. Damien’s, I hadn’t had time to get my stock pile of supplies and equipment together. So I ran down to the pharmacy and asked for some IV morphine. What Potipar, the very able coordinator of the supply area, handed me would cause me alarm that continues to this day. The bottle of liquid morphine contained morphine at a concentration of 50 mg per milliliter-50 times stronger than what we have in the United States. It would be hard enough to give an adult the dose they needed from this concentration much less the dose needed for a 4 year old child who weighed a fraction of what an adult weighed. I really couldn’t believe what I was seeing. It was hard for my mind to begin to think in the direction it would need to in order to figure out how to use this drug. I could use it all right, but it would take some calculating, diluting and then finding the right kind of syringe which would deliver the tiny amount that I would need to help Angeline without over-dosing her. My mind was already functioning in overdrive trying to prioritize, manage, be aware, assess, and care for all of these children. Now to have to do this complicated calculation would take mental energy and thought processes that I wasn’t sure I had at that particular point in time. I really needed to sit down and think about what I was going to do. This could cause a serious problem if not handled correctly. Fortunately, I didn’t have to manage it right then. Phil quickly entered the Watermelon room. He told me that Angeline had the most serious form of gangrene-gas gangrene-and he needed to operate on her immediately. Gas gangrene is a bacterial infection that produces gas within tissues. It is a deadly form of gangrene Infection spreads rapidly as the gases produced by bacteria expand and infiltrate healthy tissue in the vicinity. Because of its ability to quickly spread to surrounding tissues, gas gangrene is a medical emergency. Phil told me he hoped he could save her life-he was fairly certain he could not save her leg. He also didn’t know what the wounds looked like on her backside and the back of her legs. They would have to be dealt with when she was asleep. He had already spoken to the OR staff and they would be ready for her in about 10 minutes when they finished setting up the room. He was headed down to the OR to scrub in and asked if I could get her down there in a few minutes. Thankfully I didn’t have to deal with the morphine issue at that point. Soon she would be under general anesthesia, feeling no pain at all, so it didn’t seem to be that important and it would take critical minutes away from what I needed to do now-get her down to the OR. I put a new IV bag up, regulated the rate and again prepared myself to carry her down to the OR. Wrapped in the underpads again, I grabbed her in my arms and with Eddy carrying her IV bag, for the second time in that hour; we headed downstairs to the operating room. Just as I was rounding the corner to the hall where the OR was, I saw Phil coming towards us. Our timing was perfect. The automatic doors to the OR opened and one of the OR technicians met us. He directed me to put her on the stretcher next to the door. And with that, we left her in the able hands of the OR staff. Eddy and I walked back upstairs now, without the sense of urgency we had had for the last 90 minutes, since Angeline had arrived in my room; her diagnosis clear by the smell that surrounded her. If she had a chance to live, she was now in the place where it could happen. I breathed a quiet prayer to God that her gangrene wouldn’t be so extensive that Phil couldn’t save her. I asked for Him to guide Phil’s hands and mind in order to care for her. That was how most of my prayers were over the week. A quick thought prayer-“God, help me to do the right things”. “God, give me a clear mind right now”. “God, please help this individual get the care they need”. And then I would get back to my work. Nevertheless, it was clear that they were heard and answered. When we got back to the room, things were pretty stable. Eddy and I had a moment to sit down at the desk and get some water. It was the hottest part of the day. We were both drenched in sweat. I thought about taking a quick break again at the x-ray room. How wonderful that would have felt at that moment but I contented myself sitting across from the fan blowing right on my face. I still had other patients to take care of, so we couldn’t dawdle. Another young girl had come in earlier in the day. She wasn’t injured from the earthquake. Her mother told the ER that she had a history of a seizure disorder. She had a seizure that morning and hadn’t woken up from it in the time that she usually did. When she arrived in my room she had an IV running which had a label on it indicating it had Dilantin powerful anti-seizure drug, in it. Dilantin can be fatal when given through an IV if not monitored carefully. There was no machine controlling the rate and I had no idea how much of it she had. Since she wasn’t seizing right now, I shut it off. It was dangerous to have it running when I couldn’t control the rate it was going in at. In the United States, someone would get written up and likely suspended for this kind of action. But there were no machines that controlled the IV rates available. However, since I had no information, I just shut it off. This child wasn’t conscious and was breathing in a manner that people often do after having seizure -deep heaving snoring type breathing. I noticed that the IV wasn’t working well so that needed to be restarted. I wasn’t really sure what we could do for her. I knew there wasn’t a neurologist available at St. Damien’s. So I tried to stabilize her and wait to see if she woke up. Since she wasn’t a surgical patient, the Haitian pediatricians would be caring for her. The surgeons only took care of the patients they did surgery on. Since she had a medical problem—as opposed to a surgical problem--the Haitian medical staff would care for her. When one of the Haitian pediatricians came in, I told them about her. I gave them a brief history of what I knew. Her condition hadn’t changed in a couple of hours. The Haitian physician felt she needed to be transferred to one of the rooms on the other side of the upper floor where medical patients that were more seriously ill were being monitored from there. I was relieved that someone else was going to be responsible for her since there wasn’t much to do except to watch her. The Haitian nurse, who was helped out occasionally, got her ready to be transferred by inserting a tube into her stomach, putting her on some oxygen and transporting her to the new room. I was grateful as I had had my hands full with the other patients. In a couple of hours, Angeline, accompanied by Phil, was brought back to our room. She was alive but missing the lower part of her right leg. He told me that the gas gangrene had invaded most of her lower legs and he couldn’t really save it. He felt the infection was localized to that area, which was a relief. She was now on IV antibiotic around the clock which would lessen her chance of the infection getting into her bloodstream. The wounds on her buttocks and back of her left leg were extensive and likely would need skin grafts but that was something that could wait until later. When I went to check her after talking to him, I noticed that on the pristine clean dressing on her lower right leg which was now missing a foot-was written in large letters “America-1”. That was how each team identified the patients they were following. The Italian team did the same thing. It made it easy for us to know which team to contact when there was a problem. Personally I think they liked signing their work this way-it was a sense of surgical pride-at least for our team. When I left a little after 5 PM, Angeline was still sleeping. She would wake up easily so I knew that this was the normal recovery process from general anesthesia but I didn’t wake her very vigorously. I really felt like I was looking at a miracle. A child, found 12 days after the earthquake in a lot where buildings had collapsed, with extremely serious injuries and infections was brought to the ER without parents and was now lying comfortably-yes without a lower right leg-but alive. She was almost lost in the system. A few more hours of not being noticed and the gangrene would have ravaged her body, making saving her life impossible. Even with that she wasn’t out of the woods yet. It had been an exhausting day. At supper I was contemplating this part of my extremely complicated day when Phil came up to me, leaned over my shoulder and said “You do realize, April, that you saved that little girl’s life today?” I thanked him but said it was something we all did together and that she could still die of sepsis (a serious blood infection). His response caused me to stop eating. He said “No, you picked up that she needed attention NOW and brought her case to me with the forethought that we needed to act quickly. That was the turning point for her. Yes, she could die of sepsis, but I really believe she has a fighting chance”. I hadn’t thought about the reality of it until he said it—just how fragile her life was and how close to the edge she had been. I guess I knew it back in some recess of my mind which was filing all of these experiences away. They were getting saved in my minds hard drive but weren’t ready to print yet. There just wasn’t time right now. It wasn’t until Phil spoke it out loud… and it was only then, at that point…… that I began to weep. What I had done was part of my training and it comes as second nature. I had acted and reacted without much thinking, thanks to my training and experience. And then it was filed away for later. But when Phil said that, my mind began to quickly reflect on what might have happened if I had been MORE tired, MORE stressed, LESS concerned with what was going on and I might have missed this opportunity to save this child’s life. That was the moment when the tears of relief flowed. But I had acted quickly and acted well. Together we had saved a child’s life who likely would have succumbed in a few hours. God was gracious—keeping Angeline alive until we could get to her. Now she had a fighting chance. I reflected that as I was to go forward in this work, much of what I did was a result of our professional training and years of experience. It becomes second nature. One must think on one’s feet in situations like this. I realized that this isn’t a place for someone at the low end of the learning curve. The huge responsibility of literally holding a life in one’s hands became very apparent to me at that point in time. While I tried to have a good perspective that tragedies like this would be here long after I was gone, and many more would need to be helped, I still could do my part. It also drove home to me the point that I must continue to be as diligent as I could and not become complacent or distracted. People’s lives were literally in the balance here and I was here to keep them from going over that edge as they lay so close to the precipice. But I also realized I couldn’t fix it ALL. For me, I realized, yet again, as I had so many other times in Haiti that it was only through the power of the Holy Spirit that I could do any of it. It certainly wasn’t something I can do on my own. It was an amazing experience for all of us. And one I wouldn’t likely forget…ever.

Source: http://lukesmission.files.wordpress.com/2012/05/chapter-11-for-website.pdf