Left To Die On A Tile Floor

“Dr. SW101,”  said Father Larry, “There’s a woman lying unconscious in the church courtyard.  Can you go see her?”

With little more than a quick nod, I grabbed my interpreter and headed out the door. How, I wondered as harsh sunlight spilled into my eyes, is a doctor supposed to help an unconscious patient?  In Haiti.

I tried to think of all the reasons a woman might collapse, and what sort of assistance I might be able to offer.  Again…in Haiti.

Quickly, I reviewed ACLS in my head.  I tried to revise the arcane algorithms based on the fact that we probably did not have ONE SINGLE med used in a typical code.  I thought through hypoglycemic coma, and stroke signs and symptoms.  I tried to recall how I might distinguish between ischemic and hemorrhagic types (and would it help to know the difference?).

Our team working on the patient

Also on my list of worries were seizures, pulmonary emboli, electrolyte disorders, dehydration and the difference between heat exhaustion and heat stroke.  Distantly, I pondered the probability of this being a simple “waiting delirium” where people fake a collapse to get to the front of a line.

I approach what must be the patient but of course I can’t see her.  All I see is a giant throng of people hovering in a circle; a shark frenzy of curiosity.

My interpreter helps me push through the crowd to a thin elderly woman lying with eyes half closed on a tattered blanket.  She was placed in the half-shade of a skinny, leafless tree on dusty cobblestones just outside the church offices.  People are yelling and pointing in all directions.  They give me space grudgingly.

I learn that the woman had a seizure sometime in the night, passed out, and has been seizing regularly ever since.  She is completely unresponsive.  Someone tells me she’s around 70 years old.  Someone mentions that she’s a grandma.  Someone says it’s hot out.

After a brief exam, I have her brought into our clinic and placed her on a army-issue stretcher.  I rummage around our supplies with the help of a spectacular nursing student named Kim.  Together we come up with an angiocath (for IV’s), a bag of normal saline…even some gauze.

We place the IV and get some fluids running to treat possible dehydration.  Kim and an OB nurse place a foley urine catheter we happen to have too.  Clear urine runs into the bag, ruling out dehydration.  We find urine test kits and note that there is no blood or glucose in the urine, thus arguing against diabetic problems or UTI.

The immediate problem was the seizures.  And we had no medicines we could give a patient who, every 15 minutes or so, had a full seizure on the entire left side of her body.  Kim and I riffled through the meds again and found some dilantin (good for seizures)…but in pill form, which made them totally useless.

Knowing the patient would die in her current state, I wrestled with the problem of how to get some sort of sedative – ANY sedative – into her tortured body.  At one point a group of us seriously considered IV Haitian Rum.  I thought about crushing up the dilantin and trying to trip a slurry down her throat, or pushing it rectally.

We eventually found liquid dilantin; made for oral administration.  The discovery felt like a ray of sunshine in a mausoleum.  Now all we needed was a naso-gastric (NG) tube.  Gotta be lots of those lying around, right?

None.  The patient is seizing again, Dr. SW101.  The family is getting frantic.  People are looking in at the patient through every window.  What do we do?

Kim and I did find a feeding bag. Looking at it, I envisioned how we could fashion some version of an NG tube out of the tubing from the bag.  I talked up my plan to Kim.  Seeming like this kind of thing was a daily occurrence for her, she retrofitted the tubing, reversed the adapter connections…lubed the thing up and slid it right down into the patient’s stomach.  Perfect.  I had my tube.

I dose out my best guess for the patient’s weight, not knowing her renal function, her hepatic status, her chronic diseases or her current metabolic state.  I gave it my best guess – shooting for safety and efficacy – and we started a regimen of dilantin.

Along with trying to treat this patient urgently, we knew this woman needed to be in a hospital, and Father Larry had been working on the weirdly complicated logistics of transporting a critical patient to General Hospital in Port Au Prince.  Father Larry also supported my desire to stay with my patient to make sure that someone on the receiving end knew the story and could adaquately take over for us.

Our best effort at an ambulance

Not ungently, we put the woman in the back of a tough Isuzu jeep and then blasted out of Thomaseau over rocks and roots and dusty country roads, headed for the thriving city of Port Au Prince.  Nearly 2 hours later, sweaty and dusty, we pulled in through the hospital gates.

My driver and translator is something of a celebrity in the village and knows many people in Port Au Prince also.  He did some quick talking at a back entrance to the ER, and ran back to our car and told me to, “help me pick her up…quick!  They’re letting us in the back.  Otherwise we have to go through the front and it will be at least 8 hours until she is seen.”

We carry the woman through wards teeming with people.  I sense many stares as I pass as quickly as possible through hordes of sick patients, family members, hospital staff and equipment.  We enter an austere room made of tile and bricks, with windows high above us grudgingly tossing some light to the floor.  A kid of about 15 is walking back and forth, tears streaming down his face as he intermittantly screams and jams his hands down his pants (psych?  testicular tortion maybe?).

“Lay her here.”  Instructs Bobby, my interpreter, the celebrity-guy.

“Right here?  On the tile?”  I reply, looking around anxiously.  “Where’s the bed?”

“No beds.  There won’t be one for hours.  Maybe days.  It’s leave her here or we take her back.”

We lay her on the floor.  Two of her family members that came with us huddle on the cold linoleum next to her.  I tell her story to a bored and tired looking orderly.

“Ok.  They’ve got it from here.”  Says Bobby, already heading for the exit.  “Stay any longer and they’re going to demand more money to keep her.  We need to get out now while we can.”

Fighting a sense of revulsion at the place where I’m leaving my patient, and vicerally wrestling with nearly-overwhelming waves of guilt for abandoning her, I snap a quick photo and leave.

As we walked away, I knew she would die on that cold, lonely floor.  Her family trusted her to me, and I left her lying in a tile grave.

Her Final Moments

Not long after we returned to Thomaseau, after a harrowing drive through some of the worst slums in Port Au Prince – and in the entire Western Hemisphere – after hours and hours of efforts to save a life…she died.  Probably from a stroke that occurred before we found her in the courtyard.  Within 2 hours of our return to the village we were notified that the patient was gone.  Please come collect the body.  We wouldn’t have given her a bed in the hospital anyway because you didn’t pay for food and supplies.

We did calm down the seizures, by the way.  By the second dose of dilantin, the repeated convulsions faded away and our patient clearly became more peaceful. 

A small consolation.

The news of this woman’s death was somehow devastating to me, even though I knew she had no chance.  I couldn’t help but get emotionally involved in something that required so much effort and focus. 

And for all that work, I ended up with a dead patient; her last moments spent in squalor, destitution and abandon. 

I have now spent hours trying to frame this experience in some sort of meaningful context; actively resisting raw emotions of fury and hopelessness and sheer nhilism.  So far, I know only this:  all I can really do for Haiti, is care about the suffering there. 

And never, ever forget…

Hard Work Index

I’m currently fielding all kinds of wonderful offers for jobs.  Christmas time has truly arrived, in many ways.  Tales of excellent income potential and inspiring patient populations tumble around my head regularly.

But guess what every job offer has in common:  WORK.

I’m not opposed to working hard.  Anybody who drags themselves through undergraduate bio and chem majors, medical school and years of residency should have at least some work-ethic cred.

But my view of “hard work” has changed slowly over my years in residency.  This is why I probably was primed to really take home the message delivered to me from one of my favorite surgeons in our hospital.  I should mention that he waved his barely-functioning right (and dominant) hand at me as he gave me this adominition:  Don’t work too hard.  It just isn’t worth it.

Sure.  The European thing.  Wine and 2-hour lunches.  4-day work weeks.  Great.  I’ve kinda always thought that sort of work life was reserved for the rich and asset-ed.  For those of us in debt and assts-LESS, the equation is different.

But as I spoke with this surgeon, he made a strong impression.  Young, at only 54 yeras, he recently suffered a serious stroke.  Sadly, the part of his brain that suffered most is the part that controls his right hand.  The hand he uses to perform surgery.  In essence, this guy was struck down in the prime of his career.  He’s aggressively pursuing rehab, but for now he can only assist in surgery.  He has improved significantly, but he’s looking at other lines of work, too.

This guy had a good cholesterol profile.  His blood pressure was controlled well on medications.  He ate well.  He is not overweight.  His only problem, he said, was that he never exercised.  He never really did anything, except work.  In the rare moments when he wasn’t working over the past 20 years, he hung out with family and restored his classic 1960’s Mercedes.

Every job I’ve looked at requires quite a large number of hours.  Many of the hours will be spent dealing with stipulations from lawyers, insurance companies and governments, but this is another discussion.

Many people I know say that medicine is a GREAT…hobby.  It’s not great as a job.  The education is so expensive that you are relegated to virtual indentured servitude by the time you’re ready to start practicing.  The only way to get out, is to work like a dog.  Many people begrudge a doctor’s salary, but they’re usually doing it from their couch, watching the game, while the doc is missing yet another morning at church with his family as he gamely walks into yet another patient room.

Long hours are part of being a doctor.  Sometimes, you don’t even notice as they pass because you are so emotionally and mentally involved with the job.  But when you finally do go home, and so much has been left forgotten or unattended, it’s hard to see the value in the enterprise sometimes.

In choosing a job, I’m using this surgeon as my hard work “index” case.  I’ll work nearly as hard as him, but unapologetically not as hard.  It may take us until the next ice-age to pay off the capitalists who are getting rich on my loans.  But I’m not going to donate the motor function of an entire hemisphere of my body to make it happen any faster.

Certain Lawsuit

Here’s a sure way to get sued:

Use TPA on 100 patients. That’s all it takes. 100 times, statistically, and it’s off to the courts.

TPA is a pretty cool drug because it is the only one that actually breaks up blood clots. Effectively Drain-O for the body, TPA drills through plugs holding blood from crucial areas of the brain. Ostensibly, it could be used for clots in other areas like the heart and the legs, but it usually isn’t. In fact, there are EXTREMELY strict guidelines for exactly when to prescribe the drug. Roughly, those rules claim that you can only use it within about 3 hours after a person exhibits classic symptoms of a stroke. An ischemic stroke, by the way, not a hemorrhagic one.

Why so many rules? Wouldn’t a drug like that be the answer to the world’s medical problems? Think of how many people die every day because of clots forming in our vasculature that shouldn’t be there. This is why docs are so obsessed with cholesterol, for example. It contributes to clogging up coronary arteries. Arteries get blocked, heart muscle doesn’t get oxygen…heart attack. Pretty simple, really. So this drug should save the world. Maybe we should all take it on a regular basis, just to keep things thinned out.

The problem is that the drug works incompletely. It does, in fact, break up clots, but sorta like a photon torpedo from the Star Trek Enterprise would break it up (it must be quite cool to watch). You end up with bujillions of little clots in your blood stream. If they’re small enough, they will pass through even the smallest capillaries and not clog anything up. But usually, all those clots will lodge somewhere else and cause more problems…like mini-strokes, mini-heart attacks etc.

But the legal problem with the drug is that approximately 1 in 100 patients will end up with a brain bleed as a result of the drug. The reason is because after a clot forms, holes open up in the artery downstream from the clot as things dry up. The holes are basically caused by shrinkage like anything shrinks after it dries out. Then the TPA comes along and busts up the clot. Blood starts flowing again, and viola! it rushes across the newly-formed holes and pours into the brain.

“My doc gave me a hemorrhagic stroke.” Defend THAT mister docta man.

There is no incentive in our system to NOT bring litigation against doctors or anyone else. Sure, most lawyers don’t want to waste their time, but when there is a basic complaint as glaring as “my doctor caused my brain to bleed”, most will give it a whirl. Think about it: Plaintiff attorneys have a 50-50 chance of winning on the basic charge alone. Some poor patient gets on the witness stand, drooling and drooping and describing what their life was like before Dr. Flamethrower over there pasted him with that terrible medicine. But even if the case loses, most lawyers make money. Bringing charges…brings charges. Trial lawyers bring cases with big pay off potential (most stroke cases fit this bill), settlement potential, or when the patient can pay up-front.

I think there should be a litigation approval process where complaints can’t be filed unless approved by a board of medical professionals. The proper use of TPA should never lead to litigation – bleeding or otherwise, if the risks of using it are described to the patient, or the patient’s family if the patient is incapacitated.  In many situations, TPA is the patient’s only hope of salvaging some brain tissue.

But this isn’t how things work in this country. A person can sue for any reason – rational or not, understandable or not. Fortunately for me, family docs don’t often use TPA. Use of the drug is left to ER docs and neurologists. With this kind of involvement of the un-trained legal profession in the medical world however, more and more docs of all specialties are taking a hard look at that 100th patient who could use TPA. Statistically, the lawsuit is virtually assured.