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Grand Rounds

Making do

By Brian D. Remillard, M.D.

We in medicine spend a lot of time these days complaining. We're stressed by productivity goals, new information systems, changing Medicare policies, and more. Struggling daily with issues like these, we rarely pause to reflect on what we have, on our successes, and on how well we work together as a team. Sometimes it takes a major calamity to put things in perspective.

Such an event began about a year ago. On January 12, 2010, a 7.0-magnitude earthquake struck 10 miles west of Port-au-Prince, Haiti. In this country of 10 million people, 250,000 were killed, 300,000 wounded, and more than one million left homeless.

Perhaps it was Haiti's proximity to the U.S. or the date's proximity to the holidays—whatever the reason, I found myself the next day in Dr. John Butterly's office, offering to help. He asked if I could leave the next morning, and within hours I was being vaccinated.

The Grand Rounds essay offers insight or opinion from a member of the Dartmouth medical faculty. Brian Remillard is an associate professor of medicine at DMS, as well as the section chief of nephrology and hypertension and the director of dialysis at DHMC. See here and here in this issue for more on collaborations between Dartmouth and Haiti.

Call: For the next week, my gear sat packed beside my bed. Just when I thought I might not go at all, I received a call from John Butterly at 4:00 a.m. on January 21, asking if I could be on a plane by 11:00 a.m. that morning. Our team in Hinche, Haiti, had patients with renal failure and wanted me to bring everything I would need to perform dialysis. Over the next few hours, I witnessed the amazing skill and expertise of my colleagues as they helped me prepare.

Scott Slogic in respiratory therapy and his team had two duffle bags of equipment ready to go within an hour of my call to them, including a portable device to analyze blood samples and another to give fluids rapidly to patients in shock. Next I met with Ingrid Mroz and the intensive care team. Two hours later, everything I needed to set up a dialysis machine was packed and ready to put on the plane. Many members of the hospital staff helped get those supplies into an ambulance headed to the Lebanon airport, where we loaded the supplies onto a corporate jet donated by General Mills. By 11:00 a.m., we were off the ground.

Hot: When we arrived in Haiti, the door of the jet opened and let in a blast of hot air. Several Haitian members of the Partners in Health team met me with a pickup truck to transfer the supplies. Within minutes I was sweating profusely and already thirsty. I cleaned out the small refrigerator on the jet and passed out cans of soda. That was the last cold drink I would have in Haiti.

Port-au-Prince was in chaos and all the supplies I'd brought were lost for a day. Only after riding around the city for eight hours did I find them—half were in a warehouse and half on the ground behind a government building. We reloaded the truck and were off to Hinche, several hours away on Haiti's central plateau.

We work in an environment with an excess of resources compared to almost every other place in the world.

Once there, I swiftly had to make the transition from the U.S. standard of always having more than enough resources to making do with whatever was at hand—or simply doing without. Successfully completing the first two dialysis treatments ever performed in this part of Haiti—despite unreliable power—was not my biggest challenge. The hospital wards were full beyond capacity. Many patients had open fractures, and some were ill from dehydration and infections. Working without the simple tools we rely on, such as routine vital signs and basic lab tests, hobbled me as an internist. Most interventions weren't recorded on patients' charts, making continuity of care very difficult. Ensuring that patients continued to receive intravenous fluids required returning to each bedside three or four times daily, an effort that needed to be multiplied by 200 patients. After rehydrating a two-year-old to the point where he could take fluid by mouth, I learned that the nursery did not have any baby bottles or sippy cups.

Most of these people could have been saved with a fraction of the resources we take for granted back home. Yet neither our Haitian colleagues nor our patients ever complained; Haitians have endured unimaginable social and environmental challenges for over 200 years. I remember drawing blood from a six-year-old boy. He held his arm still and watched quietly as the needle entered his vein. These are tough people. Haitian physicians know the inadequacies of their clinics and hospitals but do what they can with what they have.

Chaos: I also worked with several Haitian medical students and learned that their medical school was in ruins and their future uncertain. I was struck by their resilience and determination. We made rounds together despite the chaos. The students wanted a lecture on renal failure, so we fit it in at 10:00 p.m. one evening.

Many visiting health-care workers had trouble coping with the constant need for improvisation. But something about living in the Upper Valley must foster that skill, because the Dartmouth teams handled the challenges very well. Our surgeons invented tools for the operating room and traction devices for broken femurs. Our anesthetists came up with new ways to give anesthesia. Our nurses improvised everything from dressings to bladder catheters.

Upon my return on February 1, I noticed that my colleagues and I no longer identified ourselves as being from the College, the Medical School or the Hospital—we were just from Dartmouth. I know all of us who went to Haiti felt privileged. We work in an environment with an excess of resources compared to almost every other place in the world. Our accomplishments are limited mainly by our attitude and determination. From the classroom to the operating room to the boardroom, we have an amazing group of individuals here. Going to Haiti allowed us to realize the power of collaboration.

If you'd like to offer feedback about this article, we'd welcome getting your comments at DartMed@Dartmouth.edu.

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