One Whirlwind of a Day

Day 3: November 2, 2010

We're finally getting to sit down and take a break now at 3am after a whirlwind of a day that started at 7. After morning meeting, making rounds, and orthopaedic clinic, we take care of a 16-year-old boy with a femur fracture. This is an injury that as recently as World War I was triaged into the "too far gone to help out" category when seen in a mass casualty type situation. Nowadays, the standard of care for this type of injury in an adult is an intramedullary rod (titanium or stainless steel) essentially shish-kebabing the pieces together - or at least if you're lucky enough to have been born in a country where they have them available. If you're born in much of the developing world however, you're oftentimes like the hapless French WWI soldier on the battlefield ... essentially SOL. Fortunately, we now have these nails called SIGN nails (Surgical Implant Generation Network) developed by Dr. Lew Zirkle which lets people just about anywhere, even without intraoperative xrays, put them in. He's an orthopaedic surgeon in Richland, WA who uses his personal savings and company donations to set this all up - the nails are free for the international surgeons who use them in places like Vietnam, Afghanistan, Nigeria, and yes Haiti. We have them here at HAH, our temporary home. I'd scrubbed on a few cases when I was volunteering in Uganda but it had been a year, so we email Dr. Zirkle this morning right before the case and within minutes, poof, he's kind enough to email us the technique guide in PDF format. We put Andrea's laptop up on a Mayo stand in the OR and Tom and I refer to it as we do the young gentleman's surgery. Sounds trite but that's truly technology put to good use. Kinda reminds me of the oldster who came into the ER last night who had dislocated his jaw from yawning too widely, and pop! there goes his jaw out of whack. (Don't you hate when that happens?) Now I normally don't do this kind of thing back home, but Jessica (the long-term nurse from Hotlanta) grabs me anyway to go see him because, well, who else is there? I call Lance Svoboda, an OMFS colleague back home at Hennepin County Medical Center, and within minutes he's texting back directions step-by-step on what to do. The last instruction about having to watch your fingers because when you relocate the jaw you might get bitten is a bit disconcerting until I realize this gentleman has no teeth. Thank God for small miracles, eh?

So after we get done with fixing the kid's femur, the poop really hits the fan. I think it's the bad karma I stirred up when I accidentally dropped the "q" word earlier today, as in "We're keeping today's surgery schedule quiet on purpose so we can leave room for emergencies that come in." I mean, come on, isn't that just inviting a bunch of bad stuff to happen? The first couple to hit the ER doors simultaneously are a 25-year-old woman with left acetabular (hip socket) and femur fractures who was riding a motorcycle, and an "old" woman (no one knows how old she is) with an open ("compound") left tibia-fibula fracture whom she hit. They were ambulanced down here from Petit-Goave, about a 4 hour drive away. It takes about an hour for Tom to have the SIGN nail set reprocessed so that gives us time to squeeze in a quick washout of a patient with a nasty foot infection whom Beth admitted from clinic yesterday. He's probably going to lose at least a toe but we figure he deserves at least one try of washing things out and seeing how things go. In the meantime,  people come pouring into into the ER ... a guy with a left hip fracture after falling at work, another with a both bones forearm fracture after being hit by a rock,  another guy riding a motorcycle with another open tibia-fibula fracture, a guy who got shot in the clavicle ... All of them are medically stable for now, except for the woman with the pelvic fracture. We've been up with her all night (it's almost 4 am now as we write this) and she may not make it. Her hemoglobin's 7 (that's low) and we have a pretty good idea most of that blood she's lost is sitting in her pelvis and her left thigh. We don't have a CT scanner here but it's not in her lungs or belly. Unfortunately it's not the kind of pelvic fracture that you can stabilize with an external fixator or a bedsheet tied around her pelvis ... it's the kind that you really can't do anything about, that in the States you'd send off to angiography to see if the radiology whiz kids can embolize (block off) any bleeding arteries, and that if you did squeeze it together with a sheet or external fixator you'd probably do a real good job of pushing her hip joint into her bladder - generally not a good thing. It's frustrating but there's absolutely nothing we can do for her here except stay on top of her fluids and give blood. We give her 4 units of blood. Blood is super hard to come by here in Haiti and even getting 1 unit is an ordeal. There are several other guys laying around in the hospital waiting for surgery because their families have been driving all over tarnation trying to find blood. One of them, a guy upstairs on the ward, just got his blood, 2 units, which we promptly divert to the lady who's dying downstairs with the pelvic fracture. At some point the question arises (I won't say who brought it up but it wasn't me) as to what point you stop diverting blood to a woman who is likely to not make it through the next day, when you could use it to fix up a bunch more people who have been laying around waiting for surgery, delaying things, potentially increasing their risk of dying because their risk of getting a blood clot is going up, and potentially making their surgeries more difficult and dangerous because of the delay ... the ethical issue is there but I think you have prioritize the 25-year-old woman for whom you can increase by even a small amount the chance she might make it.

In the meantime we do have to fix the "old" lady, who's the pedestrian the dying woman just hit on her motorcycle. Whereas on the surgery dry erase board in front of the OR, as well as the scheduling book, everyone else's age is listed ("16yo male, right femur fracture"), everywhere this lady is listed, she's just listed as old. Kind of mean, isn't it? We get done with her SIGN nail for her tibia fracture about midnight and at that point I'd love to keep working all night and fix up at least the motorcycle guy with the open tibia fracture, but we face a revolt by the rest of the team who needs some serious rest. They are used to pacing themselves and having a reasonable schedule even if I and the two med students, Beth and Andrea, are not (I did stay up 60 hours in a row once). We're forced to concede that it is totally reasonable to delay what would normally be urgent, middle-of-the-night kinda surgery back at home so that we can recharge ourselves and do a better job in the morning. After all, Paige is crucial to our game plan of doing a lot of surgery here and we feel bad about stretching her thin. Beth and Andrea spend a few hours updating our patient list and organizing the schedule for tomorrow, even after the crazy day that all of us have just put in - Elinor and Jess, Frank, our team of Andrea, Beth, Jessica, Paige, Tom, and I. We could use an easy day tomorrow, but as we're looking at the surgery list for tomorrow, filled up with the cancelled cases that got pushed back from today due to the emergencies, plus the emergencies that came in tonight that we never got too, we see that we have ten cases on. Well, we knew this could happen, that crappy things could strike this many good people, and this is what we signed up for when we came down here to Haiti. Going to try and grab a few hours of sleep before the poop hits the fan again tomorrow.