San Marc

Back to work yesterday after what one can only say was the experience of a lifetime. And I hope to go back for more.

Walking through the gate at San Nicholas, in San Marc, about 2 hours north of PAP, there was an incredible scene, that most of you have now probably seen on TV. People essentially on cots and blankets on the ground all throughout the central courtyard of the hospital and lined up side by side in each ward including the radiology building and ER. The entrance was guarded and one has to step on a foam pad soaked in bleach to enter/exit with a hand washing station there too. Orange construction webbing fences cordon off 1/2 the hospital marked as contaminated. People lined up waiting at the triage tent to either have and IV started and admitted to the hospital or else sent to an observation tent to make sure they were tolerating Oral Rehydration Solution (ORS) well enough to go home. The hospital is a partnership of MSPP (ministry of health) and Partners in Health. Once the epidemic hit, Mediciens sans Frontiers joined the partnership to run the logistics and manage strategy for the epidemic.

I worked Saturday from the AM until Sunday morning, then swapped to nights as one of 2-3 docs taking care of 300+ people in the hospital overnight. I ended up running triage up front, which ended up being an incredible job. When one hears that cholera can deplete 10-20 liters in the 1st 12-24 hours, it is really hard to imagine what that looks like. People came in all night, some looking literally like skeletons with eyes sunken in, flat temples, unconscious. One would assume that they were chronically ill, and while some were, you could literally watch people reinflate to normal people after 10 liters of IV fluid. The 1st night (about 4 days into the epidemic) so many people were coming in almost too late, nearly pulseless on arrival to the gate. Luckily as the days went on, community education was spreading and people were coming in as soon as symptoms started for the most part, and few were as sick.

Cholera, luckily is quite easy to treat. Cholera unluckily, is much harder to control and prevent on a population level when people are in crowded conditions with poor sanitation on top of baseline starvation and a high rate of previous existing illnesses that set people up for badness. It is thought that 80% infections are asymptomatic and really only 10% have the severe rice water stools and projectile vomiting with hemodynamic collapse, but we put IV fluids into 300 people daily. Not sure what the denominator is for that number, but one can assume that in a population with zero immunity (last case of Cholera on Hispanola was >50 years prior), the ratio of severe illness is higher. Treatment is simple: IV fluids until people are conscious and the vomiting has abated enough to keep fluids down, then transition to ORS until stools <3>

What is tricky, is finding veins on someone 10+ liters depleted when they are already cold to touch and with barely a carotid pulse. We had some great saves however, including one where 2 med students and myself put a peripheral IV into each limb and grabbed 4 men to squeeze bags of fluid in and delivered 8L in about 15 minutes to someone in that situation. 1mg of epinephrine helped a little too...

I already had learned how to place intraosseous lines at MGH, but we usually have a gun/drill tool that bores through the tibia. But, I learned that with a little elbow grease, one can put them in a kid without the gun, by which I mean just screwing a 16G needling into the bone until it pops through and you can pull marrow back. Each night I put 3 or so in on kids that were too dry to find veins on and were minutes from death, and in each case, were able to revive the kid!

Other highlights were meeting Sean Penn, working with PIH, getting interviewed on NBC nightly news by Nancy Snyderman, and accidentally having to deliver a breach baby on a non-cholera patient because I ran into the labor ward to get something, found a woman there was failing to make progress with a baby in trouble (compressing cord) and no obstetrician in site, so I had to just start pulling! Baby looked awful at first, blue, not crying, not moving, but after a few minutes of vigorous resuscitation, she perked right up and looked great.....wow. I have never had to do that (she would have had a C section if there had been a real obstetrician there).

There have been so few times in my still short medical career where I can honestly say to myself that I am so glad to have been there to save someone's life. In most other medical situations I am in, if I wasn't there, there would have been someone else with the manpower or the knowhow to do what needed to be done or else they would have probably done fine on their own. And nothing egotistical at all, but I can think about 10 people each night I spent there that would have died if I hadn't been there...and I mostly feel honored and humbled to have gotten to take part in the amazing colossal effort put forth by so many groups to run San Nicholas hospital as an emergency cholera center. Situation ongoing, but seems to be cooling off. Hope that the trend sticks in San Marc and that the epidemic continues to stay out of PAP for the most part. There are a few cases here, but most are friends/family of people in the Artibonite, no evidence of it in our water supplies here yet, though people are bracing (but not quite actually preparing) for that likelihood.