Story of Teresa, Haitian patient in Sabana Grande
September, 1997, letter to To Dr. Mary Gootjes in Michigan, from Barbara in South Carolina:
I heard little snippets of the story of the Haitian woman who the surgical team operated on then nearly lost, just as our group from South Carolina was leaving the project at Sabana Grande. Could you fill me in on what happened with Teresa after we left?
Also, did you see the man we sent to the hospital from the clinic that had the grapefruit-sized tumor in his cheek?
From Dr. Mary Gootjes:
I saw the man with the grapefruit size mass on his cheek. It was a large salivary gland tumor with superimposed infection. We cleaned his wound, gave him some antibiotics, and Dan Cantrell gave him some money to try and catch a bus to the capital for the major surgery needed. Our surgical equipment and supplies were way too rudimentary to resect a tumor like that.
We saw an awful lot of unresectable disease during this surgical project. A toddler with huge genital warts around his anus. I gave them some tubes of A & D ointment to help him with passing stool, but he looked terrible. We had several bad machete wounds that were never repaired and now were scarred tight. Mangled hands, sliced up feet. So sad. We really could have used an orthopedic surgeon. But in an operating room with one electrical outlet, high school students serving as scrub techs, an anesthesiologist who couldn't speak English, and minimal supplies, we really couldn't have pulled orthopedic surgery.
About the Haitian woman: It was June 13, l997 and a busy day in the surgery ward of our Sabana Grande Hospital. I say surgery ward with a bit of irony. Our ward consisted of fifteen metal beds crowded side-by-side in a long, narrow, high-ceilinged room. A room with open windows and no screens, variable electricity, and an odorous adjoining toilet room with no running water. But despite these deficiencies, we had spirit. It was a beautiful day, the sun was shining, and our surgery organization system was beginning to click. The ward was a hectic place. At any time we had patients lying in bed waiting for surgery, some immediately recovering from anesthesia, and others staying for several days following a hysterectomy or other major surgery. And all of this run by myself (a former nurse and now recent medical school graduate) and three helpers Melanie Goff, a nursing student, Tanya Hintz, a premed student, and Sara Roelofs, our faithful and invaluable interpreter.
We started the day with immediate needs. We had four patients recovering from total abdominal hysterectomies the day prior, all who needed to be assessed and receive more IV fluids, and six patients to discharge before the next set of patients came for surgery that day.
Dan Cantrell, our trusty general helper, was assigned the task of finding more beds. Dan is a real estate agent from Bellingham, Washington, who even gave the shirt off his back to a man in the clinic one day. He ran endless errands keeping the generator running, running the autoclave, organizing the stockroom, helping us carry patients to and from the operating room (no such thing as wheeled stretchers there!).
We had twenty patients that day and only fifteen beds. The children routinely shared beds in the ward, lying head to foot, but our beds were a bit too narrow to put two adults that way. Sara set about discharging patients with instructions and meds. Tanya tucked in the new patients assigning to beds, and made arm bands and our rudimentary charts. Melanie started the job of endless IV starts prior to surgery. And so our day progressed.
We did nine major cases that day. Of those, three were pediatric cases which truly tasked our staff. The children were our favorite patients repairing a pediatric hernia is truly a life-saving operation and the families were so grateful. But the children required a great deal of care. It was our policy that each child had a helper assigned to them so the children could bond with them and also so the family could learn how to care for their child by watching and helping. Before surgery it was a matter of playing -- blowing bubbles, driving matchbox cars with them and giving away our care packages. The only bad part was when I started their IV and even that passed quickly.
But after surgery was another matter. All of the children came back fully anesthetized -- requiring a helper to manually maintain their airway and occasionally shake the child to remind them to breathe. That plus the inevitable nausea and vomiting that pediatric anesthesia brought required a full-time care taker for several hours after surgery. Our helpers were marvelous. In two days, Melanie, Tanya, and Sara had truly become professionals at recovering children. With Melanie singing to her babies to quiet their Ketamine nightmares, with Sara endlessly coaching the children in Spanish to take their first dose of liquid Tylenol for pain relief. Tanya showing them how to blow bubbles to promote their deep breathing and coughing after surgery, our patients received love and care unequaled to that of care "back home."
In the midst of our busyness, Doug Kelly brought a welcome delivery one hundred bags of IV fluids! What joy and dancing occurred! In order for a patient to have surgery at the Sabana Grande government-operated hospital, they had to bring four things: a sheet or blanket for their bed (we had no linens), drinking water, a family member to care for them during the night when we were not there, and a bag of IV fluids and IV tubing. IV fluids were readily available in the town apothecary shop at a cost of about $2.50 US. And most of our patients did bring fluids. But the hysterectomy and cholecystectomy patients required four to five liters of fluids each, and several of our poorest patients, especially the Haitian cane workers, simply could not afford fluids. Two days prior we had realized our precarious state we had very little extra fluids and soon would have to stop doing surgery if we could not replenish our supply.
I made an announcement at dinner that night, asking if anyone could donate toward IV fluids, and what amazing generosity! Before the meal was over I had hundreds of pesos stuffed in my pockets and I was grinning from ear to ear. As we said often in the hospital those two weeks, God is good! By the next day, we had enough donations to purchase almost one hundred liters of IV fluids. And what a wonderful morning when Doug backed the truck up to the door and filled our supply room.
I remember that day as a long hot memory. I just cannot communicate how hot it was. We wore the same scrubs everyday, because they were soaked with sweat just 2 hours into your workday. I remember dripping sweat onto patients as I leaned over the low beds to take blood pressure and IV's. I remember the endless thirst and that never-ending swirling-head syndrome from standing up too fast when you are too dehydrated. As workers, we had our private supply room with its two coolers full of drinking water. The patients had only their cups of water carried from the scummy cistern in the hospital yard by faithful family members.
The electricity was out that day and along with it our fans so we showed family members how to fan patients using pieces of cardboard and cloth.
One of the early cases of the day was Teresa Fredi, a 28-year-old Haitian woman who desired a tubal ligation. She had already delivered ten children, of which four or five were living, and had no access to contraception.
She was a pleasant young woman, smiling and cooperative. She was one of the few Haitians who actually brought a bag if IV fluids for which we gratefully thanked her. She had no family present and she spoke Creole, but we managed to communicate adequately through gestures and words of Spanish. She came back from surgery around noon and was quite alert.
Her surgery was done under spinal anesthesia so she was numb from the chest down but awake and comfortable. All of the children were recovering at that time as well, each with a helper at their bedside, so at that time I was the only nurse taking care of the remaining 15 patients.
I settled Teresa in, checked her blood pressure and slowed her IV down. She was nauseated, as most of our patients were, so I gave her some anti-nausea medicine in her IV and also loaded her with one of our precious doses of Toradol. The only IV pain medications we had were ten vials of IV Toradol which my church back home had donated, and a couple of vials of Nubain that the anesthesiologist had brought. Thus IV pain medication was a precious commodity. But most of our patients did not require much pain medication. For the majority of patients, a large dose of Ibuprofen or Tylenol right after surgery was plenty for them. We saved our Toradol and Nubain for patients who were nauseated or had major abdominal surgery. Amazingly enough, Toradol and Nubain are rarely used in the States -- they just are not strong enough. Our patients had never had a Tylenol or Motrin in their life. Their pain receptors did not require narcotics for pain relief.
I continued my circling the room. Checking blood pressures, hanging new IV bottles, settling in new patients, and assisting the helpers with the children bed to bed. Carlo, a four-year-old with an umbilical hernia repair; Penelope, an 8-year-old with an inguinal hernia repair; Luiz, Rosa, Cecilia, and Modesto all recovering from abdominal hysterectomies; Edito, a 20-year-old recovering from bilateral hydrocele repairs. The room overflowed with patients, family members, and ever-present curiosity seekers. I completed my circle about 20 minutes later and checked on Teresa. She was resting quietly after her pain medicine but her blood pressure was a bit low. I checked her dressing which was dry and her belly which was soft. I hung another liter of IV fluids. Teresa, like most of our patients, had eaten and drank nothing since the day prior, so I thought she was perhaps a bit dry. Ten minutes later her blood pressure was still in the 90's not terrible for a healthy young person and her exam hadn't changed so I didn't think she was bleeding internally. So I just kept running in IV fluids.
Ten minutes later she was quite restless -- a bad sign in a post-operative patient. But her oxygen level was good (thank God for our precious pulse oximeters donated by another team member!) and she was breathing well. On abdominal exam, her bladder was hugely distended, so I helped her on the bedpan and she calmed down. I can't imagine the need to have to use the "banyo" and not being able to tell anyone because you speak only Creole! But she couldn't use the bathroom, understandable since she had just had spinal anesthesia and now her bladder was distended.
I placed a urinary catheter (hiding under the sheets to do so because we didn't have any screens in our coed patient ward) and had over 2000 cc of urine back. Not good -- most people can hold about 300-400 cc of urine with 500cc as a max. Her blood pressure was even lower and the urine kept flowing out of her. And now she was difficult to arouse.
I started 2 more large IV's and started racing in IV fluids. The whole time praying and thinking my hardest. What could make a healthy patient become hypotensive and lethargic with huge volumes of urine output following surgery? And then I though to check her blood sugar. You have to understand our hospital no such thing as a laboratory here, our pharmacy consisted of two suitcases full of medications that I had brought from home. There was no cardiac monitor, no crash cart, no ICU personnel nothing. It was God, Teresa, and me. We had a blood sugar meter with 10 strips her blood sugar was less than thirty (normal is 70-110). And that was when I knew.
She was in an Addisonian Crisis -- a shortage of steroids in her body. That was all right and good. But now what to do. Somehow we needed to find some steroids to give her. I sent one helper to hunt through the pharmacy, another alerted the OR crew, another prepared to race back to camp to check the medical team's pharmacy. And I just kept hanging more and more IV fluids bag after bag, 4-5 bags per hour, sugar water, salt water, sugar water, salt water.
And then a miracle we found a single vial of injectable steroids. I injected the whole thing into her muscle without ado. But it wasn't enough. And then Dave Clarke, our family practitioner, found a donated vial of Prednisone. One of his patients back home had given it to him as a donation, and he threw it in the corner of his bag. Little did he know that it would save a patient's life.
I crushed up pills and placed a paste on her gums and under her tongue. I put several crushed pills in her rectum hoping the rectal mucosa would absorb some steroids. And we prayed. A worry in Addisonian crisis is potassium levels. Ninety percent have high levels and ten percent have low levels both of which can kill you. Determining that was out of my league. And so I called for help. The medical team was back at camp by this time and we sent a van to collect an internist.
Waldon Garris arrived and brought his calm manner and head full of knowledge.
I can just imagine the scene for his eyes. A room darkened by approaching dusk -- full of patients and family members. And a bed in the very middle. A bed which held a quiet, lethargic Haitian woman. A bed surrounded by IV bags hanging from the walls. A bed surrounded by quiet, praying volunteer medical personnel all wishing they had an ICU, laboratory, and pharmacy at their disposal. Teresa actually looked a bit better at this time. Her blood pressure was better with the IV fluids and she was responding to verbal commands. But her urine continued to flow and her blood sugar remained below thirty. Waldon and I talked and decided that the rest of the team should go back it was a long, hot day and people were tired and needed fluids to rehydrate themselves. And I needed to search the camp pharmacy for any medications I could find.
We arrived back to camp into the normal flurry of activity. I immediately searched the pharmacy for any more IV steroids, potassium, or possibly some IV blood pressure medications. I also grabbed a Washington Manual (a textbook of medicine) and prepared a survival kit of food, water, and flashlight for the long hours ahead. As I hurried the camp quieted. The word had spread of our near-tragedy. The support and advice poured forth as doctors gave their thoughts and ideas. And just before I left again for the hospital Melanie prayed for Teresa. She lifted Teresa's name up and asked for God's healing mercy and strength for Waldon and me as we did our best to care for Teresa. Peace came upon our camp and my fear lessened.
I returned to the hospital and Waldon and I continued our work. I had never spent time at the hospital at night before. Family members took care of patients during the night while we were normally gone so I did not realize the nightly routine. It was beautiful. Family members gave sips of water, fanned family members, walked or carried them to the bathroom, and cared for everyone. Some patients had no caretakers and yet other family members cared for them. They slept two or three people per bed. Some slept under the bed of their family member to be close enough to care for them.
The night always brings difficulty for post-operative patients pain and nausea, fevers and chills, nightmares and restlessness. And the family members dealt with it. They administered pain medicine that we left for them, cleaned the floor after patients vomited or lost their urine on the floor. It was a microcosm of caring and love. Everyone cared for everyone else. Family members showed each other how to empty urine drainage bags and how to hang new IV bottles all things we taught them how to do after surgery but never knew if they understood. In moments of pain parents sung to their children, wives rubbed their husband's backs, grandmothers went bed to bed checking and comforting. Coming from a medical world and society where families are excluded from hospital care "oh call the nurse for that no getting up without the nurse to help you" I was in awe of how medical care could be provided by family members.
The night progressed slowly. Waldon had some sugar gel that we placed on Teresa's gums which finally brought her blood sugar up, after about twenty liters of IV fluids her blood pressure began to stabilize, and her urine output slowed. Her heartbeat became a bit irregular, which told us her potassium was low. Praise God. A low potassium we could fix by administering potassium I found in the camp pharmacy. A high potassium could only be fixed by dialysis which we definitely did not have available to us.
By early morning Teresa was able to take Prednisone by swallowing pills. By the time the sun arose Teresa's eyes were open and she was conversing with us. By 9:00 that morning, she was taking sips of oral fluids and we felt comfortable in leaving her long enough for us to return to camp briefly. In my afternoon and evening checks of her she smiled and gratefully ate the American peanut butter and jelly sandwiches I brought. It took twenty-four hours before Teresa's blood pressure and fluid status allowed her to sit without fainting. But on Tuesday morning four days after her surgery, Teresa Fredi walked out the door of our hospital. God is so good.
Miracles abound. Praise God that donations had provided that endless supply of IV fluids as without them, Teresa would've died. Praise God for that single vial of IV steroids and that bottle of Prednisone that Dave just happened to throw into his suitcase, praise God for providing the blood sugar machine that allowed us to diagnose and treat Teresa. Praise God that the electricity never once went out during our long night sitting at Teresa's bedside, and praise God for healing mercies and for reminding all of us that He is in control, not medicine or medical technology.
From Waldon Garris, III, M.D., (Tennessee):
I went to the DR as part of an "International Medicine" rotation arranged through the Pediatric Department at Vanderbilt University. Every year, Brian Riedel would take two residents to the mission field for a two-week project.
I had always wanted to do some short-term mission work but had never been able to do so before. I applied for the project and was one of the 2 accepted. (Gretchen Wasserstrom was the other.)
I knew a little about MMI from Brian, but was very nervous about the trip. In fact, I had so much anxiety about it I thought about backing out. Most of the fear was from the "unknown." I had visions of us hacking our way through the jungle (snakes and wild animals abounding) to get to these isolated villages. You would not believe all the "survival gear" I brought with me including a rescue blanket, portable saw, compass, Swiss army knife Somehow I guess I didn't really get a good appreciation of the DR before we left for the trip. The only Dominicans I knew were all from Santo Domingo so, they couldn't tell me much about the remote parts of the country. Brian tried to paint the picture but when I heard about mosquito nets and the bateys all I could picture was "the jungle." Gretchen helped to calm me down and kept me from backing out.
Here's what I remember about Teresa. On Friday of the first week of the project, all the way back to camp from the clinic, I was thinking about getting some rest and going to the beach the next morning. I was exhausted after the grueling, emotional week of seeing such need in the bateys.
We had just gotten back to camp when I was going to shoot some hoops before heading to the shower and calling it a week. I was about fifteen minutes into my recreation when the van came back from the hospital. I remember someone calling my name to come quick.
Rawle Jibodh, the Ob/gyn, who spent the first week on the surgery team, met me and told me briefly about a woman with no significant past medical history who had just undergone a simple tubal ligation. However, there were problems immediately after the surgery and several members of the surgical team had stayed behind to help stabilize the woman. Her three biggest problems were severe hypotension (low blood pressure), low blood sugar, and massive urine output. I was told to go to the hospital and see if there was anything that I could do to help take care of this very ill woman. In the States she would have been moved to an intensive care unit with these symptoms!
When I arrived at the hospital I remember being taken inside of a rather plain, dark yellow block building to "the recovery room." This was a large room about twice the size of a school classroom with about 15 beds lined up along the walls. I was taken right to the bed of a woman named Teresa. She was laying there in a white cotton blouse with a dark blue, floral print skirt, and a blue bandanna on her head. She was quietly laying there, with little expression on her face. In broken Spanish, I said, "Hello, my name is Doctor Garris. What is your name?"
She opened her eyes, and weakly said, "Teresa." I remember listening to her heart and lungs and touching both her brow and patting her hand all good things to do when you are a doctor and don't really know what to do. I remember Dave Clarke, a family practice doctor from Ontario, and Craig Cole, the surgeon from Mississippi being at the bedside. We quickly discussed her problems and tried to come up with a reasonable plan for treatment.
We were not really sure what was wrong with her but guessed that she could have an Addisonian crisis (adrenal insufficiency) which can be life threatening and is sometimes unmasked by undergoing a stress like surgery. It presents with hypotension, low blood sugar, and can result in a person going into shock death is possible if it's not treated promptly.
The kicker is we not only had no lab test to confirm the diagnosis, we had only one dose of IV steroids, and some oral Prednisone with which to treat Teresa. The treatment here in the States is high dose IV steroids three times a day. Dave Clarke drew up the precious dose of steroid in a syringe and Mary pushed it into the IV. Then we took stock of the remaining number of Prednisone pills that Dave had brought on the trip for no good reason that he could remember.
I also remember Doug Kelly getting me the only glucose meter that was in the hospital so that I could check her blood sugar. We had only enough strips to check her sugar about 4 times and that was it. Fortunately, I had about 4 tubes of "glucose gel" with me that we could use to help get her blood sugar up if she could swallow. With Doug Kelly as the interpreter, we got Teresa to swallow some of the glucose gel. She seemed to look at me with hope in her eyes. Maybe we would make it.
I offered to stay with Teresa while the surgery team, also exhausted from a week of grueling work in a hot indoor hospital, often with failing electricity (including lights going off during surgery) went back to camp. They offered to bring me back some food in about 2 hours. However, I must say that I have hardly ever felt as isolated as I did when the taillights of the vehicles left the hospital grounds. Here I was, a well trained young physician with limited medicines, no monitors, and a severely limited Spanish vocabulary left to care for this critically ill woman and surrounded by about fifteen other post op patients and their families.
I remember praying extremely hard that God would show me what to do how to take care of Teresa how to figure out what was wrong with her.
I kept a constant eye on her urine output, and the IV fluid, counting drops to set the rate like they did in the days before IV pumps. I made careful notes regarding the time and findings I got each time I checked her blood pressure and urine rate so that I could look for and respond to trends in her response to our limited, make shift therapy. I listened to her heart and lungs. Taking vital signs is always a good thing to do when you are trying to think of what else to do.
I kept repeating my limited Spanish phrases to Teresa. "Teresa. God bless you." She said, "Amen." Thirty minutes later. "Teresa, God bless you." Again, "Amen" came her reply.
When her blood pressure started to come up, I prayed, "Oh Lord, please let the steroids work. Help me to take care of Teresa." Ironically I had had a "great case" of adrenal insufficiency while in my residency at Vanderbilt. I flew to San Francisco to present it for other doctors to learn about. Was this what God was preparing me for?
I knew how to take care of Addisonian crises but in the DR? With no intensive care unit? With no colleagues there with whom to discuss my uncertainties? (Even the phone didn't work.) With no nurses to help? With no monitors? All alone except for God with, a blood pressure cuff, stethoscope, some Prednisone pills, a foley catheter, and some IV fluid. Could Teresa survive? With God yes, all things are possible. If fact, I remember thinking about some of the miraculous healings done by Jesus and he didn't have any of the advantages/equipment that I had at my disposal. And God was the same God. Yes! She could make it.
Time passed. "Teresa, God bless you." This time, a little stronger, "Amen." Before long, it was time to check her sugar still low. Another tube of glucose gel.
Her urine output was starting to slow down to a reasonable rate. "Oh yes, please let Teresa get better." Things quieted down enough that I was able to walk around the ward and see about other patients. "Hello, my name is Doctor Garris. What is your name? I would then say the patient's name and "God bless you."
Looking around the room every bed but one, had at least 2 people in the bed usually a family member to help care for the patient and sometimes a child or two.
I remember a woman patient in the next bed throwing up and being amazed that family members from another family sprang to her aid and cleaned up the patient and the mess on the floor.
I remember the child who had just had a hernia repair and his grandmother sleeping in the same bed. I remember an elderly man with no family there being watched after by others in the room.
I remember being extremely relieved when Doug and Nancy Kelly returned with Mary. At last there would at least be one other medically trained person with whom to discuss plans for treatment. That was a big help. Doug and Nancy bid us farewell but promised to return in a couple of hours to see how we were doing.
The night went much faster after Mary's return. I wolfed down the food she brought, out of site of the patients and their families who had limited food and water.
I remember the husband of one of the patients who arrived at the hospital at about 10:00 in the evening, but who had a motorcycle wreck en route to the hospital. I ended up suturing his arm, which is always a lot of fun for those of us who usually treat people with medicines and rarely get to do much sewing. He was most appreciative.
I remember the patient with the severe infection and discussing with Mary which of the limited supply of antibiotics we had at our disposal would be most likely to help the patient get well.
Eventually, Mary and I decided to "split the night" where we would take turns taking a one-hour nap while the other one stayed up and kept circulating around the room, checking on patients. Mary would sleep first. By this time I was in a groove. This was fun. In fact this was about the most fun I had ever had as a doctor. Lots of thinking about patients no tests, no x-rays, no insurance forms. And, hey, even though we had a limited drug supply it wasn't because some hospital executive had decided that drug A was cheaper than drug B it was because it was all that we had.
I remember thinking we were still better off than doctors and patients were, probably even 35-40 years ago in the States, with our understanding of diseases and our "modern," albeit limited, drugs.
I wouldn't trade this night for anything.
Later, I got my hour of "sleep" on the uncomfortable exam table. Tossing, turning, praying. Teresa was getting better. God was with us. I was remembering why I wanted to be a doctor.
|Wake Up Barbara!
And Help Me Find This Snake!