Life in the time of cholera

Mirebalais Cholera Treatment Center; November 14

Shift 6 at the CTC (Cholera Treatment Center); my team has covered 1600-0800 in two eight hour shifts here at the PIH CTC here in Mirebalais. Set amidst the rolling greenery of the Haitian countryside, this treatment center is hydrating and treating upwards of 150 patients a day, one by one by one.

Cholera spreads through the water, and recent heavy rains from Hurricane Tomas exacerbated the spread of the bacteria. People bathe and drink the water from the river, and campaigns to drink and bathe in "dlo pwop" -clean water- have accelerated across the country. Unknown in Haiti for the past 50 years, cholera is thought to have been brought in by the Nepalese UN contingent, and recently UN forces have been subject to violent riots due to this epidemic. Cholera is already beginning to be stigmatized; we watched the Haitian nurses don masks and caps before entering the cholera tents, and although you cannot catch cholera through the air (or your hair), the lack of education and familiarity with the illness results in this fear.

We show up to work after we bleach our arms and shoes, are given our disposable scrubs (or biohazard suits when we run out of scrubs), booties to cover our shoes, then bleached again, and corralled into the "cholera tent". Our team, 5 nurses and 1 nurse practitioner from Vancouver, 1 logistician, and 2 translators, has worked in this tent nightly for the past 5 nights, treating patients of all ages, from the very young to the very old. The treatment is simple, basic, easy. Almost to the point of being mindless and boring. But the results are immeasurable.

Patients come in close to death, dehydrated beyond belief, limp figures on stretchers or in their parents' arms, having lost all fluid in their body through vomit and diarrhea. We often struggle to find veins, poking them many times before getting a decent line in. The more severe cases we ask the doctors to insert an IV straight into the jugular. And then many liters of fluid later, we discharge them home; alert, eyes open, and looking so much better.

One patient stands out to me. She was admitted at 5:30 in the morning, a lifeless girl of 9 years, skinny and malnourished, and completely limp. We poked and prodded so many times, trying desperately to find a decent vein, failing even her jugular. She lay there completely disinterested and unaware of the pain we were causing her. Eyes rolled back. Reddenned hair: kwashiorkor- sign of malnutrition. No family with her. One leg significantly thinner than the other- "polio?" our Nicaraguan doctor wondered. We are strictly a cholera treatment center, nothing else, a fact that frustrates us often due to the lack of any other resources. No diagnostic tools other than two blood pressure cuffs, the stethoscopes around our necks, and a handful of thermometers. No emergency equipment. The doctor motions for me to get the ambubag. I look at him, eyebrows raised- we have no resuscitation equipment; the last time someone was resuscitated he placed a mask on the 9 month old on and gave mouth to mouth through the vomit. The baby died; no one was able to get a line in. He runs over to the desk and pulls out his own asthma spacer and mask: "we can use this if she needs it". An improvisation. Then, as we continue to poke her, looking desperately for a vein: "Go get the epinephrine. But don't break it [the ampule] yet." Resources are scarce, and we only have a few precious vials of epi. Finally the other doctor gets a line in her jugular, and we all breathe a sigh of relief as we watch her twitch, coming back to life as fluid pours in to her bloodstream. Fifteen minutes later and the line has gone interstitial, which means we have to pull it and start all over. The scramble begins again, and we seem to be losing her again. Climbing over each other and her, we are all trying to find access to her veins. 10 minutes pass and we have another line. Its small- only 24 gauge- but its something.

We watch her closely and after about half an hour she is back with us. She opens her eyes. The Cuban doctor sees this and jumps on it. "Como ou ye?" he asks- How are you? She looks at him, trying to focus. "Huh? Como ou ye?" he repeats. We hold our breaths, wanting a response. She blinks. Then a tiny, almost imperceptable squeak of a voice responds. "Pa pi mal"- not too bad. We laugh and smile at her, and my heart fills with love. Moments from death, but not too bad. Another life saved.