Monday, Nov 8th, 2010...Where do you go....when there's no place to go?....Jeff's Story

Woodley "Jeff" Meriska is a chubby 8 month old with big cheeks and short braids all over his head. It has been an easy morning.  I've seen only 30 patients, some of them sick, some of them not.  We are just about to pack it in for lunch when Jeff is rushed into my room.  He is having a seizure.  His arms and legs are shaking rhythmically.  His eyes are rolled back in his head.  His mom says that he's never had a seizure before, that over the last 3 days he's had a fever and a cough, but this morning when she went to get him, he was doing this shaking.  That is bad news because it means that he is in status epilepticus or uncontrolled seizure.  Short seizures, less than five minutes, are usually harmless, but the longer they go on, the more ominous they are.  Status epilepticus for more than 45 minutes has a 90% mortality rate.
Jeff comes to us after more than 4 hours.
The first order of business is to stop the seizure.  Chantel loads him with the anti-seizure medicine Dilantin by intramuscular injection because Jeff is a difficult IV stick.  Then Burney Miller, one of our two anesthesiologists, gets an external jugular line in, and we give Jeff Versed, a different anti-seizure medicine.  The seizure stops.  Jeff, though, isn't looking good.  He is posturing, meaning that his body is stuck in a rigid position, a sign that all is not well with his brain.  He also has very tight "crunchy" breath sounds. We suspect pneumonia and/ or meningitis.  We don't have a way to check for either, no X-ray or spinal taps are available so we give him antibiotics , just because we want to start treating again.  A little while later, he starts to go into a seizure again, so we give him another dose of Versed.  This again quiets the seizure, but between his lung problems and the seizure medications, he deteriorates and starts to need more support for his breathing,  Now we are bag-mask ventilating.  He doesn't improve, so we intubated.  Dr. Lori Borella, our anestesiologist gets in an endotracheal tube, with considerable difficulty.  She later tells me it's the most difficult pediatric airway she remembers.  He still does not oxygenate very well, so we give him some more seizure medication and a muscle relaxer.  We continue hand ventilating him for a while,  In the meantime, we discuss where we might go to get some more help.We finally get word that we might find some help at a hospital run by University of Miami on the other side of Port-au-Prince, an hour and a half drive away.  we pack him up in an ambulance run by the local Mennonite Mission, and we are off.

Rush hour traffic in Port-au-Prince is an experience in itself, cars and trucks and motorcycles and pedestrians everywhere, continously cutting each other off, merging in, suddenly stopping. Our ambulance driver Matt seemed very mild mannered and calm, but he drove like a madman, very skillfully, but fast, sliding the ambulance into spaces and changing lanes with inches of clearance.  The traffic does not respect the flashing lights and sirens, but it yields to the sheer daring of the driver.
Hand or bag ventilating means that we are essentially breathing for Jeff.  If we don't compress the bag rhytmically, he doesn't breathe.  I find after about an hour that I don't have to think about ventilating him, my hand has fallen into a rhythm, and is working on it's own.  We have to put a little tension on the tube to keep it from obstructing, and we have to guard Jeff from the constant bumps and swerves.  We plow through Port-au Prince, car by car, intersection by intersection, and finally arrive at the Miami Hospital.  As soon as we open the doors, the head shaking starts.  They need to check,  who did you talk to when you called.  Doctors, nurses walk past the ambulance , glance in, then avoid eye contact.  some do stop, talk with us briefly, and regard Jeff with sad eyes.

Finally, Autumn, the acting Chief Medical Officer, appears and tells us that they can't help us, that we'll have to try a different hospital Petits Freres et Soeurs, a pediatric hospital that we already sort of passed on the way.  One that has been less that helpful to our teams in the past.
We have been hand ventilating Jeff for 2 hours.  My forearm starts to ache.  My hand starts to cramp.  Sabine, Erika, Chantel start to take turns.Erika we've met just last night, is a nurse from Santiam Hospital in Stayton, Oregon. She and Chantel watch Jeff tirelessly, though both are to an extent, carsick.  Sabine talks to Jeff's father, who has come with us.  Jeff has a 5 year old sister.  He is the only boy.
45 minutes later, We are in Petits Freres et Soeurs.The Doctor there is not pleased, but we are arrriving with an intubated baby, and we are nearly out of oxygen.   We get a bed in the ER.  We look around, and there are desperately ill children around us everywhere, with IV's, oxygen.  None is as sick as Jeff.  The doctor says that they have one ventilator, and she will have to check to see if it is being used.  45 minutes later, she gives us a choice: there is no available ventilator.  We can stay there and hand ventilate Jeff ourselves, teach the father to do it, or take him somewhere else.  As soon as they swap out our oxygen tanks, we leave.  They agreed to give us oxygen, we think, to get rid of us.  We have been hand ventilating Jeff for 4 hours, by far the longest I've ever gone.  30 minutes later, we arrive at the third hospital.  Sabine goes in.  We don't take Jeff inside, just continue to take care of him in the ambulance.10 minutes later we have our answer.  Our only other option is the City Hospital.  no one wants that.  We head back to Fonds Parisiens.

Matt explains that this is an all too common theme in his work. He is here on a one year mission as part of the Mennonite church.
We arrive back at the Haitian Christian Mission.  We have been hand ventilating Jeff for 6 1/2 hours.  He is starting to wake up.
Inside, as he wakes up and starts to fight the bagging, I have a decision to make.  I know his lungs are compromised. I know he's had some sort of brain insult.  I don't know the severity of either, and I have no way of knowing except for my eyes, ears, and hands.  My preference would be to keep him intubated, on a ventilator, and follow him with serial x-rays and measure his blood levels of carbon dioxide and oygen.  I don't have that open to me.
The other option is to give up my secure airway and see what he'll do on his own.  It's possible that he will do better on his own.

We watch him.  He is vigorous, coughing.  He opens his eyes and seems to be moving purposefully.  I decide to extubate, to pull the tube.  We are excited.  He looks good.  He is keeping his oxygen level up.  We had hand bagged him nearly 8 hours.  I watch him for a time, then head to bed, planning on taking the 2 am to 6 am shift.  If anything goes wrong in the middle of the night, I'll get awakened anyway.  Maybe now I can get 3 hours of sleep. I am tired.
Jeff is tired, too.  His lungs are very stiff, and it takes all his strength.  Then his strength is gone.  I am blogging, this blog, when they come and get me.  They've been looking for you, I rush down.
Lori has been watching him.  As he tired out, he went into respiratory failure.  Jeff simply couldnt keep up with the work involved.  Lori tells me she tried to intubate again, but was unsuccessful.  We are back to hand bagging, with a mask, to keep him alive.  His lungs are bad.  Where do we go from here?  There is nowhere to go.  I knew that this was a better than average possibility when I started this.  Jeff, if there was ever a time to rally, buddy, this is it.  I stroke his cheek.   His skin is so soft. Chantel comes down.  She was going to sleep until the 2 am shift.  She looks at my face and tears start to well up.  I look around, everyone who has been invovled with this baby all day is around the bed--Lori, Sabine, Chantel, Erika, me.  "Does anyone have any other ideas" No one does.  We continue hand ventilate, to bag.  The father goes to get the mother.  Our plan is to continue bagging until the parents get back, so they can hold him.  We bag.  At this point, if I could will that my life would transfer into his body, I'd do it.  The parents aren't back.  We bag.  Jeff's oxygen level starts to decrease, slowly but inexorably.  I can't bring myself to stop bagging while his heart is beating.  We disconnect the tubes, the monitors.  I continue bagging. Chantel periodically checks his heart rate and calls out the number. No miracle is coming.  The parents have not returned.  We disconnect the oxygen.  Chantel listens and calls out the number.  Then she listens and just shakes her head.  I listen.   There is no heart beat.  "Time?"  "11:17pm."
We spend a lot of time holding him.  We talk about the day, what went right, what went wrong, what was frustrating.   Sabine tells us that the father said he was very grateful that we were there.  That he could see how frustrated we were and how much we cared.  We talk, holding him, waiting for the parents to come back.  Finally, we need to go to sleep.  It's 2 am and there are patients in the morning.  We wrap Jeff carefully and place him into an isolette in a quiet corner of the hospital.
We find out in the morning that the father came in about 3 am and took him home.  He was grateful.

Woodley "Jeff" Meriska  March 1st, 2010-November 8th, 2010.

Doug