A resident's report from the field

By Michelle Morse

Dr. Michelle Morse is a Global Health Equity resident at Brigham and Women's Hospital who is currently working with PIH in Haiti. Last week, she traveled to St. Marc to help with PIH's efforts to treat and control the cholera outbreak. She wrote the following piece about her experience.

	Patients receiving treatment at the hospital in St. Marc. Photo courtesy of David Darg, Operation Blessing International.

The trip from Cange to St. Marc on Thursday, October 21st was filled with uncertainty about the magnitude of the diarrhea outbreak, the potential number of people affected, and speculation about the causative agent. I traveled with Cate Oswald (PIH's Program Manager for Psychosocial Support and Mental Health in Haiti) who would be managing the community response to the epidemic, and Dr. Merly Robert, an internal medicine resident from the General Hospital in Port-au-Prince (HUEH) who was doing a rotation at Cange when the outbreak began. We all had our theories, but cholera certainly was not at the top of the list.

We pulled into Hopital St. Nicholas in St. Marc just as rain began to fall. The courtyard was filled with people and there were rows of tents with patients crammed into every inch of space, mostly on the ground lying on blankets and plastic. There were few obvious medical personnel, and many empty bags of IV fluids attached to clearly dehydrated patients.

We walked upstairs to the Zanmi Lasante office to get updates from PIH's Dr. Koji Nakashima who had been at the hospital since the outbreak started. The CDC had several samples for testing, but we still didn’t have a diagnosis.  The clinical teams already at work were stretched thin, and they really needed extra hands. We made our way to the wards, and it was clear that the influx of over 500 patients within 24 hours had overwhelmed the hospital’s capacity. Nurses were hard at work changing IV fluids and putting in IVs, but everyone had a certain shell-shocked frown upon their faces, perhaps most apparent on the faces of family members of patients.

The first patient I cared for was a young man in his 20s. I could not measure a blood pressure.  We started two IVs and asked the patient’s mom to squeeze the bag of fluids since we had no pressure bags or IV pumps. We got a stool sample from the patient, and it was clearly “rice water” diarrhea, a characteristic unique to cholera.

A few hours later, the CDC confirmed that cholera was the cause of the outbreak. The large majority of patients I saw for the rest of the night were also in shock with no blood pressure, no pulse, and severe vomiting and diarrhea, the likes of which I have never seen. Luckily, with IV fluids almost every patient survived the night and I only saw one death.

What I could not forget that night was a 2-year-old boy who I found alone with an empty bag of IV fluids, lying in a puddle. I was told that his parents had died of cholera the night before, and there was nobody there with him. He was doing well and had responded quickly to rehydration. After changing his diaper and having him drink two big cups of Pedialyte, he was off to sleep. The next morning, a family member showed up to take care of him, and I couldn’t have been more relieved.

The second night, I was overjoyed to see that most patients had stabilized. There were still several cases of patients in shock, but many fewer than the night before. There were still not enough hands to do the work, but there were more hands than that first, very difficult night. Nurses from the Port-au-Prince nursing school and from HUEH came to offer their help, and it was beyond inspiring to see their compassion, diligence, and commitment to taking care of the patients despite the obvious risks to their own health. Somehow, we still found time to smile and tell a few jokes. I was honored to be a part of the team.

Bearing witness to this outbreak has been transformative. Every patient that recovers within hours from shock gives me strength. Every nurse that succeeds in placing an impossible IV gives me hope. Every new set of hands that shows up, every kind-hearted, humble volunteer, every health worker that knows the risks and comes anyway, seems like a miracle.

It is the injustice of the circumstances of this outbreak that hurts. The injustice of the ongoing poverty, lack of potable water, lack of access to health care, and weakened public health infrastructure that produces the perfect storm of opportunity for cholera to be this week’s cause of preventable death in Haiti. For this reason, our commitment to improving health in Haiti must be revived and reinvigorated. We are now more than 9 months post-earthquake, and there is no better time than the present to renew our vows.