Global Doc: Countdown

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Author: Dr. Vincent DeGennaro Jr. ’02

Vincent DeGennaro

There are only two numbers that I’m concerned with for Antoinette. One is her age: 22. The other is her oxygen saturation: 85 percent and dropping.

A normal oxygen saturation, signifying the percentage of red blood cells that are holding onto oxygen, is over 98 percent. The lower the number, the less oxygen in the blood and the higher the danger of death. Anything less than 90 percent is frightening and below 80 percent for any length of time is not compatible with life. Completely stuck in traffic in Port-au-Prince, we are going to be in real trouble very soon.

“84…83.” the EMT calls out, reading off of the portable monitor wrapped around her cold finger.

Antoinette is a young woman with an aggressive form of tuberculosis called miliary tuberculosis, and she just gave birth at 28 weeks and lost the baby the day before. She was being treated at another hospital that does not have adequate resources and where she would have rapidly died from respiratory failure.

“81…80.”

When I saw Antoinette breathing at 45 times per minute, eyes rolled back in her head, I knew she didn’t have long. The work of breathing tired her out so much that she vomited up her pills mixed with protein shake that had been fed through a tube in her nose.

Project Medishare’s hospital has the only adult ICU with ventilators, or breathing machines, in all of Haiti. Here was a young woman with a reversible process that could be saved with two to three days on the ventilator, but who would certainly die in the other hospital for lack of means. I asked Antoinette’s friends, her only family since the deaths of her parents, if we could transfer her and they agreed.

“78…77.”

The Land Cruiser arrives at the tent, carrying an American emergency doctor and one of the Haitian EMT’s, trained at our hospital. We slide Antoinette along the floor of the car and gently lay her where the doctor could intubate, or place a breathing tube in her trachea, without which she won’t survive the transfer. She now requires so much oxygen that any movement or slight decrease in the flow causes her oxygen saturation to drop.

“What’s her saturation?” I ask the EMT as we are positioning and arranging her for intubation. A dozen people stare into the car through the windows, watching our every move on this unfortunate woman.

“75 percent. Let’s get her intubated.”

“Push the meds for sedation,” the ER doctor says to me, thrusting two syringes of medication into my hands. I push the drugs, tilt her head back and apply gentle pressure to her trachea to make it easier for the doctor to see her vocal cords, the landmark for intubation.

“I’ve got cords,” he says, looking down through the scope, “and we’re in. Check for breath sounds.”
“Bilaterally, you’re in.” I say to the ER doctor and then turn my attention to the driver. “Ok, let’s go.”
“96 percent,” the EMT updates us.
“Ale vit?”asks the driver.
“Wi, ale vit.” Yes, go fast. 96 percent was perfect, but any number of things could go wrong. We pull out of the hospital and immediately start weaving through traffic, the driver using the horn like an ambulance siren. While we are being thrown around as the car accelerates and brakes, I squeeze the IV fluid bag to make it run in faster, and steady the heavy metal oxygen tanks with my free hand and feet. The ER doctor holds the tube in her throat in place and gives her breaths by squeezing the bag, and the EMT continues to monitor her vital signs. After 15 minutes, something is wrong, and the countdown begins anew.

“89…88.”

We cannot figure out what changed. The tube is still in place and it is easy to compress the bag. Then I see it. The meter on the oxygen tank is in the red zone, indicating the tank is almost empty. She required such high amounts of oxygen that the small tank quickly depleted. Time to switch tanks, but I notice that the other tank is also on the red, and the nozzle is open. Did we not close the tank after we intubated her? She could die on the road because of the chaos of the transfer and the time-consuming traffic.

A policeman on a motorcycle pulls alongside us and I gesture and shout out the window that we need his escort to speed through traffic. I’m wearing a mask as protection from the tuberculosis and gesticulating with gloved hands, but I’m not sure that he can see Antoinette in the vehicle. He nods in affirmation though and speeds around the car and in front of us but doesn’t turn on his sirens. After 50 feet, the traffic slows and he darts into a gap between two cars, too small for us to fit, and he disappears into the smoke. The light fades.

“86…85.”

I switch tanks, hoping the second one has more in reserve, and turn the oxygen down. We fiddle with the oxygen regulator, attempting to give her the least amount of oxygen possible that will keep her above 80 percent. It’s not ideal, but she should be able to survive at 80 percent long enough to get to the hospital.

“82…81.”

We achieve a new equilibrium, and I become aware of my surroundings. We are not moving anywhere, completely stopped in a long line of traffic on a two-lane road. I search in a panic for some sign of help outside the car windows. The driver is honking the horn, Antoinette’s friends in the front seat are yelling out the window to get cars to pull to the side, but we’re not moving. She will never make it without a siren to part the traffic or some other miracle. There’s simply not sufficient oxygen in the tank to last the 30 minutes to get back to the hospital at this pace. There is no other facility closer to where we are. For a minute, I think about hopping on a motorcycle to get to the hospital and bring oxygen back to the car, but even the motorcycles are not moving in this Friday rush hour.

“70…69.”

Amid the chaos, we pull alongside a police car. The driver shouts at them that we have an emergency and need to get to the hospital. Mercifully, they agree to escort us and switch on the sirens and lights. The cars slowly open up and a path through the traffic lay before us. A tiny window opens up, the light flickers a little more brightly.

I turn the oxygen up, determined not to let her die as long as there is one molecule of oxygen in the tank. The car is going fast enough again that we’re being thrown up against the walls with each turn, falling forward when the driver slams the brakes. I call the hospital to warn them that we are approaching and that we’ll need a new oxygen tank ready as soon as we enter the gates. The police car is now driving down the wrong side of the road and we’re following close behind. Oncoming-traffic frantically swerves to the right as we speed down the wrong way of the main artery, but at least we’re in the neighborhood of the hospital. We arrive at a light and meet head-on with a lump of cars going the correct direction but unable to move out of the way, and so once again, we’ve stopped, so close to the hospital.

“79…78.”

“Monte’l,” I yell to the driver. For the first time since we ran out of oxygen, I have the sense that she might survive the voyage.

“Monte’l? Ok,” he responds as he turns the wheel and directs the car over the concrete median to the right. The shocks groan and the ER doctor firmly grabs the tube in Antoinette’s throat to hold it in place as we rock over the tall median and down to the pavement, straighten out and continue on full speed, now in the proper lane of traffic. I wave out the back of the car at the policemen, the strongest gesture of gratitude I can offer for their gigantic part in saving Antoinette’s life.

The road opens up considerably and we’re speeding down the boulevard. We turn down the side street that the hospital is on and try to thread our way through the throngs of people promenading along the thriving market. I throw one arm out of the window and bang against the side of the car to scatter the pedestrians while the driver lays on the horn and doesn’t let up until we pull inside the hospital gates.

I switch the oxygen tank to the one waiting for us, and utter words of gratitude to the two oxygen tanks that sustained her. Then the cavalry arrives. The car is swarmed with EMT’s, nurses and doctors who place Antoinette on a stretcher and take over giving her breaths and squeezing IV fluids into her veins. It is over.

The adrenaline that sustained me over the last 45 minutes drains out of my body. My knees shake as I remember that it’s nearly dinner time and I never ate lunch. I swallow the lump in my throat and breath deep to avoid tearing up.

“95…96.” the EMT calls out as they rush Antoinette into the ICU.


Vincent DeGennaro is an internal medicine doctor and a global public health specialist at the University of Miami’s Department of Medicine and works part time in Haiti with the nonprofit Project Medishare. See his An American Doctor in Haiti blogs.


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