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Business as Unusual

At our 4 a.m. census this morning, we saw 20 adults and 18 children with cholera - a constant level for the past 4 days. As I walked though the hospital between the adult cholera section to the children's cholera section, both of which are isolated from the regular hospital, it was immediately apparent that there has been no change in the demand for clinical services at HAS.

The pediatrics ward had 63 patients, including 10 in the neonatal special care unit, and the medical and surgical ward had 31 patients. There were 38 patients in the Evaluation, Diagnostic and Stabilization unit, which is designed for about 20 patients, so the hallways were crowded with litters and cots as patients were stabilized pending the morning rounds and scheduling for lab tests and X-rays. This total of 132 inpatients does not include the several women who were in the high-risk pregnancy unit.

By mid-morning, referred patients and others with return appointments were filling the benches under the large mapou tree, waiting for the ambulatory clinics for medicine, surgery and pediatrics to open in the large donated tent.

While every disease outbreak or epidemic is unique, there appears to be strong indications that cholera will be found in Haiti for years to come, and that in the near future, we may continue to see new cases of the disease at HAS. However, the level of the future demand is unknown. At this time, and for the near term, we will have to plan on managing an institution with a total inpatient load of about 170, of which almost 40 will require special care as cholera patients.

Cholera Patients Continue to Arrive at HAS

Today is a holiday – All Saints’ Day, as is tomorrow, the Day of the Dead. The hospital’s outpatient service is closed, but patients still arrive, either to the Cholera hospital, or to the regular hospital. Urgent cases are seen in the sal dijans (salle d’urgence, or emergency room), which is aptly named, because it is merely a room, off the primary care waiting area.  If the patient’s condition appears to be serious, the patient is transferred to the Evaluation, Diagnostic and Treatment room, a bay of about 25 beds under the direct observation of several physician extenders, nurses and physicians on call.

Patients with the symptoms of cholera proceed directly to the cholera reception area, where they are evaluated and either started on an IV drip, or offered oral rehydration solution, depending on the intensity of their symptoms. According to our visiting CDC team, as many as 80% of the persons affected by cholera do not show serious symptoms, and do not require substantial rehydration, or do not come to the hospital at all.

We watch two trend lines every day; one is the daily census, as this indicates our work load for cholera patients, and the other is the new admissions for each day. The daily census reflects a stabilization at about 30 patients a day for the past three days. The new daily admissions also reflects a stable pattern at about 15 patients a day for the past 4 days, and there appears to be a balance between admissions and discharges.  This pattern is apparently similar to that seen at the two other major cholera hospitals in this region, at St. Marc and Petite Riviere, although the total number of patients is higher at each of these facilities.

Many patients arrive with rather minor symptoms, receive oral rehydration and leave the same day (these do not show up on the admission or census figures). Several of the newly-arrived patients reflect a pattern which had caused us some concern, and they were the caregivers of a sick person, who were exposed to the patient’s effluents while caring for them.  While I was translating for a writer from Newsweek today, we talked with a woman who had arrived with serious symptoms yesterday. She said that she had cared for her 16-year old daughter who had died on Thursday, and she had prepared the daughter’s body for her funeral. Now she apparently also has cholera. This person-to-person transmission of the disease is of great concern to the Ministry of Health, the CDC, and the Pan American Health Organization, all of whom are tracking the trends in our area with great attention.  Their great fear is that the disease will spread in this way to the large camps of refugees in Port au Prince and nearby.

As if Haiti could not emerge quickly enough from one disaster to prepare for another, we are all watching the progress of Hurricane Tomas, as it drifts Westward just to the south of Haiti, with a forecast by the NOAA for it to turn sharply to the North on Thursday to connect with the southwest peninsula of Haiti, where the frequently-battered cities of Les Cayes and Jeremie are located.