It’s 6:40 pm on Thursday evening. A patient arrives on a moto. He is unconscious. He is placed on a bed and the nurse on call attempts to get a history from his parents. He is 14 years old. He lives very rural, up in the mountains. He went to school this morning. And apparently on the way, he decided to get a mango. And while doing so, he fell out of the tree. His parents did not witness this fall and so cannot provide details. The principal of his school took him to the closest government hospital (an hour away?) on a moto. His parents arrived at the hospital around noon. He was unconscious. We do not know what treatment he received at the hospital or what was communicated to his parents, we just know that his parents left with him because they ran out of money. They put him on a moto and came to our clinic.
The patient responds to noxious stimuli only. So he has some degree of traumatic brain injury. He moves all extremities to some degree- even if just wriggling his toes. Both of his thighs are swollen and warm- probably has fractures of both femurs. His left upper arm is swollen. Possible fracture of the humerus. He has a laceration on the front of his head that has been sutured and a laceration on his jaw that has been sutured. He starts to wake up some- moves more, makes sounds. But is not following commands or speaking.
Vital signs are within normal limits. What to do next? There is not a neurosurgeon in the country. There are several CT scanners but not clear which ones are functioning and most of them are in Port au Prince which is not accessible by ambulance or private vehicle from Cazale. Partners in Health in Mirebalais has a CT scanner but again we do not know if it is functioning. And if it shows significant cranial abnormalities, how will this be managed as there is no neurosurgeon in the country? The hospital is about 5 hours away over an unpaved mountain road that can be treacherous if muddy.
We decide to send the patient to a nearby hospital (40 minutes away) with an x-ray machine and an orthopedic surgeon is available for consult- if he is able to get to the hospital. The patient is transported to the hospital. The orthopedic surgeon says that he needs emergent referral for a CT scan of the head. Well, transport by air is not available and transport to Port au Prince is only possible, sometimes, via public transportation. Mirebalais seems like the best option, but there was heavy rainfall overnight and the mountain road is not passable. So the patient comes to back to clinic. He is monitored over the weekend. His mental status improves, he opens his eyes and talks some, though still does not have normal mental status. He also develops bruising of both eyelids on both eyes (raccoon sign) indicating probable skull fracture.
He is transported to the hospital in Mirebalais on Monday. Though the truck breaks down and a second vehicle was sent to transport him to the hospital. The road is very rough, but he arrives safely. The hospital is full. The ER physician is concerned because the hospital does not have a neurosurgeon (though no hospital in Haiti has a neurosurgeon). The patient is received, though kept in the ER until a hospital bed becomes available. The patient is awake and talking.
This boy has a long journey ahead of him. Please pray for him that he head injury will continue to heal and that he will receive the best care that Haiti can offer.