I am awakened at 4:35 am with an urgent call from the Emergency Department. An eleven month old baby has arrived in respiratory distress, and a chest Xray reveals a pneumothorax. Without prompt intervention, he may die.
I'm there in ten minutes, arriving to find a team gathered around the child, who is pale, listless, and fighting to draw air into his lungs by using every muscle in his chest/neck/abdomen. In children, this is called “retracting” and is a very bad sign. I glance at the chest Xray and see that the left lung is nearly collapsed.
“Let’s get a chest tube set up.”
“I need an 18 gauge angiocath.”
I insert the needle between the second and third ribs on the left side, just below the clavicle. As the needle enters the chest cavity, there is a rush of air through the catheter. The child’s breathing immediately eases, and oxygen saturation improves. This is a temporary measure, sufficing to relieve the pressure on the lung until the chest tube can be inserted.
“He’ll need to be transferred to the children’s hospital. We should intubate him first then insert the chest tube.”
The Emergency Physician agrees. We administer medications, perform further Xrays, draw blood, insert a breathing tube, connect it to a ventilator, and insert a chest tube. Within an hour, the Pediatric ICU transport team arrives to take him to the Children’s Hospital in Portland.
FONDE BAPTISTE, HAITI
An eighteen month old baby girl comes to or clinic with her parents. She’s had a cold and cough for several days, hasn’t been eating or sleeping well, and they believe she has worms.
We’re holding the clinic in an unfinished concrete building in this village in the mountains above Port-au-Prince. Two days before, we came up the mountain in a pickup truck, and had to get out and walk several hundred yards five different times while the driver eased the truck over rocks and ruts. The distance is about nine kilometers, but the trip took us over four hours. Locals make the journey on foot or on motorcycles, which can navigate the rocky, rutted terrain more easily than larger conveyances.
There is no medical care available on the mountain, but the community is hoping to change that by building a clinic to provide basic treatment of common problems. We have come to administer what care we can, assess the medical needs of the community, and assist with strategy/planning for the future clinic. We don’t have much in the way of equipment/supplies/medications, but are able to provide diagnosis, relief, advice, and reassurance to many of those who come to see us.
It is a disheartening endeavor. For this team of six Americans, the daily reality of the villagers is appalling. The community is poor, and living conditions are primitive. Lice, scabies, intestinal parasites and malnutrition are endemic. We see children who are shockingly underdeveloped for their age, and who suffer from a host of chronic illnesses related to malnutrition.
The baby girl with a cough is typical: she appears at least six months younger than her stated age. We administer de-worming medication, provide a sample of over-the-counter decongestant, and instruct the parents on the importance of hygiene, clean water, and how to use steam as an aid for cough/cold symptoms.
An hour or so later, they return with the child, who is having a coughing fit. The mother reports the baby started crying and then began to cough. This has happened before, as recently as last night, and usually subsides in a few minutes. I listen to the child’s lungs and determine she is having an asthma attack. I have brought along an inhaler, but they can be difficult to use, even for adults. For children, it is nearly impossible to use an inhaler correctly. We need to add a spacer-- a closed chamber which affixes to the inhaler and has a mouthpiece or mask on the other end, through which the child can breathe the misted medication mixed with air in the chamber.
We do not have a spacer.
Looking around, I see an empty plastic water bottle. By cutting the bottle in half, I create a mask. I connect the mouthpiece of the inhaler to the mouth of the bottle with the finger of a latex glove, then place the mask over the child’s mouth and nose. The mist from the inhaler fills the mask chamber, and as she inhales it, her wheezing subsides. She drifts off to sleep in her mother’s arms for the next hour. When she awakens, she begins to cry and her respiratory distress returns. This time, the inhaler treatment is not helpful. Her breathing becomes more and more labored. We have no further diagnostic or treatment resources, and I advise the parents she needs to go to the hospital in Port-au-Prince as soon as possible. A motorcycle taxi is arranged, but they have no money to pay the driver, nor to pay the hospital once they get there. The team takes up a collection for the trek down the mountain, which will take about an hour and a half. The temperature is dropping as the sun goes down, and the father wants to go home to get a blanket for the baby. Delay is not prudent, so I wrap her in my sweater and the family heads down the mountain on the motorcycle.
The next day is Sunday. We are invited to church, the hub of the community, and there we are informed that the child reached the hospital but died during the night. While the community is saddened, no one is surprised. Children die often there. Two other children had died that week. The parents of the child we treated had lost another child last year.
Two weeks later, I walk through a cemetery in Edinburgh, Scotland. The graves date back to the late 18th century, and many belong to children. There are several family monuments to multiple children. I'm struck by the fact that the death of a child was such a common occurrence back then. It seems so strange in this era of modern Western medicine.
As I stand over the baby boy in Oregon, I see the baby girl in Haiti before me. One child lives, another dies. It’s nothing new, only new to me.