We are confronting a mystery. All around us, in the health care facilities which used to have Cholera Treatment Centers, the international agencies, such as Medecins Sans Frontieres, which supported these centers have moved out to serve in other parts of Haiti, where the epidemic has worsened. At our CTC, however, our daily census has remained virtually unchanged at about 40 patients in the adult unit and a dozen in the children’s unit. Many patients come to HAS from a single locality in the mountains to the South of the hospital, Terre Nette, where HAS used to maintain a dispensary.
In discussing this with two of the Polish physicians who have come to HAS to assist in cholera treatment, some possible explanations emerge; some are clinical, and some are cultural. Dr. Anna Szacillo explains that about 70% of the patients come with purely cholera as a presenting complaint, and they are successfully treated and discharged in 2-3 days. However, others come to the unit with underlying clinical conditions such as malnutrition, pneumonia, infections, or TB. Once the cholera has been managed then we have to address the other clinical conditions. In certain cases, the patient can be transferred to the hospital, such as the patient whose TB was confirmed yesterday. However, patients who arrive with clinical complications often require several additional days to treat the cholera.
Dr. Lukasz Jaworski describes the normal treatment process which includes four levels of protocols; for mildly ill patients such as those with diarrhea only, patients are provided with oral rehydration and monitored, usually to be discharged the next day. Patients with more acute symptoms, but still ambulatory, are supported with IV fluids. The most severely ill patients are put on protocol 4; they often come to the hospital severely dehydrated, and semiconscious. They may be given two IV lines and possibly antibiotics. Today has been relatively quiet, Dr. Jaworski reports; there have been no patients on Protocol 4, whereas usually there will be three or four.
The decision to discharge a patient is primarily related to the nature of the patient’s symptoms; once the vomiting and diarrhea cease for several hours, they are considered for discharge.
“But the patients often lie to us,” says Dr. Szacillo with a smile. “They tell us they have these symptoms, and we can’t always tell if it’s true, but they may not want to go home.” She explains that sometimes there is no one who can come to take them home, or they may want to go back to the mountains with a neighbor. Or perhaps they just want to rest. The doctors ask the Haitian nurses for advice when they encounter situations such as this. “They are wonderful,” Dr. Jaworski says. “They are very helpful and they are highly motivated. They help us to understand the culture.”
The question remains as to why so many patients continue to come from Terre Nette, which is far above the Artibonite River. The Polish doctors have decided to visit that area themselves to understand this better.