Abstract
Background: Significant resource constraints and critical care training gaps are responsible for the limited development of intensive care units (ICUs) in resource limited settings. We describe the implementation of an ICU in Haiti and report the successes and difficulties encountered throughout the process. We present a consecutive case series investigating an anesthesiologist, emergency, and critical care physician implemented endotracheal intubation and mechanical ventilation protocol in an austere environment with the assistance of telemedicine. Methods: A consecutive case series of fifteen patients admitted to an ICU at St. Luc Hospital located in Portau-Prince, Haiti, between the months of February 2012 to April 2014 is reported. Causes of respiratory failure and the clinical course are presented. Patients were followed to either death or discharge. Results: Fifteen patients (eight women and seven men) were included in the study with an average age of 37.7 years. The mean duration of ventilation was three days. Of the fifteen patients intubated, five patients (33.3%) survived and were discharged from the ICU. Of the five surviving patients, two were intubated for status epilepticus, one for status asthmaticus and one for hyperosmolar coma associated with intracerebral hemorrhage. Of the patients dying on the ventilator, four patients died from pneumonia, two from renal failure, and one from tetanus. The remaining three died from strokes and cardiac arrests. Conclusions: Mortality of mechanically ventilated patients in a resource-limited country is significant. Focused training in core critical care skills aimed at increasing the endotracheal intubation and ventilatory management capacity of local medical staff should be a priority in order to continue to develop ICUs in these austere environments. Collaborative educational and training efforts directed by anesthesiologists, emergency, and critical care physicians, and aided by telemedicine can facilitate realizing this goal.
Highlights
The intensive care unit (ICU) is demanding in skill and breadth of interventions
We present the implementation of an ICU in Haiti, guided by anesthesiologists, emergency, and critical care physicians, with the assistance of telemedicine, for the provision of an endotracheal intubation and ventilation protocol, and report the successes and difficulties encountered through a description of a pilot program
The objective of this paper is to describe the development of an ICU in the austere environment under the guidance of anesthesiologists, emergency and critical care physicians, with particular emphasis on the instruction of endotracheal intubation and ventilator management for critically ill patients in need of acute bridge ventilation until recovery
Summary
The intensive care unit (ICU) is demanding in skill and breadth of interventions. Few ICUs exist in resource-limited countries because of the cost and extensive spectrum of medical interventions required. The hospital developed a rounding system whereby the day shift ICU physician would round each morning with the previous night Emergency Department (ED) and ICU physicians on every ED patient in order to determine which patient needed ICU-level care Before this protocol, there was no ability to provide endotracheal intubation or mechanical ventilation. Intubation and ventilator management represented the most challenging clinical problem for a new ICU staff with limited practical experience in this area This was further complicated by the austere setting, without typical monitoring aids such as arterial blood gas measurements and basic laboratory availability. Haitian physicians who treated patients with endotracheal intubated and mechanical ventilation consulted by telemedicine, FaceTime, and e-mail with the University of Maryland Department of Critical Care and Memorial Hospital in order to assist in the guidance of management.
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