by JILOO SHAH, MD
It was Friday April 20, 2012 and our last day of clinic in the village of Thomazeau, Haiti. The time was roughly 5:30 in the afternoon and I had seen my last patient – a little 3 year old boy with red-orange tinted hair, a murmur, a palpable thrill, and a heart that would, for a lack of better words, jump out of his chest with every beat. Definitely malnutrition, maybe a Tetralogy of Fallot. He was referred to the local clinic for an echocardiogram. I was wandering around the clinic, looking at the remaining inventory to see if any packing could be done that evening. Abby, a fellow fourth year medical student and a great friend, was finishing up with her last patient but was then approached by a group of ten or so locals who wanted to be seen but did not have an intake sheet. For the sake of orderliness, the policy was such that only those with an intake form which listed a chief complaint and vitals were seen. While she and Interpreter Jean were trying to tell them that they could not be seen as the clinic was closed, our clinic manager and expert nurse Kathy asked me if I would be willing to see one more patient who had just fainted.
As I was walking to my station, I saw a young woman wearing a red t-shirt and jeans walking in the same direction with a companion holding on to her left arm. She looked weak and it was easy to tell she was sick. As she sat down, I gathered her intake form, which revealed her to be a 23 y/o woman named Ms. L whose chief complaint was listed as “syncope x3”. Her vitals were BP 101/74, P 133, T 99.2°F. When I asked her what had been going on during the day, she replied that she fainted and had been vomiting, but denied diarrhea. Upon touching her forehead, she felt much warmer than 99.2°F. My first thought was a possible gastroenteritis, with the tachycardia and vomiting suggestive of dehydration that led to syncope. I went to the pharmacy to get oral Zofran, an oral rehydration packet to combine with water, and two antibiotics, azithromycin and a fluoroquinolone. Honestly, I didn’t know what bug I was treating and I didn’t stop to think over the differential diagnosis. Giving an anti-emetic and several antibiotics seemed like a reasonable starting plan. In fact, we would occasionally encounter an unknown skin condition that would be treated with both antibiotic and anti-fungal medication.
While preparing the oral rehydration solution, I knew that intravenous access would be needed sooner or later. For some reason, I had decided to give the oral rehydration a chance. Maybe I was hoping that she would respond to something simple. Maybe I was, oddly enough, afraid to initiate a “drastic” and “invasive” measure such as a saline bolus without discussing it with an attending first, As straightforward as it is in the U.S. – in countless practice and actual scenarios – it seemed more formidable than clicking a button on the Epic software. Maybe, in my mind, I had equated IV hydration with a more severe illness and I was not yet ready to accept that she was that ill. I knew she was sicker than most of the other patients we had seen that week, knew there was a chance her condition could deteriorate further, and knew that no attending was within sight. (As it was Friday afternoon, the doctors with us in Thomazeau had left for Port-au-Prince to fly back home.) I suppose I held onto the hope that only small measures would be needed.
With all medications in hand, I went back to my station. I instructed her to take the Zofran first, then the antibiotics, and then to work on the rehydration solution. The pills went down smoothly. While trying to sip the oral rehydration solution, I was startled to see her struggling to hold her head up and that sucking on the straw took a great deal of effort, with her companion holding the pitcher and straw and encouraging her to drink. Any hope I had that this would be remedied with oral rehydration was dashed. She needed IV access. But more so, I grasped that she was even more lethargic than what I surmised from my first impression. I became more alarmed.
When handing her the pills, I noticed sutures on her left hand, specifically on the left thenar eminence. The prolene sutures seemed to be of a wider diameter than what I expected, based on recollections from my surgery clerkship. They were irregularly spaced with some clustered together at one end. I was curious to hear the story. She had them placed fifteen days prior at an unknown local clinic after getting a nasty cut from broken glass on a dirt ground. I poked around her hand, noting no surrounding erythema but saw an unusual induration around the sutures. She stated she had pain in her left hand and that it had been getting progressively more painful. These sutures should not have been left in place for two weeks. I knew, at the very least, that they had to be removed. But, what if her illness wasn’t from gastroenteritis but rather stemming from her left hand? She is lethargic. She has a fever. Her blood pressure is low-normal but is tachycardic. Isn’t tachycardia one of the first signs of shock? Is she in (compensated) septic shock?! She might very well be in septic shock…
I asked Kathy about starting an IV and getting a suture removal kit. She asked if I would like to start the IV. I replied, “I can, but you’ll probably get it on the first try.” She wasn’t feeling well and I didn’t want to poke around more than necessary. Kathy got the vein on her right arm on the first try and a liter of normal saline was hung. The pole was raised to its highest height, the line was kept wide open, and the bag was occasionally squeezed to speed up the flow A few minutes later, her pulse came down to low 100s. I don’t recall if she was feeling any better at this moment but she wasn’t worse.
While Kathy and I were sitting with and monitoring her, she noticed the sutures as well. We came back to the idea of removing the sutures, which Kathy volunteered to do. Maybe she thought I wasn’t interested in hands-on procedures or that I’d be queasy. With the forceps and scissors in hand, Kathy started to take out the sutures. We were both surprised to see it was not a straightforward endeavor. On the end where they were clustered together, it was difficult to distinguish individual sutures and thus difficult to know where to cut. On the other end, the tail of the suture seemed to be hidden and hard to tell if we had removed all of the thread. Most shocking were the remnants of dirt or leaves or paper or plastic or something else that seemed to be enmeshed by the sutures and which came loose when the sutures were removed. Was it that the person who placed the sutures had done a poor job of irrigating the wound? Or was it that, because she continued to use her hand for daily activities, those fragments caught on and were trapped? Kathy felt around the induration and suspected that perhaps it was a remnant of glass, a retained foreign body. We knew she needed to undergo an I&D (incision and debridement). She was my patient and I would be doing the procedure.
Abby and I had the same thought. Before I could say the words, Abby asked me if she should check to see if Dr. P had returned from her away site. As soon-to-graduate medical students, Abby and I were given ample independence to see patients on our own without checking in with one of the doctors, but we were judicious enough to know when we to ask for help. Firstly, a surgical procedure should not go unsupervised by a doctor, especially given my limited surgical abilities. Secondly, the patient was truly ill and another opinion – especially one more experienced than mine – was more than welcome. Abby told me that Ms. L was my patient and that she would help with whatever I needed. She went upstairs tofind Dr. P and returned a few minutes later with her.
Apparently when Abby had gone to find Dr. P, a fellow member, John, had overheard the conversation and decided he would come down to perform the procedure. This would be a good point to introduce him. He is currently an EMT training to be a paramedic, consequently his strength lies in stabilizing a patient but is not as well-versed in ongoing management. He was unwilling to accept a more restricted role of what he could practice due to his limited medical training. Nonetheless, he did care for patients.I had not realized until the next day that John had decided to come down to take over the care of the patient but was turned away by his mother who was in the clinic as well.
Dr. P agreed that an I&D should be done to explore for a retained foreign body. She also confirmed that I would be doing the I&D and she would supervise. She instructed us to spread EMLA cream over the wound for 30 minutes prior to starting. At around 6:30 pm, the EMLA cream was applied and then loosely covered with a latex glove to keep it moist. Kathy also administered 1g IV ceftriaxone.
I had thirty minutes to gather supplies and collect my thoughts. Honestly, I was both nervous and excited about doing the procedure. I loved doing anything hands-on in medical school, especially during my emergency medicine rotation in Green Bay where I would get to suture any wound that came in and put in dental and digital nerve blocks. On my first day of clinic in Thomazeau, I even drained a breast seroma without supervision and I wasn’t nervous then. I think that some of the anxiety stemmed from knowing that she was acutely ill and having a general worry about the situation going from bad to worse.
Perhaps some of the anxiety also came from the environment it would be performed in. Two nights prior, a gentleman in his 50s or 60s came to the clinic with severe phimosis (swelling of the foreskin) and inability to urinate. Late at night, around 10 or 11pm, the doctors had performed an emergency circumcision under a dorsal penile nerve block as Abby and I watched. The most striking memory I have is of him vomiting throughout the procedure, obviously from the pain. As I thought about this, I wondered how much pain Ms. L would be in and whether or not she would vomit during the I&D.
It was getting closer to 7pm. Sterile drapes? Check. Gloves? Check. Povidone-iodine? Check. 4x4s? Check. Scalpel and forceps? Check. Saline? Check. Needles? Check. Lidocaine? Check. My strategy in moments when I am panicked or anxious is to make a list and check off items. It worked fairly well in this situation. Though still nervous, I calmed myself down further by visualizing the beginning steps – sterilize with outward circular motions, drape, incise with a smooth stroke. I was less nervous and more ready to start.
We first moved her from her chair to an old, wooden examining table that has one end that can be raised at Abby’s station. After three comical attempts, I finally put on my gloves. Abby brought a headlamp that went on my forehead. Though it was only after 7pm, it appeared to be much darker – probably because the door was shut and the windows did not provide much light. Her left hand was prepped and then a sterile drape was placed. Abby was the circulating nurse and holder of a flashlight. Dr. P was acting as the scrub nurse. Taking a 3 cc syringe of lidocaine, I injected it into the open wound.
I took the scalpel and made a shallow, roughly 3 cm long incision. With forceps, I felt around for a possible retained foreign body and found none. Dr. P instructed me to incise deeper. What would I be cutting through? Would I injure any essential structures? I had forgotten much of the anatomy of the hand after the first year of medical school. I just hoped to not sever any tendons in the process. I did not know how much deeper I should incise nor do I know how much deeper I truly incised. Picking up the forceps again, I searched around some more to find numerous sizable pieces of clotted blood. I was able to take some of them out with the forceps. As Dr. P suggested, I Irrigated and massaged around incision to remove small pieces of hematoma left behind. After massaging and irrigating three times, I palpated again to feel for any induration or irregularity suggestive of hematoma and was satisfied with finding no more. Per Dr. P’s suggestion, a long strip of Telfa was cut and with forceps pushed into the evacuated cavity to use as a drain for the night. The incision was left open, with the goal of healing by secondary intention. Her left hand was wrapped in gauze, sharps were disposed of, and the surgical field was cleared. If a post-op note were to be written, I suppose the record would show that she likely had cut an artery with the glass, which was stitched up while the bleeding was ongoing. This resulted in a hematoma that likely became a nidus for an infection.
After the procedure was finished, I looked at her to find her profusely sweating, body shaking, and teeth chattering. A first set of vitals showed BP 156/78, tachycardic, and visibly tachypneic with respirations likely in the 30s. She felt quite warm to the touch, much warmer than the thermometer reading that we decided was not accurate. We gave acetaminophen to bring down the fever. She urinated in a pink basin; it was unmeasured but she definitely voided several hundred cc’s. At the very least, it was good to know she had adequate organ perfusion. We crafted a pillow out of a pack of fabric diapers and found a white bedsheet to use as a blanket. At some point, John showed up and volunteered to watch her and take regular vital signs. She was about as stable and comfortable as we could make her and so we left her with John, Interpreter Jean, and her companion while Abby and I went upstairs to grab dinner (the second floor of the social hall was where we slept and ate).
Abby and I scooped out food – plantains, boiled potatoes, rice and beans – and beverages for the patient, her companion, and Interpreter Jean and brought these down to the clinic. She sat up and began to eat her dinner. John acknowledged that he was quite concerned about her fever. While Abby and I contended that we should give some time for the acetaminophen to kick in before getting worried, we knew he would not be satisfied with this decision. Therefore, we went to find Dr. P and told her, “John is concerned about the patient’s temperature and would like to talk to you.” I walked down with Dr. P to hear John’s concerns. The details of the conversation are lost on me but the plan was to continue to monitor. What I do vividly remember is the conversation ending with John boastfully exclaiming to Dr. P, “you are my attending and I want to report directly to you!” Dr. P calmly replied, “you can report to me but she’s Eshana’s patient and you have to report to her as well.” I knew those words didn’t register with John, but I was incredibly appreciative that Dr. P let it be known that she was my patient and I would play a role in making decisions. Dr. P and I headed upstairs and I attempted to eat my dinner.
I’m not sure how much time had elapsed – perhaps ten or so minutes gauged on the fact that I probably had a few bites of my dinner – before John had run from the clinic to the second floor shouting, “she’s crashing!” as Abby recalled. What I remember is Dr. P sauntering over to me and motioning with her index finger to come back down to the clinic. She and I walked down the steps while John hurriedly moved in front of us, all the while continuing to exclaim, “she’s crashing!” John’s latest set of vitals showed a BP was 80s/30s. We arrived to see a patient who was alert, talking, and moving spontaneously. A repeat measurement confirmed a BP of 80s/30s. (She was most likely on her fourth liter of normal saline.) She continued to shiver, sweat and was febrile – we are not sure of her exact temperature as the thermometer never registered over 100°F while, without a doubt, it was higher than that. I asked her if she could tell me her name, where she was, and what had happened earlier; she replied appropriately to all three questions. Abby checked pedal pulses and found them to be bounding. Her radial pulses were also strong. Her pulse was around 100. It was a complete surprise to see that her blood pressure had nosedived but she was clinically stable – except for the persistent fever. By now, the time was perhaps somewhere between 9 – 10pm. We hadn’t given ibuprofen so we administered a dose to help her temperature come down. However, John had grave concerns that Ms. L could have a seizure at any moment and wanted to begin active cooling. I did not believe she was in any such danger and Abby concurred. However, knowing we had to pick our battles with John, cooling the patient seemed quite harmless despite being unnecessary. We let him actively cool her by putting cold, wet towels on her forehead, under her armpits and between her thighs.
While this fuss was ongoing, we ran into Dr. J, who would be our attending for the coming week in remote, rural Haiti. He had just arrived in Haiti and had been partially debriefed on the situation. Though Dr. J and Dr. P both seemed to be comfortable caring for her, an impromptu conference happened around her bed stemming from others’ concerns about her vital signs. (Meanwhile, Dr. J gave us another thermometer and her temperature read as 102.5°F.) Participants included me, Abby, John, Dr. J, Dr. P, a Haitian doctor who helped us out in Thomazeau, Fr. Larry, and several others. The discussion focused on whether or not it would be best for her to stay overnight in our clinic or be transferred to a nearby hospital. Logistically, if a hospital were to take her, it would require at least several hours to initiate and complete the transfer. It was also questionable what care they would provide that would be beyond our capabilities. Dr. J was uncertain if she would benefit from being transferred out of our care. The Haitian doctor believed that she should be transferred, to which John chimed in, “yes, you are my man! We’re on the same team!” I stood there in disbelief at his statement. This wasn’t about taking sides and being on opposing teams. It was about working together to come up with the best possible solution, with her health being of prime importance. I remained silent, except when clarification was needed on factual information. Throughout medical school, I would become quiet when more senior figures talked. This situation was no different and I reverted back to that version of myself. Despite the lack of experience to have formed an objective opinion, I didn’t want to let go of my patient unless it was in her best interest.
Eventually it was decided that she would remain with us for the night; we had agreed to take shifts watching over her. I would take the first shift – 11 pm to 12:30 am, Abby would take the second shift until 2 am, then Dr. J until 3:30am, John to 5:00 am, and finally pre-med Joe would take the last shift, ending at 6:30am. We also agreed on a medication schedule of a dose of acetaminophen around 1 am and 2g of ceftriaxone an hour later.
As everyone left, Ms. L, her companion, and I remained. It was pitch black (the generator was turned off sometime between 10 and 11pm), except for the headlamp and flashlight. It was quiet, except for the occasional sound of a motorcycle. She was tired and sleepy but would move to reposition herself on the table. Her companion sat on an adjacent examining table. I had my headlamp on and spent a few minutes gathering and organizing the supplies needed for the night on a wooden bench – our last 2 vials of ceftriaxone and syringes and flushes, several bags of normal saline, acetaminophen and ibuprofen, thermometer, blood pressure cuff, and a stethoscope.
At 11:15pm, I took the first set of vitals: BP 66/28, P 110 and bounding, T 102°F. I remained half puzzled, half panicked. What made it even more worrisome is that her pulse had slightly risen to 110 from 100. I had done a critical care rotation for my sub-internship and I don’t recall seeing a patient with a BP of 66/28, especially not one who was breathing without a ventilator and without a central venous and arterial line in place. Yet, here was a woman with a mean arterial pressure around 40 without any mental status changes. In fact, she would help me with taking vitals by lowering or raising her arm or opening her mouth in anticipation of a cuff or thermometer.
Was she on the verge of a hemodynamic collapse? From the moment I had laid eyes on her six hours prior, a fear that the situation would take a turn for the worse had simmered in the recesses of my mind. In medical school, we were taught that young individuals generally tend to be relatively hemodynamically stable until the very end, but then rapidly deteriorate. Was something really bad about to happen? She was tachycardic and severely hypotensive. How could that be, given she was on her 6th liter of normal saline? I doubted she had a source of internal bleeding. Was it possible to be in florid septic shock and remain fully lucid? I didn’t have enough experience to know the answer.
Everything seemed unsettling and strange. The setting – being in a town social hall with the patient sleeping on a wooden examining table with no electricity. The resources available – limited supplies of medications, unable to draw labs, or order imaging or invasive monitoring lines. And most importantly, my responsibilities – never before had I had as much involvement in a patient’s care, never before had it been my choice to try to handle it alone or turn to an attending for advice. Without any labs or tests, my decision could only be based on her clinical picture and from her vital signs. Here I was in the middle of the night in unfamiliar territory, unsure of how to proceed.
Weren’t we always told in medical school to look at the patient before us? Treat the patient, not the vitals. She looked the most comfortable I had seen her. I admit it was hard to ignore the vital signs. A BP of 66/28 is downright frightening in any situation. While her BP was low, it didn’t appear to have any effect on her. I took a leap of faith and told myself to treat the patient with the caveat that if she became more hypotensive, more tachycardic, or showed visible signs of distress, I would find an attending.
I moved a folding chair close to her makeshift bed and placed the flashlight up on the chair so that it would illuminate her face and chest. I wanted to monitor for any signs of discomfort on her facial expression or respiratory distress. I sat in my folding chair watching her breathe and sleep. Her companion sat on an adjacent table, restlessly alternating between watching her and trying to sleep. One time, he came over to look at the hung saline bag, flashed his penlight to see how much remained – about a quarter full – and motioned toward me to see if it needed to be changed. I told him, “byen,” doing my best to tell him that it didn’t need to be changed. Another time, I had forgotten to fully cover her feet after taking vitals and he came over to adjust the blanket. I couldn’t help but smile at these small gestures that demonstrated his dedication and concern for her well-being. I wished I had an interpreter around to converse with him.
At 12:30 am, Abby walked down to start her shift. John had also come with her, claiming he couldn’t sleep and wanted to look after the patient. I debriefed Abby on the rest of my shift. I took vitals every half hour. Her BP continued to be 60s/20s. Her pulse remained 106 – 110. The best news is that she defervesced, from 102°F to a perfect 98.6°F on the last measurement at 12:15am. I explained my logic on continuing to monitor, and Abby agreed that the vitals should be taken less seriously given she was clinically stable. Then I went to bed.
At 4am, Abby woke me up and we found a quiet spot on the steps leading up to the roof to discuss the rest of the night. She had stayed up this entire time. She had sent John to find Dr. J for his shift but wasn’t able to locate him and she did not feel comfortable leaving the patient with him. Ms. L was resting comfortably, remained afebrile and her BP continued to be 60s/20s. Abby gave her 1g of ceftriaxone (rather than the scheduled 2g) because she was looking better. Acetaminophen wasn’t given because she didn’t spike a fever.
At 5:30am, I went down to the clinic to find Joe, Interpreter Paul, and John watching over the patient. I skimmed the notepad that charted events for the night. Her vitals had remained unchanged. So had her level of comfort and mental status. After exchanging a few words, John left. Paul, Joe, and I sat there watching her trying to sleep and we quietly chatted, getting to know each other. She likely woke up sometime around 7am, appearing rested and indescribably better.
One detail left out is that at the discussion the prior night, Dr. J broadened the differential diagnosis to include malaria and dengue fever. Given the rapid onset of her fever and subsequent defervescence, malaria was not out of the realm of possibilities. We decided it would be best to treat her for malaria as well. Abby removed the gauze, removed the Telfa drain, and dressed again her left hand. She was given instructions along with a stash of dressing supplies and gloves to wear while doing daily chores. I got 500 gourdes, roughly $12 USD, from Father Larry to give her for travel back to Port-au-Prince by a tap tap. Around 11am, Ms. L and her companion walked out of the Thomazeau clinic.
ABOUT THE AUTHOR
Dr. Jiloo is a resident in internal medicine. She completed undergraduate studies in biology (with a specialization in immunology) at the University of Chicago. She also has research experience in protein signal transduction. She plans to pursue a career in hematology/oncology. She says, “this story that has its happy ending because of the efforts of everyone involved. I am incredibly grateful that they were confident in my clinical decision making and were willing to let me take the lead, yet became more involved when they knew it was beyond my level of training.”
Dr. Abby is a pediatrics resident. She and Jiloo are fellow colleagues from medical school who share a passion in global health.