Monday, March 15, 2010

day at triage clinic

(written 3/10)

Yesterday I staffed the triage clinic in front of our camp, and we saw over 400 patients. It was crazy - like medical speed dating. The triage clinic was originally started to determine what patients should be seen in the emergency room (or admitted), and has evolved into more of an ambulatory care clinic.

Patients start lining up at 7am, even if we're not open until 9 or later. They wait - for hours, in the hot sun - to see a medical provider. For many of the patients, this is the first time they've ever seen a doctor. In one day I saw everything from hypertension and diabetes to wound infections and STDs. Almost every patient was dehydrated, none of the pregnant women had received any prenatal care.

Back home I work part time at a compounding pharmacy, and have joked about being "a witch at the Apothecary" - mixing lotions and potions in the laboratory - well, never has that been more true than here in Haiti, especially my day at the triage clinic.

We've had supplies donated, but way more in "adult strength" than children's doses. Armed with Lexi, Sanford, and a calculator, I didn't realize I was literally going to MAKE medicine all day.

It started with ear infections and no ear drops. Simple enough - eye drops can be used in the ear, no problem (unless they're vancomycin - which I had to stop a few times - you know, that whole "ototoxicity thing"...). Then an asthma patient, whose been having exacerbations since the quake. We've had no albuterol inhalers for days - but you can drink the nebules and still get some effect (there are just more systemic effects, so I was sure to check to see that the patient wasn't tachycardic).

Before I knew it, I was splitting antibiotic capsules to make suspensions, a few variations of "magic mouthwash", and combining some childrens benadryl, tylenol, and a touch of lidocaine to make cough syrups, and then it just snow-balled. For a clearly dehydrated boy who wasn't eating - oral rehydration salts in a liter of water, with a "chaser" of megace to stimulate appetite... I know I made MacGuyver proud...

We had no bottles to dispense liquids, so we used (clean, new) urine cups with screw-on lids. Directions were written in sharpie on the side.

Pharmacy - medicine in general here - has to be "outside the box". We have a staff or rotating volunteers (that turns over weekly), and the majority of our supplies are donations. We do the best that we can with what we have, and what we have is always changing.

By the end of the day, I was exhausted, sunburned, and the wind had blown the dust through my scrubs and embedded it in my skin. A 2-minute cold shower never felt so good!

~PJ

Friday, March 12, 2010

catching up on old notes...

When I scrolled through the email on my phone, I realized there were several times I started to write stories to share, fell asleep half way through, and never sent them... Since we're having a relatively quiet night in MedSurg tonight, I'm going to try to get them all finished!


~PJ

after things settled down with the preemie

After things settled down with the preemie, I spent the wee hours of this morning trying to figure out how to nicely tell the docs (at the morning meeting) that we're out of lovenox, and since they've all insisted on giving heparin prophy to everyone, we're running VERY low on heparin - like we might run out.

(for the non-medical people: lovenox or heparin can be used to prevent deep vein thrombosis, ie. dangerous blood clots, in people who are spending all day laying in bed)

I'm taking most of their patients off of heparin and putting them on aspirin, and recommending the PTs or the family members make sure to move the limbs around.

Yeah, that will go over well before coffee...

~PJ

Tuesday, March 9, 2010

7 pounds, 6.9 ounces, C-Section

I've got so much to share, but wanted to send this quick email before life gets too crazy. When I got here I mentioned to one of the OB/GYNs that I'd love to see "the miracle of life", and last night, Tipu sent one of the PAs for me.

The mother came in late in the afternoon, and had been having contractions since the morning. We tried for a vaginal birth - one of the ER guys and I held her legs (no stirrups on our tables) and pushed while she pushed. The baby had defecated in the amniotic fluid (MAC), the heart rate was over 200, and the mother wasn't responding to oxytocin, so we had to do an emergency c-section.

I grabbed the meds and we headed to the OR.

It went well - slight complications, but today the mother and baby are doing fine.

One of the NICU nurses stayed for the birth, even though she was off, and mentioned to me that this was what she needed to see. I didn't understand what she meant, until she explained that they'd lost 3 babies today.

Since the mom wasn't very coherent (the whole being in labor all day, and having an emergency c-section), and we needed to call the baby something, I "named" her (temporarily) "Joy" - since it was such a joy to have a full term, healthy baby here.


~PJ

Friday, March 5, 2010

quick notes

Thanks for your emails! Just so you know, I do get the emails you send (may take a day or two, but I get them!)

This morning Dr. Vince DeGennaro (kind of like the CMO - head guy here) came into the pharmacy and was chatting with me. You know how I always say I never EVER want to manage? Yeah, well guess who is making the schedule, re-organizing, and speaking to the team...


~PJ

day 5

Things are a little different here. There is no middle class - only the people with nothing, people with money, and the people who had money but lost everything in the quake (and are now more people who have nothing). There is nothing like "homeowners insurance" here, so if your house got destroyed in the quake, you have nothing.

We met many of these people when we (Claire, Nia, and I) went to visit one of the tent cities. Before the quake, this had been a sort of shanty-town, but all the roofs came off of the houses during the quake. Claire grew up here, and her best friend (who still lives here) donated all the tarps that make up the new roofs of the tent city. These people have no health care, and they have no way to get to a medical center like Medishare. No clean water, many high risk pregnancies, bacterial vaginosis, just a few of the problems we're seeing. We played with the kids and heard many of the stories.

The stories we hear break your heart - like the 17 year old who was trying to help a friend out of a building during the quake. He was holding his friends hand, trying to pull him to safety, when the wall collapsed, crushing his friend to death and amputating his hand. He says the pain where his hand was is bad, but the pain of watching his friend die is worse.

And the patients we see - especially the kids - they rip at your heartstrings.

Back at the hospital, I saw a girl with sickle cell with a Potassium of 9... Should be about 3-5, and I've never seen someone alive over a 7. I don't really understand the patho-phys of how sickle cell makes that possible, all I know is I saw the fear in the pediatricians eyes when I said we had no kayexalate (binds and removes potassium from blood). We tore through the supply tent (which is less than organized), nothing. I started tearing up - I know the kid with encephalitis is going to go anytime, not another one.

So what do you do with a sickle cell kid with a potassium level of 9 when you can't find any kayexalate? Yeah, Drug Info questions from Haiti can be a little rough... Well, my plan was to give her candy, shoot her full of glucose and insulin (to push some into the cells), then start her on IV fluids and furosemide to push some out through the kidneys.

The pediatrician thought it sounded better than any ideas she'd come up with, and we followed my treatment plan... And I'm happy to say the patient is still with us 2 days later :-)

Once again, I have so many more stories to share, but not the time to write it all down.

Short version: I'm safe, alive and well, and trying to keep my patients the same!


~PJ

Monday, March 1, 2010

day 2

It's hot, I can't sleep. You'd think it wouldn't be an issue - I worked until almost 4am, but my mind is racing a mile a minute.

We landed in PAP (Port Au Prince) yesterday, way ahead of schedule. There were no working runway lights at the PAP airport, so instead of arriving at midnight, we got in about 3 pm. Nia had joked about doing some sightseeing with our free afternoon... I had to giggle about that when I realized she and I were both still working at 3 this morning.

Getting from the airport to the UM "MASH" unit was an ordeal of its own - even though we're on the airport grounds, we had to leave the airport to get to the cars to get to our complex. Wading through the crowd of locals, all begging, many with amputations and stories that bring you to tears. They took us in small groups, with security, to the vehicles to go to the complex.

Before we even go to the orientation, someone found me. The pharmacist who had been here left on a flight at noon, leaving one (amazingly talented) technician to run the pharmacy AND peds satellite, and she needed help.

I should preface this by saying things are different here - in the states, we double and triple count a narcotic prescription, here I leave the bottle of percocet on the table for nurses to grab when I'm scavenging through the supply tent. I have to trust that my aseptic technique is good, because "sterile-ish" here is, well, "-ish" is the key part of the phrase.

Needless to say, my first day was a good introduction to the chaos...

I have so much to share, but every time I sit down to type, well, there just isn't time. The joys and sorrows are like being on a roller coaster. Imagine scrambling through random piles in a supply tent - much like looking for a needle in a haystack - at 3am, trying desperately to find the calcium gluconate for the OR. You know why they need it, and lives literally depend on you finding it in time. Tears came to my eyes when we found the vitamin K. And again, when the doc came to me asking what to substitute for the dopamine we were running out of.

Almost everything for the kids has to be compounded - thank god I've been "playing at the apothecary" - and today we started switching all our amputees over to hypericum (homeopathic) from neurontin. Not that the homeopathic is better - we ran out of neurontin, and it will be days before we have anymore.

Once again, I have so much to share, but I'm finishing this email at 4am and am hoping to catch a few zzz's now that my pharmacy is no longer the middle of the ER (when the ER closes for the night, triage comes here to the ward...)


I kept making jokes about MacGuyer medicine - check out the photo below of our "premie incubators" made out of suitcases!


~PJ