Night Transport in Port-au-Prince

Jeffrey S. Cook

doi:10.3122/jabfm.2011.03.100233

Abstract

The author leaves a rural clinic in Fort Morgan, CO, to briefly join a medical relief team responding to the Haitian January 2010 earthquake. While transporting an ill newborn, he reflects on similarities between the Haitians’ displacement and resulting vulnerability and that of his patients back home. “Jeff! Jeff! Get up!”Elias’ headlamp pierces the thin tent and catches me in the eyes, blinding me.“There's a sick baby at the hospital they want to transport…they need someone to go.”

I pause. It is February 1, 2010. Elias and I had left our rural community health center in Fort Morgan, CO, the day before to be part of a small medical relief team hastily assembled in the wake of the Haitian earthquake. We gathered that evening in Miami from 4 different states. In the darkness, we took off in an 8-seat, twin-propeller Chieftain, climbing up through heavy clouds and drumming, steady rain. Several hours later, orange and yellow rays sliced through the clouds as dawn broke over the Caribbean. We refueled in Turks and Caicos Island to the north because Haiti's international airport had no jet fuel. We landed in Port-au-Prince and eventually cleared customs and US military checkpoints. We took a jarring ride in an old school bus with broken seats and shredded upholstery to our base camp across from Hopital Adventiste de Diquini.

But we did not come all this way to sleep while Haiti dug itself from the debris. So I fumble around looking for my headlamp, sweating even more in the airless tent as I think about what we might be getting ourselves into.

“We wanted to intubate, but the smallest laryngoscope blade we have is a 3.”

I peer past the tight crowd into the back of the ambulance. “She was born yesterday. There was thick meconium. She started having difficulty breathing tonight.”

Lying on the ambulance bed is a newborn baby. She has been diapered and placed on a thin, white blanket. She is breathing fast, but has good tone and color. A pulse oximeter is reading high eighties.

I exhale.

“We got a line and started some intravenous fluid. The other hospital is only 10 minutes away.”

Elias and I climb into the back of the ambulance. The doors close. We pull out of the ambulance bay and into the dark. The headlights do not work, but there are no other vehicles on the road.

“Just so you know…” An anesthesiologist swings his body around from the front seat. “Just so you know, the back of the ambulance sucks in exhaust from underneath. We transported a ventilated patient earlier tonight and the doctor in the back got carbon monoxide poisoning. He's lying on a cot with a horrible headache. I’m coming to get our equipment back. I’ll keep these windows open to get you some fresh air.”

I look down. The baby is crying, and working hard to breathe. Elias adjusts the oxygen mask and I take stock of our supplies. Some sort of bulky hand-pump vacuum for clearing secretions. A single, small, cuffed endotracheal tube. Five percent dextrose fluid hanging above me. A tongue depressor. Two small-town family doctors in the back and one half-asphyxiated anesthesiologist riding shotgun.

The oximeter is now reading in the low 80s.

“Maybe I can see the cords.” I snap the tongue depressor in half then split one half lengthwise and guide two overlapping pieces into the back of the baby's throat. The ambulance lurches in the dark over potholed roads and around tight corners. I adjust my headlamp.

Fort Morgan rests on the high plains of Colorado's dusty northeast corner. Our center was founded to care for migrant farm workers and the poor. Most of our patients are first-generation immigrants or undocumented workers. Many constantly travel back and forth between their families in Mexico—or further—and their work in the nearby beef plant, fields, and ranches.

I can’t see a thing.

We slowly pull up to a hospital and the anesthesiologist gets out. The baby has stopped crying. Her tone is deteriorating.

“What did they say?”

“They can’t take the baby. Much too sick. They said the best bet is the United Nations compound. It's about an hour away.”

I look at Elias. The ambulance doors close.

“Is that pulse oximeter right?”

It's reading in the 60s. We start bagging the baby. 70s…80s…

Port-au-Prince is motionless that night. A suffocating mugginess envelops everything. Occasional lights illuminate rows of dirty tents made of sheets, tarps, and wood that line the streets. The people are displaced, their homes demolished. They are afraid to go into buildings. They are afraid of being crushed in an aftershock. The ambulance suddenly jerks to one side. The intravenous tubing snaps away from the bag, spilling everywhere. I am coated in dextrose and sweat.

The baby's skin is starting to mottle. The oximeter is not reading correctly and Elias removes it.

We pull up past a gate and weave around barricades.

“This is it,” comes a voice from the front.

The ambulance doors swing open and a tense, young doctor appears. “The primary medical team just left. The replacements won’t arrive until morning. All our beds are full.”

“We’ll stay with the baby and take care of her ourselves,” I hear myself saying. Pleading.

She leaves and shortly returns.

“We are going to lose power at midnight. And there is simply no room. We can’t take one more patient.”

The baby is not moving. She is barely breathing. We have been bagging her for almost an hour.

“Then what, exactly, are we supposed to do?”

The USNS military hospital ship Comfort is anchored in the bay 1 mile offshore. I had seen it when we landed: towering and white in the tropical sun. “We will contact them. They can send somebody to meet you at the harbor.”

“Can you get us some antibiotics? Amp and gent, or claforan, or anything? And can you get some normal saline?”

They find ampicillin. I’m kicking myself for not getting this sooner.

Elias checks the baby's heart rate. It's in the 50s.

We start chest compressions. Elias gives 3 saline boluses in a row and administers the antibiotic. The baby's stomach is taut from all the positive pressure ventilation. Thin, dark fluid is draining from her nose. I make an orogastric tube out of the dextrose intravenous tubing that is now lying on the ambulance floor. The US Navy is really going to enjoy us calling them out at midnight to hand them a dead baby, I think bitterly.

Our clinic back home has a worn, frayed look that is all too common among organizations that share our mission. Daily we strive to keep people healthy enough to work in the harsh conditions their jobs require. Many of the older patients cannot read. Many can barely write their name. They, too, are displaced. Not by an upheaval of earth, but driven by the need to seek work to provide for their families. Our hospital's birthing center has 5 labor and delivery suites. In our cluttered nursery we can intubate babies. We can place umbilical lines. Had this baby been born there we would have flown her to a neonatal intensive care unit in Denver, 40 minutes by helicopter, as soon as her illness became apparent.

I look down.

She flexes her arms.

“Maybe the fluid is doing something.”

The bracing smell of salt and night air rushes in as the ambulance doors open. A small motorboat approaches, rocking in the black water. I get queasy on elevators. I had already vomited 3 or 4 times on the Chieftain. I have just spent the past 2 hours facing backward on a weaving, stifling, diesel-fogged ride from hell. My wife, a flight nurse, laughs at me all the time. There is no way I am getting on a boat.

I watch as Elias gently wraps the baby and climbs onboard. The engine sputters, starts, and they pull away.

The soft breeze feels like it is piercing my very soul.

February 1, 2010.

One night in the world. One baby born into some of the harshest circumstances. One broken city so different from my own farming town. And yet, from its muted cry come the faint echoes of my very patients.

I peer into the night, but they are gone.

Godspeed and God bless, little one.

Acknowledgments

The author would like to acknowledge Jacob Holt, MD (Bristol Regional Medical Center, Bristol, TN); and Jean Neely (University of Southern California, Los Angeles, CA) for their review of the manuscript and editing assistance.