Chaiten Hospital

A truck crash leads to a first-hand look at a small hospital in a Chilean frontier town.

Dr. Loofbourow wrote this article during an earlier trip to Chile, at about this time of year.

In 1988 the Carretera Austral first opened a major part of the Chilean archipelago to vehicular traffic. It is a two-lane gravel road interrupted by ferry transfers, and was a major engineering feat.

Chaiten is an ocean front frontier town on the Carretera Austral, of 2-3000 people, still far north of Patagonia and the Straits of Magellan. It is a gateway to a region dominated by glaciated mountains, rain forests, fiords and islands.

Back from the tidal flats, behind a row of small hotels, hostales and shops, Chaiten is laid out like ranks of soldiers, in regular squares, separated by ambitiously wide streets, often with a bare central boulevard. The gravelly streets are sparsely populated by foot traffic, stray dogs, bicycles and motor vehicles. Behind inconstant sidewalks are small one-story wooden houses, with shingle or tin roofs.

The settlement also features several other typical frontier structures: a police station, a school with a large gymnasium serving also as a community center, a fire station, and several small churches which tend to be from minor denominations; better established churches seem to invest in more profitable areas.

Chaiten is also a district administrative center, and has several other important features: an airport, a hospital, and headquarters for the Pumalin complex of National Parks.

My short flight left Puerto Montt on a rare and beautiful clear February summer day, between snow capped mountains to the east and the island archipelago below and to the west. Though the single pilot talked often on his cell phone, his old 9-passenger twin Cessna appeared to be well equipped and maintained. (The cell phone is ubiquitous in Chile, where it is offered free to users and the caller, rather than the cell phone owner, pays for calls. This makes it possible for the most impoverished citizen to walk down the street appearing to talk business.)

Though Chaiten airport runway was ample, new and well cared for, the small terminal was deserted on our arrival. No other planes were visible, no hangars. Accustomed to such things, passengers waited patiently, as if their forlorn condition were normal; and indeed, after a few minutes, a luxurious new 12-passenger van arrived to take us to our various destinations.

On the spur of the moment, I was invited to have supper with fellow tourists, a Chilean family who were driving the Carretera Austral, a trip of several weeks. As my addition would leave them short a steak, we went together to a small butcher shop. But a middle-aged woman entered the shop and sang out an old chilling refrain familiar to many physicians on vacation:

"Is there a doctor here by any chance?"

When traveling, I generally remain scrupulously incognito where my profession is concerned. Yet in this circumstance, it is hard to hide; and in small towns like this strangers are always carefully observed and assessed by locals.

I asked her the dangerous question: "Why?"

There had been a major accident involving two large trucks carrying soldiers. Some 50 people were injured, and were beginning to arrive at the local hospital, staffed by only one physician. What could I do but confess to my physician condition? The situation was even appropriate to my own specialty, emergency medicine.

So I bid my new friends hasta luego, and promised to try to look them up later. It was about 7 pm, still several hours before dark in that latitude and season.

The Chaiten Hospital is a sizeable one-story cement building in good condition, but sparsely equipped, consistent with its scant use. As I arrived at the ambulance entrance, which doubled as the front door, the area was crowded with onlookers, among various vehicles disgorging the injured. They were generally transported by litter, and placed on 1 x 2 meter pieces of decomposing dirty yellowing sponge-like mattress material, laid on the hospital hallway floor.

I noted some 15 people laid out outside and, entering, found about 30 more deposited along interior hallways. The lady who collared me in the butcher shop introduced me to the physician on duty. However, he was "scrubbed," repairing a 10 cm scalp wound, with the sweaty dedication and pace of one who is not accustomed to such things, and was assisted by his nurse, leaving only one nurse aide available. No one was triaging. I was told that other nurses were on their way, as well as another doctor.

Fortunately, most of the injured appeared to be stable, awake, and not in severe shock, despite fractures and wounds. They had been standing close-packed, in the open bed section of large trucks, while descending a steep grade (Cuesta Moraga). The brakes had failed on one truck, which plowed into the one ahead of it. Two people had died at the scene, and the remainder generally had been thrown into each other, or out of the trucks.

A second nurse arrived and informed me that no narcotics were available; I had to make do with an injectable anti-inflammatory related to torodal. There was a small Xray machine suitable only for chests and extremities. The lab was limited to whatever the physician could do. There were no monitors, either for blood pressure, EKG, or pulse ox, no chest tubes or long IV catheters. She could start saline and do sequential checks of vital signs, keeping me informed of any significant deterioration. Fortunately, helicopter evacuation was available.

One lacks such simple things in these situations! I sent the aide for a blood pressure cuff and stethoscope which defied detection for what seemed an eternity. Someone had laid a blank piece of paper on the chest of each injured. Rummaging in the doctor’s office, I located the other most critical triage item, a pen, and began to assess those who seemed to be in the most obvious distress or pain, writing orders and impressions as I went.

The first time around, rather than delay for blood pressures, I relied on PALS-like criteria of pulse, respiration, capillary refill and individual responses to my questions, reserving blood pressures and orthostatics for only the more suspect patients.

By the time I had finished, hours later, the hospital doctor was done with his surgery and we conferred. I suggested that of the 49 injured, four patients needed urgent transfer by helicopter that night (head injury with probable basal skull fracture, neck injury with probable fracture, blunt abdominal trauma with suspect intra abdominal bleeding, and chest injury with hypoxia and lung contusion). The rest, mainly fractures and contusions, were relatively stable, and could await treatment or transfer as convenient. The second doctor arrived, and I quickly seized the chance to become a civilian once again.

The following day I revisited the doctor. He was a military physician, paying back year for year of medical school training, and he intended, in time, to become an anesthesiologist. Seven people had been transferred that night by helicopter, and five more with fractures were to be sent off later in the day.

My chance acquaintances had saved our steaks, and went with me to Pumalin park.

One of the dead soldiers was a local. It is customary not to delay funerals in Chile, and two days after the accident, a funeral was attended by many relatives, neighbors, soldiers, and military officials. The Chaiten Hospital again resumed its stolid and tranquil aspect.

The lady who had hooked me in the butcher shop looked me up, took me to see the wrecked trucks, steered me to a local fisherman’s fundraising party, and discovered in the process that I was some sort of pilot.

As there are few secrets in a small town, later when I boarded my return flight to Puerto Montt the real pilot asked me to act as co-pilot. Though instrument rated, I am not current. Surprised, I found the twin engine plane much easier to handle in bad weather than the small singles I was used to.

I reflected: one who is privileged to be a physician should not reject the opportunity or the obligation to respond to an emergency. Sometimes it seems the farther from home the more rewarding that is.

lufboro@jps.net