CRNA Volunteer Juan Quintana, CRNA, DNP

Haiti Medical Mission of Wisconsin

Thiotte, Haiti — March 5-13, 2010
 
Juan Quintana, CRNA, DNP, responded to many requests from colleagues asking about his experiences in Haiti, by posting an account on some of the CRNA chat lists. We reproduce that account here with his permission.
 
Here is a mini story of my trip to Haiti. The trip was taxing and not for the faint of heart. I don't usually share too much about my experiences on trips, (they are a very personal gift for me). 
 
How it all started?
I responded to a message forwarded by Art Zwerling, CRNA, DPN, DAAPM, from a group needing anesthesia services. This particular group is associated with the town's (Thiotte's) Catholic church in Haiti, via the Catholic church in their own town in Wisconsin. The group was sending a surgeon but would otherwise have been relegated to local anesthesia. It just happened that no one was on vacation from my group at the time, and the group with whom I normally travel in May, was well staffed with anesthesia providers. So, I agreed to provide their anesthesia. The surgeon had traveled two other times with this group and indicated he performed hernias, hydroceles, wound debridements and incidentals...oh, and rarely an emergency C-section. The group is composed of a pharmacist, surgeon, two emergency room doctors, one family nurse practitioner, four certified nurse-midwives, two volunteers, two registered nurses, one administrator, and one CRNA. In addition, we picked up four translators, a Wisconsin reporter, and a camera man.
 
Yes, portions will be on TV in May, I think.
 
Arriving in Haiti...
Madness at the airport...30 duffle bags plus personal luggage for 14, four vehicles to transport – one for luggage and three for human transport. We waited two hours for a truck transport at the airport. Many other groups traveling for various reasons, were in the same situation. The airport was under reconstruction at the time of the quake, so only parts were functional. The baggage was delivered to a warehouse approximately two blocks down from the terminal.
 
While waiting at the airport (two hours later), as in many Third World countries, one is accosted with "help"...folks willing to do anything for a tip (not bad, but the down side is they can also "borrow" your bags). The group had helpers so the trick was to watch carefully that all our bags stay with us. Easier said than done, as one is trying to travel two blocks with a bunch of bags and luggage. Immediately your eye is caught by the number of military vehicles traveling back and forth, the number of military helicopters moving overhead, and the variety of countries' flags displayed on the soldiers traveling in the vehicles. This is a busy place.
 
Trash of all kinds is prevalent around the airport and everywhere. Though this is not uncommon for Third World countries, the quantity is dramatic, perhaps enhanced by the number of individuals traveling into Haiti to assist in the recovery. Next to the trash, food vendors cook and sell their wares. I sprayed myself with insecticide, 100 percent DEET. until I felt slightly toxic, just right. Preloaded with anti-malarial drugs, anti-diarrheals and Cipro... bring it on.
 
Our objective on this trip was to travel to a small town with a catchment of 30,000 population, close to the border of the Dominican Republic, to provide basic healthcare, maternity, and some surgical care. Port-au-Prince is the capital of Haiti and many Haitians travel there for care, to sell at market, etc. However, recently Haitians have traveled back to their home towns after the devastation. Some of the towns that experienced damage and are now facing increased populations and the need for provision of healthcare services which were sorely lacking anyway. As has been described, injuries that have gone untreated are everywhere, but the Haitians are afraid to go to Port-au-Prince to seek medical attention, while others simply have no money or transportation to get there.
 
Transport finally arrived and the trip started - five hours to travel 75 miles. We actually traveled on paved roads for about 10 miles. Then perhaps the best way to describe it is to travel via a river bed complete with rocks, ditches and water for 65 miles. The first hour it's funny and bumpy, then all your parts start to cramp, you're constantly attempting to sit up after getting tossed and bounced from one side to the other, your sides hurt, your butt hurts, your neck hurts...you get the picture. Only four hours left to go. It's raining.
 
While in Port-au-Prince the temperature is warm and humid, as we traveled on through and into the night and up the mountains, it is now chilly. We arrived in Thiotte (pronounced Chiote) at about 11 p.m. The electricity from the city is only on from dusk to 10 p.m., so the lights were out. Originally this group was to stay in a part of the church, however, the building is unstable and the government felt it would be best not to have people sleep in the building with moderate use in the day, so we slept in two-man tents in the courtyard. Those that know me realize the irony of all this, since my idea of hardship in the wild is a Radisson without a jacuzzi tub. We unloaded all the bags and decided to bed down for the night. Before we left Miami, I purchased five bottles of water. Since no running water is available, I used some of it to brush my teeth and headed to bed. It's raining...a lot. The tents were consistently damp, as were the sleeping bags, and anything else in them, including you.
 
Sleep is an interesting concept in Thiotte, more like an intermittent process. At about 3 a.m., the roosters start to crow... there are a lot of roosters in Thiotte. They all feel the need to participate and it is loud. After 30 minutes, this really pisses off the dogs, who begin to bark. Ear plugs are a great idea. As people travel down the windy roads they have difficulty seeing each other around corners so they honk the horns to warn oncoming traffic...all night.
 
Day One
Up at 0600 (6 a.m.) the next morning ready to get the day underway, I had breakfast - soup - and went to check out the operating room (OR). As I mentioned, there is no electricity, so the hospital has a generator they run but not until 8 a.m. We began the organization part of the process. Apparently a couple of years ago, Al Garven, CRNA, sent an anesthesia machine down to the town which was a blessing, though no one had used it since its' arrival. I began the check out process and realized no oxygen was attached. They supplied an H-tank which they had filled with oxygen, but had no pressure valve or attachment that could be modified to use with the anesthesia machine. After several hours of looking and trying various methods to attach the tank...I gave up. I found the only E-cylinder oxygen tank attached to a bag valve mask (Ambu bag) and plugged it into the machine, it had about 300 psi left in it. I cleaned all the parts and got the basic machine set up to work. After a little more work, even the ventilator functioned. Though we would need more oxygen for cases, the anesthesia machine was alive and operational! — I knew that class would come in handy one day. I believe a mouse just scurried across the room?
 
I looked around and found a vital signs machine.. oxygen saturation, blood pressure (BP), and pulse. No electrocardiogram (ECG) and no end-tidal carbon dioxide monitoring (ETCO2). The procedures we could perform would be limited. Fortunately, I had brought along several spinal trays. Looking over the anesthesia drugs available — lots of propofol and isoflurane, our most basic needs. Checked over the equipment and supplies, not great but functional. That evening one of the midwives advises me she has a patient that just arrived in labor... BP 230/110.. they are trying some medications (meds) and magnesium to bring it down. They perform a sonogram (small portable) and question abruption... the decision to go to Caeserean section (C-section) is made. Poor history, quick spinal,... baby out.. Apgar score 2/10, floppy, blue, not breathing — lots of resuscitation final Apgar after 15 minutes: seven. Baptized three days later. In the meantime, mother bleeding like stink, midwife resuscitating baby...I scrub in, help close, and direct the translator on administration of Pitocin and antibiotics (thankfully, already drawn-up). Clean up, dinner: beans and rice, off to bed. Wonder if it will ever stop raining?
 
Day Two
It stopped raining! (The crowd goes crazy.) Spaghetti for breakfast — okay, I ate it. Clinic gets going, postpartum mom comes in six days post with pain in axillary area, temperature 105, tachycardia — looks sick. Hasn't eaten in two days. Axilla (armpit) with a palpable mass tender to touch. Interesting...further interview reveals about any other problems... mother says she has not bled since her delivery (?) and now has a "smell" down there, not the initial complaint. Quick exam (not by me)...not good. In the OR, anesthesia induced, precordial and the available monitors. Retained placenta — dilation and curettage (D&C), lots of intravenous (IV) fluids, pit and the mom look better, axillary mass — most likely tuberculosis (TB) — treatable. Stayed in hospital ward (five beds) — two days. Immediately after, called to the clinic to see a 14 month old for IV start...arrived to find this kiddo breathing 80 — yes, 80 times per minute, clammy, non-responsive to IV start attempts — can't find a damn thing. Put in an adult intraosseous infusion — slowly. Didn't infuse fast but it worked. Had to disconnect my O2 tank from the machine and use a cut-down nasal cannula on the kid. [Crappy] night, up and down checking on the kid. Did a couple of hernias with minimal versed and spinal anesthesia. Four oxygen E-cylinders arrived at lunch. Our brave sick reporter gal is working on her laptop in the OR, I advised her I thought I saw a mouse a day before in her general vicinity...I was headed out of the clinic when I heard the scream. Next morning with the kiddo, smiles and a lollipop — prayers answered (I think my brain is exhausted.. lol).
 
Day Three
Cereal for breakfast. I have advised the locals that in Texas if a rooster crows at 3 a.m. routinely, it becomes lunch that afternoon... they are unimpressed. By the way, I am getting good at Haitian Creole.
 
Busy, eight procedures, some very large hernias and 1,000 cc hydroceles, one spade to the foot and a very bloated abscessed looking, hot finger on a 12 year-old. Kiddo went home, septic mom with retained placenta is better. At 2 a.m., I hear retching and vomiting followed by desperate plea to God...I check it out. The anchorwoman is green and going at both ends and somewhat panicked, this is shortly followed by a volunteer, the pharmacist, and an RN. I start IVs all around, Zofran/Reglan/Immodium and Granola Bars when they can take it. Three folks of a 14-man team — out. Hot day, tents are retaining the humidity. I think it's raining in my tent. Crawled further into the sleeping bag — one hour to sleep before the damn roosters start again — I hope breakfast is rooster soup.
 
Days Four Through Six
Various cases. All is going well. The sun is shining and getting increasingly warm/hot. I am a bit nostalgic about having a full night's sleep. Breakfast varies. The sick folks took two days to walk around again and ate gingerly again on the third. I've noted taking a bath with water out of a bucket these last few days does not somehow make me feel clean. I'm not going to shave and risk a cut with water from a cistern and I guess I'll just keep my cap on. The cistern is running short on water. Wish it would rain. 
 
We've settled into a routine, I am preoperative (pre-op), intraoperative (intra-op), and postanesthesia care unit (PACU) person. The patients are moved just outside the OR and I observe them while I administer anesthesia to the next guy. Nothing is optimal, but this is working. Most cases I do with either room air or 1l/min of O2—reminds me of plastics. Last two days are hot, the windows are open, of course there's no air conditioning... sweat and stink are the common ground, just don't throw up on me. Sixth day, last minute ax to ankle (amputation) — quick clean, leg BP cuff to upper thigh and clamp to stop the arterial bleeders, clean, partial closure...OR closed.
 
A couple of patients in the hospital ward, one 45 year-old in congestive heart failure (CHF) with gastrointestinal bleeding (GI bleed) — Hematocrit blood test results (HCT) 17 percent, BP through the roof, pitting edema of all extremities, one patient apparently stroked — looks bad. IVs for all. This group was very good at brainstorming each case and deciding the best course of action. Collaboration was the standard and to be commended. The CHF patient was alive and improving when we left, the stroke patient expired the next day. It is relevant to note that approximately 80 percent of the patients I saw had BP systolic (sys) 190+, diastolic (dias) 100+, few on BP medications (meds), and no other history — which primarily meant they had no idea what health issues they or you might face. Found a few diabetics but no oral meds or insulin were available. BP meds for 30 days, then what?
 
Day Seven: Headed Home
Packed the trucks, headed home, back on the same rough road with three vehicles. About one hour into the trip the vehicle in which I am riding has a blow out, we get out and get ready to change the tire when I check out the spare.. well you could call it a spare, the tread was basically gone, wire exposed.. nevertheless we put it on and continue our trip.. four miles later.. the spare is gone. Two vehicles remain. We pile all 14 into the remaining vehicles.. we all stink, we're dusted with dirt and half are recovering from being sick.. just get us to the airport.
 
We catch our flight and land in Miami, each heading our separate ways. Hugs to the group. Tough experience, snapshot into the lives of Haitians who find a great deal of happiness in their lives, despite what we might think. Circumstances could be better. I will take a moment and apologize to anyone who might have sat next to me on the return flights... ripe cannot describe it.
 
Special thanks to the CRNAs in my group who worked hard while I was away and permitted some good things to happen to some folks who have had it rough.
 
P.S.: I stopped to get a bite to eat in the Miami International Airport. As I loaded up on food and sat down to eat, a nice lady sitting at the table next to me took a long look at me, smiled and offhandedly remarked..."How was Haiti?" I laughed so hard I thought I would cry.
 
Glad to be back.