Hope For Two People

HOPE FOR TWO PEOPLE

 “The quality of mercy is not strained;

 It droppeth as the gentle rain from heaven  

Upon the place beneath. It is twice blest; 

It blesseth him that gives and him that takes” 

                   -William Shakespeare, the Merchant of Venice 

It seems odd that I can’t remember her name. When you, quite literally, save someone’s life, shouldn’t you remember her name? 

Or, possibly, I never actually knew her name. One of the nurses must have shared it with me, but I was probably too tired that night for remembering names. I had been part of the humanitarian relief effort in Haiti for about two months then, in the chaotic aftermath of the massive earthquake that razed entire cities and villages. I was stationed at L’Hopital Albert Schweitzer, in the village of Deschapelles, where cholera had broken out on the island’s northern peninsula in the valley of the Artibonite River. In the tiny hospital built in 1956 by Larry Mellon, a scion of the Mellon family of Pittsburgh and his wife, Gwen, our makeshift team of doctors and nurses had become progressively overwhelmed by an unrelenting influx of people who were critically ill.

In over 30 years as a physician working primarily in Boston’s teaching hospitals I had seen a vast spectrum of human afflictions, but I had never witnessed anything like the cholera epidemic that raged around Deschapelles. Scores of villagers near death were arriving on the rusted beds of mud-caked pickup trucks, on the backs of slumping donkeys and even carried like sacks of sugar cane on the shoulders of family members. Our understaffed medical team consisted of a few Haitian doctors and volunteer physicians and nurses from the United States, Switzerland and Poland. After every bed in the hospital was filled we were treating incoming patients in the sweltering heat of the hospital’s outdoor foyer, using army cots hastily assembled in erratic rows under a huge mango tree. 

On a cracked terra-cotta wall near the tree was a crude plaque that expressed the fundamental ethos of Dr. Schweitzer and had been adopted as the hospital’s motto: Reverans pou lavi (Reverence for Life). 

As an internist at Massachusetts General Hospital I had volunteered years earlier to be a member of the hospital’s Global Disaster Response Team. But the humanitarian effort in Haiti was my first actual “deployment” overseas and, before leaving Boston, veterans of the team warned me that it would be a shocking initiation. Three decades earlier, I had studied epidemiology as a graduate student at the Harvard School of Public Health, but this would be my first exposure to a real disaster. On the flight from Boston to Port au Prince I seriously doubted that the fading classroom knowledge from so long ago could possibly have prepared me for the apocalypse I was about to enter.

In a kind of dissociated state, I spent several weeks in the wretched refugee camps of Port au Prince. It didn’t take long to realize that the modern medical care I participated in at home was of little use in Haiti. There was no laboratory to process blood samples and cultures, no MRI scanner and no specialists with whom to discuss puzzling cases. The main clinic where I worked—a huge windblown tent— had actually sprouted on the foul surface of a toxic waste site. Feral piglets rummaged near the dirt entrance and the surrounding squalor was startling.  My naive hope that a well-meaning foreign volunteer could make a dent in the desperate misery of Haiti was quickly fading. In the morbid camps of Port au Prince I wondered if I had stumbled into a hellhole that was truly without hope, a place abandoned by God and man.  

In communicating with colleagues at home I found it hard to describe that place. Understanding it was visceral. You needed to actually smell the stench of festering garbage and overflowing latrines. You needed to see the crumpled buildings that encased corpses. You needed to hear the creole rap music that throbbed from dilapidated taxis. You needed to meet the hollow eyes of emaciated souls, likely suffering from AIDS and TB, slumped on benches outside shanty towns of rusting tin huts. 

But there was something else you needed to experience—the laughter of children. Even though many of them were naked and innocently playing in the filthy water of sewage culverts.

Their laughter floated above the country’s ravaged surface like a psalm of hope. Somehow, within Haiti’s abject wretchedness, life was  surviving. The vibrant hibiscus and bougainvillea bushes were still alive and the children were still able to laugh. I took photographs each day of the beautiful faces I saw. Looking at the images later, I saw a strange dichotomy of despair and hope. 

In the spectrum of life-threatening diseases, cholera is relatively easy to treat. The cholera bacteria are ingested in contaminated water (in this case from the Artibonite River which provided the area’s water supply) and produce progressive diarrhea and vomiting. The disease typically clears in a few days, even without antibiotics, as long as an adequate amount of the lost fluid is replaced. Gatorade, or any fluid with some sugar and salt, works well in early cases in which the patient is well enough to drink. Patients who receive fluid rapidly enough by mouth, or intravenously, generally survive. But if the patients live far away or if they wait too long to come in, they can die of “circulatory collapse.” Simply put, they no longer have enough fluid in their bloodstream to maintain the blood pressure that is needed to bring oxygen to the heart, brain, kidneys and the rest of the body. 

Many residents of the Artibonite Valley held voodoo beliefs. One was that an illness like cholera was the result of a curse, not an infectious disease. Herbal remedies and “faith healing” were typically offered to them by “houngans” (priests) or “manbos” (priestesses). The individuals sick with cholera were, in some cases, hesitant or embarrassed to seek health from “western medicine.” By the time they did, it was often too late.

Before I arrived at L’Hopital Albert Schweitzer I had never seen a case of cholera, let alone managed a major outbreak of a virulently contagious disease. Shortly after my arrival I was joined by an unassuming senior pediatrician from Switzerland who spoke perfect english. To our mutual amazement, we found ourselves essentially in charge. Two American doctors who were at the hospital when we arrived were thoroughly burned out and were gone within 24 hours. The challenge facing my Swiss colleague and me was not only treating the sick, but devising strategies to prevent spread of the disease to everyone else around the hospital campus. Three earnest young interns showed up from Poland, eager to help, along with a small group of benevolent volunteer nurses from the US. A number of hardened Haitian nurses on the staff of the hospital completed our improvised cholera team.

We quickly learned to look for the simple clues that cholera patients were becoming dangerously dehydrated. They were in trouble if their eyes appeared sunken, their pulses were weak or their skin had lost its elasticity. At that stage of the disease cholera was a medical emergency. One of us needed to find a way to get fluid back into the patient’s bloodstream or bone marrow quickly. Or they would die. 

By the time I was transferred from Port au Prince to help with the cholera outbreak in Deschapelles, there was about a month left in the commitment I had made to MGH and the international relief agency sponsoring us, Project Hope. Port au Prince had been deemed too dangerous for us due to kidnappings and, by that time, every instinct in my body was telling me to just go home, back to a place of safety, clean water and freedom from despair. What possible difference was my presence in Haiti making, anyway? But having been taught from childhood to honor commitments, I knew I would stay. Working up to 20 hours a day under harsh conditions, I wasn’t at all sure I that I could make it. I found a calendar and began to check off the days until I could leave Deschapelles with my honor and self esteem intact. 

After about three weeks of battling cholera around the clock, with a week left in my deployment, I was nearing exhaustion or, perhaps, beyond it. I saw no humor in my dormitory circumstances: six roommates in a tiny hospital room who snored like cartoon ducks. One night I found a huge industrial fan and turned it on next to the loudest of them. My life was reduced to a numb, mechanical cycle: Sleep for a while, put on scrubs, count the new patients, try to start IVs, ration the few remaining antibiotics, eat some beans and rice, give heartbreaking news to another family, try to sleep again. I was suffering burnout and knew it. I was too depleted physically, mentally and emotionally to feel much empathy for my patients or their families. I just wanted to go home. 

At supper in our modest dining area, Jarek, one the three Polish interns, a bespeckled, serious young man, burst breathlessly into the little kitchen and asked if I would go back to the clinic with him to help resuscitate a woman in dire distress. Neither he nor the skilled Haitian and American nurses had been able to get an IV line into her collapsed veins. Her blood pressure was dropping and she was about to die. 

Together we pushed our way through the familiar horde of beggars that perpetually loitered around our quarters and sprinted across the100 yards of gravel that separated our dining area from the clinic building. Rushing into the bleak concrete ward that reeked of vomit I saw Jarek’s patient at the end of a line of cots. She looked to be about 40 years old. She was surrounded by family members who were weeping and chanting in creole. I knelt at her right side on the rough concrete floor and felt for a pulse. Nothing. I put my ear close to her mouth listening for even a faint breath. Nothing. She was pulseless and not breathing. By definition, she was dead. 

The family gazed at me with pleading looks of desperation. The nurses, too, were staring at me, their eyes challenging me to do something. Jarek and his fellow Polish intern, Luka, were scrutinizing me, hoping to follow some heroic order that could change the inevitable outcome. 

I knelt on the foul floor in my filthy green scrubs and felt all those eyes riveted on me. Nothing in my training prepared me for a moment like this. I was a primary care internist, not a trauma surgeon, not a doctor trained in emergency procedures. There was nothing that I could do. 

But the desperate eyes remained fixed on mine, beseeching me to do something. I realized that, even if it was essentially a sham, I needed to make an attempt of some kind, if only to demonstrate to the family, the nurses and the interns that no heroic measure, no last resort, no matter how sure to fail, had been neglected.  

I asked Jarek for a large bore IV needle and catheter. To gain access to the patient’s bloodstream I decided to attempt a “femoral stick,” placing a plastic catheter tube through a puncture in the groin into the large vein that drains blood from the leg. I had never done this myself and only seen it, once or twice, decades before, during my residency training in the emergency room at MGH. Even there, in far more experienced hands, I recalled that the procedure was rarely successful. The “femoral stick” is accomplished by entering the skin with a large needle a centimeter or so inside the pulse from the femoral artery which courses through the groin on its path to the leg. Once the needle is positioned in the vein, a catheter is then threaded into the vessel by carefully sliding it around the needle. 

The woman on the cot, however, had no femoral pulse at all to serve as a landmark for me. There was no realistic possibility that the procedure could work, but, at least, I could look at the family and say we had tried everything possible. The weeping and chanting continued as I pushed the large needle blindly into the place in the patient’s groin where I hoped the femoral vein might be.  

A fraction of a second later—to my astonishment—a vigorous pulse of blood flowed back into the catheter around the needle, indicating that  the IV line had been successfully placed in the patient’s right femoral vein. 

Daring not to move even a millimeter, despite aching in my knees on the concrete floor, I directed Luka to attach a liter bag of IV fluid via a tube into the catheter I was pinching precariously between my right thumb and index finger. I watched in awe as the fluid passed easily into the catheterized vein and ordered Luka to run the fluid “wide open,” allowing the full liter to empty into the patient’s circulation in seconds. 

And yet our patient did not breathe. She had no discernible heartbeat. Without daring to move from my frozen position on the clinic floor I told Luka to attach a second liter of saline and push it into the tube even faster, literally squeezing the bag with his hands. And the same with a third liter. 

No response. 

We were simply too late. As Luka attached a fourth bag of saline to the IV tubing, I looked up wearily toward the head of the cot, searching for the words to tell the family that it was time to stop.  

At that exact moment the patient opened her eyes. 

She look wildly around the room with a bewildered expression. She coughed. She was clearly breathing. A nurse announced that there was a pulse in her left arm.

I knelt on the floor for another two or three minutes as Luka continued to manage additional bags of IV saline, finally slowing the infusion down to a slow drip. We taped my IV carefully in place in the patient’s groin and I stood up for the first time in six or seven minutes, my shins scraped and my knees stiff and aching. Tears of joy were flowing all around the cot. The patient’s family probably thought that this miraculous little trick was something that I did quite routinely. 

I tried to hide the fact that I was the most stunned person in the room.

Walking back to the dining area a few minutes later I barely felt my feet touching the ground. Making my way through the pack of beggars, I wanted to hug them. I didn’t know whether to shout, sing or cry. What in the world had just happened? 

I saw our patient the next morning, waiting for her son, a middle school principal, to take her home. For the first time I gazed at her face. She was radiant and beautiful. I was not sure I had ever seen anyone who looked healthier. Her son thanked me and took a picture of the two of us on a bench outside the clinic. Goodbyes were said, and contact information exchanged. But in the crush of new medical crises relentlessly arriving on that beautiful Caribbean morning, the scrap of paper was lost. 

The next day I took a final walk around the hospital campus and took some photos as mementos. There were children playing on the grounds behind the clinic building where families hung the laundry of their loved ones who were patients in the hospital. In that unremarkable area I spotted a small bronze plaque that I hadn’t noticed before. 

You cannot change the world. You can try to give hope to one human being.  

                                                    -Albert Schweitzer

 Two nights later I left Deschapelles. A guarded minibus picked me up at 4:00 AM (traveling by day was still considered dangerous due to robberies and kidnappings on the roads to Port au Prince). I left my clothes and personal items with the beggars along with a few dollars and an old ipod. In the grimy van that took me to the airport on rutted dirt roads I felt intense emotions. Selfishly, I experienced an overwhelming relief that I was finally going home and a nearly euphoric sense of deliverance from the relentless squalor that had haunted me every waking moment for the past three months. 

As we neared the airport, the first weak orange rays of dawn appeared and through the stained windows of the van I discerned shadows beside the road. I looked more closely and realized that the shadows were, in fact, human beings. Scores of people, still homeless three months after the earthquake, were sleeping in the open on the narrow island between the road and the barbed wire fencing around the airport. I knew then that I had not influenced Haiti’s overwhelming misery in any meaningful way.  

During a long wait in the airport I fell asleep. In one dream my own son was a hungry Haitian boy lurking in an alleyway. In another, I clearly saw the vibrant face of the woman we had saved, but her name escaped me. The boarding announcement woke me up and for a moment I wondered where I was. I felt depleted and discouraged, but Schweitzer’s quote echoed in the back of my mind. I found an aisle seat and tried again to understand the meaning of what had happened two nights earlier in the valley of the Artibonite River. Placing that IV in her right femoral vein was pure luck. Wasn’t it? 

On the plane I struggled through my exhaustion to recall another famous aphorism that was resonating with my feelings in those moments. It came to me, in a half dream as I fought to stay awake. It was a passage from the Talmud:  

    Whosoever saves even one human life saves all mankind.

Through a fog of weariness I felt a sudden gratitude unlike anything I had ever experienced. I was grateful that I had chosen a life in medicine, grateful that I was part of an extraordinary institution like MGH and grateful that I had volunteered to join the Global Disaster Response Team, even though the warnings that I had received three months earlier had been spot on. It had been a shocking introduction to global public health. 

As my flight prepared to land in Boston and I soaked in its familiar skyline for the first time in a long while, my heart was full. Wondering about that radiant woman and what would become of her, I whispered to myself:

No, you did not change Haiti. But you stayed. And you gave hope to one human being. 

In the poignant moments as the plane touched down, it was equally clear to me that a patient whose name I could not remember had, in turn, given hope to me.