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Combating cholera in Haiti.

When a cholera outbreak erupted in Haiti in October 2010, doctors from around the world responded to the emergency, including Dr. Kwan Kew Lai. In December, the internist spent a week in the island nation, sponsored by Medical Teams International Disaster Response, treating cholera patients of all ages at the Northwest Haiti Christian Mission in St. Louis du Nord.

Dr. Lai is no novice to providing medical relief services overseas. She has worked in Africa treating HIV/AIDS patients as part of the Global Medic Force. Here, she shares her experiences in Haiti.

How did you learn about Medical Teams International Disaster Response?

I found out about the group immediately after the earthquake last year, when I searched the Internet for a team to go to Haiti to help care for patients there. I was asked to go with Partners in Development (PID) as a physician for their response team. MTI required me to formally apply to be on their team. Last April, I was interviewed by phone, and later I was accepted to join their disaster response team.

In October, when the cholera epidemic began in Haiti, MTI contacted team members to go. But I was in West Africa at the time, completing HIV/AIDS mentoring work for the Institute of Human Virology Nigeria, and Global Medic Force, Abuja, Nigeria, so I could not respond immediately. In December, I heard from MTI again, and they asked me to be ready to go in a few days. Our team included sis doctors and a nurse.

Did you have any previous experience in treating cholera?

I had no previous experience in treating cholera patients, except that when I was in South Africa in 2009, near the border of Zimbabwe, I arrived at the end of a cholera outbreak among the refugees. So I did see a few cases in the hospital then.

What steps did the medical team take to avoid becoming ill themselves?

We used a lot of hand sanitizer; there were no sinks at St. Louis du Nord. We were vigilant about cleaning our hands between patients and before meals. MTI provided gloves, but they were used only for starting IVs and in cases when there might be possible contact with body fluids. No masks were required because cholera is spread via the fecal-oral route through contaminated food or water.

What were some of the challenges of treating cholera in Haiti?

There seemed to be a difference in opinion between Haitian doctors and visiting doctors as to how vigorously a dehydrated patient should be resuscitated. The World Health Organization guidelines were posted on the walls and I believe in giving fluids aggressively, but our Haitian counterparts seemed to be more conservative and tended to turn the fluids down. So there was an ongoing battle. Our team would turn up the fluids only to find the fluids turned down shortly thereafter.

The language barrier is an issue, because we did not have an interpreter with us all the time. It was especially difficult to communicate with the Haitian nurses.

The lack of accessibility of clean water continues to be a concern, especially when patients are sent home to unsanitary conditions.

There were also cultural differences. Some Haitians believe in fate. If a patient seemed to them to be dying, they accepted it and thought that it was time for him to go, so there should not be any heroic measures. However, to us, cholera is an extremely treatable condition. Vigorous hydration can generally save a life.

What was your basic treatment strategy for most patients?

Our standard treatment strategy was to do a quick assessment of the patient's state of hydration. Patients with severe dehydration generally received an IV immediately. Patients who were moderately or slightly dehydrated, with no persistent vomiting, were generally encouraged to drink oral rehydration solution (ORS).

The elderly and very young cholera patients are at the greatest risk of dying from extreme dehydration. Patients who arrived at the clinic from long distances, and those who had been ill for several days, were also at increased risk of dying. Lack of clean water plays a major role in the spread of cholera. Malnutrition, which is common in Haiti, certainly does not help the immune system to fight infections. Near Port-au-Prince, we saw people washing their clothes and bathing in dirty river water; we were not at all sure where their drinking water came from.

At St. Louis du Nord, we were lucky to have ample supplies of intravenous fluids provided by MTI and delivered by the United Nations Humanitarian Services. We also had a good supply of clean water.

Space was limited, however, and patients were put on cots and even on the floor. The floor and the cots were constantly being washed with bleach. Patients were provided with basins to use as toilets for their diarrhea, since cholera cots were in short supply and constantly soiled.

What was the setup at the hospital where you worked?

"The cholera treatment area was divided into three areas: the so-called ICU, which held the sickest patients, all of whom were on IVs and encouraged to take ORS; the step-down unit (where patients were taking ORS and had been discharged from the ICU, but who still had diarrhea and some vomiting); and the ready-to-discharge unit (patients on ORS who were ready to be discharged).

"In the units with the less severe cases, patients and their relatives slept on mats on the floor. After the first few days, we were told that the patient count had decreased by half. There were 20 or so patients in this area. In the ICU there were about 25 patients lying on cots, some of which were diarrheal cots, with holes in the center. The ward was surprisingly free from strong stench. Many of the patients had the classic glazed look, with sunken and listless eyes, and were either restless or motionless," she wrote in her blog.

What were some of the specific cases that you managed?

"One day, two men carried a sick woman in on a bed-frame. She had been sick for 5 days with vomiting and diarrhea, and it was rumored that they had to travel for 2 hours to come to the mission. The woman was not able to answer questions; her eyes were glazed and she was dehydrated. I examined her and felt her belly and asked if she was pregnant. She turned out to be 7 months pregnant. I told my interpreter that we would need to put two IVs in her. She asked me why. I replied that she was very dry, having been sick for 5 days and that she was pregnant. My interpreter looked at me and said, "Is the second IV for the baby?" Her face brightened up at the idea. The woman improved within 2 hours, after initially only being able to whisper to us.

"Another case was a baby being breast-fed by her mother. One of the doctors placed an intraosseous line in the tibia, but it wasn't working, so we used a nasogastric tube. After 100 to 200 cc of fluids were pushed into her, she became quite feisty. IVs and ORS made a huge difference for so many of these patients," she wrote in her blog.

Dr. Lai was featured in an earlier World Wide Med column "Traveling Around the World to Help Treat AIDS" (INTERNAL MEDICINE NEWS, August 1, 2009, p. 60).

GLOBAL PERSPECTIVES ON MEDICAL PRACTICE

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, visit internalmedicinenews.com or send an e-mail to imnews@elsevier.com.

Interview by Heidi Splete. Blog excerpts are from haiticholeraoutbreakkwankew.blogspot.com.
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Title Annotation:WORLD WIDE MED
Author:Splete, Heidi
Publication:Internal Medicine News
Article Type:Interview
Geographic Code:5HAIT
Date:Feb 1, 2011
Words:1293
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