WHAT NEXT?

I have not found a place where life and death, survival and ‘thrival’ hang so precariously in the balance as in this country of Haiti, and this last week has been no exception. The closure of the border by the Dominican president over a group of Haitian farmers trying to irrigate their drought-plagued land has affected everyone. Commerce is grinding to a halt on certain items, among those medication, fertilizer, and food. Banking and travel are going to be severely limited if not almost impossible, as the road to Port au Prince is hot with gang activity. What do we do? There are still blessings: gardens are being planted, rains are plentiful, cisterns are full at the moment. 

The clinic numbers seemed to have leveled out and we see around 60 to 100 people a day. I had a lady who hadn’t been to the clinic since 2016, according to her chart. Her nonsensical explanation to this was that she heard the ‘whites’ were back, so here she was. 

A lady gets carried up on a bed. The husband seems frantic, telling me she’s not talking, not eating, not drinking for three days. Others inform me that no, she has been getting nourishment. She says words to us. I dig deeper… only three days? She looks a lot sicker than that. Ok, about 9 days, with the last three being much worse. Ok… I ask what the leaf doctor gave her, tricking them into admitting they tried him first. A pill and a syrup, they tell me. Then he tells me they come from far away, and everyone listening bursts out laughing as he says Oplimèt, the area right next to Oriani and not considered far at all. Jonathan establishes an IV with the help of ultrasound, as her veins are pretty flat. Blood test shows HIV. I test the husband, who also has a non-healing dermatological condition on his chest. HIV positive. We explain the malady and put them in touch with the Croix-des-Bouquets TB and HIV clinic for the much-needed anti-retrovirals. It may be too late for the lady. 

A mom silently labours as she waits for her prenatal consult and delivers almost as soon as she’s called into the consultation room. The quietest Haitian labor I’ve witnessed, I think! She doesn’t have a name picked out for her girl, so when Nurse Vitanie fills out the certificate we start suggesting. The mom rejects one suggestion of Roselande but takes my suggestion of Daphlinka (my go-to for naming baby girls here). I tell the mom she can give her two names, and suggest her name, Jackline, for the middle name. Mom seems quite enthused. Another bonus: she’s sitting on a hard bench, breastfeeding the minutes-old newborn as we discuss this. I have high hopes for this baby!

I am seeing a patient in my room when Sè Papi comes in with a bundle. Look at this baby, she says. A tiny baby, dead of malnutrition. We ask the mom when she had died. While she was waiting for her appointment here today she says. Yes she had gone to Forèt clinic with her. They said she was malnourished. Did she give the baby any milk or breastfeed her? No. She was a month old. The mom has a very flat affect and quite a few children at home. I add a piece about postpartum depression into my prenatal course.  

Vitamin Angels donated prenatal meds, vitamin A, and albendazole, so we are working on rolling out a program where we try to keep better track of dewormer and supplements for children under 5 and continue pushing prenatal vitamins on all pregnant and breastfeeding moms. One old wives’ fable I’m trying to quench (one of the many!) is that taking prenatal vitamins will make your baby big and therefore make labour more painful. 

MSPP, the national health care authority, has sent a vaccine nurse to help us for 6 months. Wednesdays are her busiest days, so in the meantime she helps out in the consult rooms and the pharmacy. 

And coming up in November, the Lord willing, there will be a vacant position for a nurse. However, with the indeterminate DR border closure, will there even be enough supplies and funds to run a clinic at that time? This is a day-by-day adventure like none other, this Oriani clinic life! Please pray for us and the people we are here to help. We don’t know the future, but we know Who holds the future.

THE CIRCLE OF LIFE

Another month has passed. This is turning into a monthly update. You will notice several changes to the report. Hopefully these can better reflect what we see at the clinic. August was our busiest month to date. Old reports we have on file from 8 years ago show we are seeing numbers similar to then. It is busy with only 2 consultation rooms operating full time. Carmina and I help out as needed. The biggest change for the last month is the opening of the pharmacy to patients. This has streamlined things by having patients move out of the consult rooms quicker. Patient education on how to take medications is still provided in the room and the nurses administer medications in the room. Then patients go to the pharmacy for medications to take home with them, rather than waiting in the room. I came up with a list of our common medications with dosages and amounts linked to our protocols. This is a cheat sheet for the person working in the pharmacy to check how to dispense the medications. Continuous small improvements to help things run smoothly.

A man was brought to our house on a Sunday afternoon on a bed. He fell and had an open left forearm fracture. I told them to bring him to the clinic. While they headed off, I got a board and cut it to size in our shop. Then I met them at the clinic. I gave him an antibiotic injection and an injection for pain. Then I padded the board as best I could. His bones seemed surprisingly well aligned considering; so I wrapped it in place with the board as a splint. I told them he should be taken to a hospital with an XRay to be sure the bones were in place. They said they would and asked about the ambulance. I contacted Fre Bartelomy to see if he would drive. He was agreeable. But when he got to the clinic they had changed their mind. I sent the patient home with pain medication and antibiotics. He was able to move his hand and had good circulation. So hopefully it will heal OK? Two weeks later he showed up at the clinic. He went to a witch doctor after leaving the clinic. The witch doctor had replaced my splint with some short boards and some goop that hardened around the arm. It was much too short to be an effective splint. So we pried it off and replaced it with a cast. It didn’t look infected so the antibiotics seem to have worked.

It was 4 in the morning and I was sleeping soundly. I woke up to our dog barking and people knocking at the gate. When I went out there was a small group with a 2 year old boy in clear respiratory distress. They told me this started yesterday. Why didn’t they come yesterday? They said they couldn’t find a moto then. But they could at 4 in the morning? Not important now. We hurried to the clinic. The boy’s lungs sounded wheezy and tight and his oxygen level was 35%, critically low. I quickly put him on oxygen. I cranked it up to 25 liters a minute (LPM), as high as it can go. Then I started giving medications. Nebulized albuterol and budesonide. I guessed his weight and calculated the pediatric dose for intramuscular epinephrine and dexamethasone, anything I could to help his breathing. I set up my BVM in case he quit breathing. The initial round of medications helped for a bit but quickly wore off and he got worse. After almost continuous nebulized albuterol and 4 IM epi shots over 2 and a half hours, I was able to titrate his oxygen down to a more manageable 5 LPM. At 25 LPM I kept having to refill our portable oxygen tanks from the large tanks we have in the back. At 5 LPM I could use an oxygen concentrator. By this time Carmina came in and was able to take over. We were planning on going to the Dominican for a shopping trip that day. We were gone for 2 days. Carmina kept the boy on oxygen for that time and kept giving medications as necessary. He was able to go home in 2 days, but it was a close thing.

            After we got back from the Dominican, I woke up again at 4 in the morning. This time it was for a woman in labor. No problems, just pain with labor. Can you do anything for her? She is suffering. No, sorry, we don’t have anything for that. Pain with labor is normal, unfortunately. Somehow these people think I can give a magic medication to fix their problems. They give me the impression they think I am holding out on them if I don’t give them something. Could also just be my poor Creole. We went down to the clinic for a check up. Everything was normal and labor was progressing nicely. I had her walk with the help of 2 other women to help advance the baby. Meanwhile I went to find her chart. After a bit I heard a commotion. She was squatting in the hall with a healthy baby boy on a blanket on the floor. I cut the cord and the people with her helped her get comfortable. I made a birth certificate for them and gave it to the dad. I wanted to tell him “See, you didn’t need me”. But watching him hold his son and smile at him, it didn’t seem the time for that.

            Sunday night we were at home relaxing and reading stories. A knock at the gate. It was Fre Bartelomy. He said there was a woman who had been sick for almost a week. He showed me a video of an old woman guppy breathing. Not a good sign! They thought she needed IV fluids and wondered if I could give them some to take to her. Who would start the IV? Miska, a local who tries to run a small clinic. I have no idea if he has any medical training. This seems like a bad idea to give the supplies and hope he knows what he is doing. Maybe she is in heart failure and fluids will make it worse? I grabbed my stethoscope and an Oximeter and asked if they could take me to see the patient. We left in the dark in a slight drizzle. They stopped at the clinic. Bartelomy’s moto driver left. I asked again to go see the patient. He got behind me on my moto and we headed out down the slippery muddy road in the dark. Part of me was really regretting not just giving them the supplies and going home. After a mile or 2 we stopped at the bottom of a steep hill. We started up the trail. The moon had come out and was shining through the trees and lighting up the mountain. After a while we get to the top of the mountain and come into a clearing to a nice house by Haitian standards. In the house is Pastor Boyle. He is currently a member of the local clinic advisory committee. He has good English and I was happy to see him. In another room is the patient, surrounded by family and being held up in bed by a younger woman. I listened to her lungs. The bases sounded congested. She is very warm and possibly has a fever. Maybe pneumonia? I put the oximeter on her finger. It reads 52%. Critically low. I knew immediately she was in God’s hands and beyond my help. I went back into the other room and talked with Pastor Boyle who translated for the husband. I told them she was very sick and would probably die that night. I told them if we could get her to the clinic, I could try to put her on oxygen and treat her pneumonia. I said she would still likely die. Considering how difficult it would be to get her off the mountain and to the clinic, I didn’t think she would live long enough to get to the clinic. Initially the husband said he would try to get people to help carry her down the mountain, then he said we would leave her where she was. Pastor Boyle told me he was the first member of his church in Oriani. We talked a little more and he said he had seen her get worse over the last few days. Part of me wanted to ask why they didn’t bring her to the clinic several days ago, but again it didn’t seem like the time for that. Walking back down the hill I was struck again by the beauty of the night. Did I make the right choice? Should we have tried to get her to the clinic? Could we have helped her? So often in the ER at home where we can do all the things, we get cases like this. We intubate, we start pressors, all in a desperate attempt to avoid what we know is inevitable. How much more beautiful to accept the inevitable in your own bed, surrounded by family. It’s never an easy decision and always part of you wonders, did we make the right choice? At the base of the hill it started raining again. As we slipped and slid our way back to Oriani, I thought of all this. Remembering the peace and beauty on the top of that mountain, I can be at peace with leaving it in God’s hands.

            The next day at the clinic, I was in my office when I heard a commotion. I heard Carmina say something about a baby already being here. I went to check and found a woman brought on a bed into our ambulance bay. One twin was born but the other was not yet. One of the aides took the baby to another room while Carmina and the other nurses checked the woman. I went to check on the baby, he was doing OK. I went back to the woman. She was fine with minimal bleeding. Fetal heart tones showed the unborn baby was in no distress. No need to hurry anything, the baby will come when the time is right. We are asked multiple times if we can give the woman a shot of oxytocin to hurry the baby. We always reply with the same answer. The baby will come when the body is ready. Research shows trying to hurry labor can lead to bad outcomes, such as vaginal tearing and fetal distress. We encourage the mother to walk as much as she can. After several hours the first twin is joined by another healthy baby. A boy and a girl. The parents now have 10 children, 5 boys and 5 girls. Maybe a good round number to stop on? Often in health care the best thing to do is nothing. God made our bodies wonderfully to take care of themselves. The difficulty comes in knowing when and how to intervene. So it goes here in Haiti. The circle of life. Not that different from at home, but in comparison, in difficult and exotic surroundings.

Jonathan Kurtz - Clinic Administrator

Successes, Failures, and Near Failures?

Many inspirational quotes for success and failure say success is personal, not the outcome, and failure isn’t the end… but in the medical world, I beg to differ. Success is a good outcome, and failure can mean harm or death. I think we all have ‘what if’ thoughts, and here, in a remote, low-resource medical setting, it’s often difficult to not ruminate on the failures, as they feel like your fault.

As Jonathan and I are doing a paracentesis in one room, a twin is born in the outhouse. The other nurses and aides situate mother and baby in our delivery room and encourage her to push. When I get there, I see the second twin’s placenta has come out before the baby…how long? Time to get this little one out. But mom seems stalled with pushing and the baby is high, albeit with head presenting. I find a vac-assist device and start pulling, worried this mom will have to go down for C-section if we don’t get the babe out. After a few good pulls, mom pushes, and a little blue girl is there. Not much sign of life. An occasional heartbeat. The rest of the staff encourage me to start CPR, which I do. Not much improvement, and I think of how hard life is for babies here, never mind tiny preemie twins, and a possible hypoxic brain injury? I talk to the mom. I tell her she has a beautiful girl, and she should name her and her sister. She can always tell her little girl she has a sister in Heaven. Surprisingly, the mom comes up with two names, Mirlandy and Mirlandia, and specifies which is for which. She is calm as she leaves. 

The paracentesis: liver failure, ascites, jaundice from? hepatitis? in a young lady. Came to us twice and we took off 6 liters each time before they went to Fond Parisien. FP hospitals said they couldn’t help; she needed a bigger hospital. So when they came back and asked us for help getting her past the gangs to one, we managed to get Haiti Air Ambulance to fly up. It was lovely to see Larissa again. And know that our patient would be getting the care she needed at last. 

P.S. Word on the street 6 days later is that she died. Likely only a transplant would have saved her. What ifs crowd into my thoughts. 

One of the youth boys came in with a 4-day foreign body in his eye from grinding metal. I did my best to remove it, first with a swab, then a plastic wand, and, finally, a needle tip (yes, this stuff is scary, but can be effective). Sadly, the little speck of metal had started getting embedded into the eye and I only got a piece off. Some research later, I found that the eye clinic in Roche Blanche was operating, open Monday to Friday, as per their website that had the date of 2023 on it, and I told him to rush down there (past the gangs) as fast as possible. Off he went. 

The next day I had another eye injury come in. Well, I thought I knew where to refer. Tried to pull up the website again and what also came up was a letter saying that they were closed due to gang activity since November, not to refer patients there, etc. I was horrified. I immediately called the youth boy. No answer. Asked his family. Yup, he went down right away yesterday, and we haven’t heard from him since. Oh, one of the nurses said, yeah, that area is full of gangs. What had I done? Had I unwittingly sent him to his death?

A few long hours later my phone rings; the youth boy calling me back. I’m so sorry, I blurt out. I thought they were open and here I sent you into gang territory. No problem, he said. They were open. Took out the foreign body. Gave him a follow up appointment. Everything went well. Whewwwwwwwwwwww!!

We changed up our system here a bit, and it is more streamlined. With the central pharmacy, we now have the aides doing weights, vitals, etc. This frees up the nurses for more time with each patient, and more efficiently spent time. The results were immediately noticeable. The other day there were about 100 patients, and with 2 nurses we were done by 230. Pretty amazing. Our receptionist feels the pressure, though, and says he doesn’t have as much downtime now. 

In my prenatal class I am adamant that they should not drink ginger tea in pregnancy, especially in the third trimester. I repeat, cajole, reiterate, make them repeat back to me, show pictures, hand out pamphlets, act out problems graphically, to what avail? A young girl comes to us. First baby, cramping. The nurses check her. Not dilated. The next day, again. I take one look. Ginger tea? Yes. And she has attended my class. 3 cm dilated. Later in the evening, the family has been to Forèt clinic (which has a real doctor) and sent home, and they are back. 4 cm. We can’t help this, it’s the ginger tea. By this time, they say they want to go to Fond Parisien. Sure. If we get a driver and they can pay the ambulance fee, do they want to go? Oh, no, they aren’t ready. Next afternoon they are wanting an ambulance ride but through all the back and forth with multiple people and discussing the price, we eventually don’t hear from them again. 

A sister in the church gives birth on Friday, but I only hear about it Sunday afternoon when they come with the baby (mom still at home for the obligatory 14+ days) and say it isn’t breathing well. Looks like a baby boy peacefully sleeping, no nostril flaring, no respiratory distress. But when they went for further assessment to Jonathan’s, they say the baby hasn’t had any milk at all since birth, as he won’t breastfeed. What? This mom has raised 6 other children; how does she not think nourishment is important? And she came to prenatal class too, at least once. I talk A LOT about breastfeeding and formula preparation there. 

Maybe I’ll have to stand on my head next prenatal class. Note to self: practice handstands. Or maybe someone who already knows how to do handstands wants to come in my place. I plan to leave for Canada in November, to put my Prenatal Class knowledge to practical use. The Board says I can leave if I find a replacement. So help me out here! Haha. -Nurse Carmina

Emergencies and After Hours

Hello again. The month of July was the first month we were open five days a week. We are still reserving Wednesdays for prenatal class and checkups as well as immunizing children. This is partly why the amount of patients is higher for the month of July. Let me explain more about our monthly report. This was a report the CAM required for the donations they were providing. Since CAM is no longer in the country it might be a little irrelevant. I felt it would be good information to have and have modified it slightly to better reflect what we do. Since last month I changed 2 boxes to show emergencies and ambulance trips. Emergencies are after hours visits usually to our house. If I can treat them at home, I do. Often I have to bring them to the clinic. Sometimes I will have one of the nurses meet them at the clinic. Not included are ones that show up but don’t require medical treatment (despite what they might think). This number keeps going up and can be quite tiring for one person to manage. (We still have space for another nurse). Please note the total number of patients is patient visits. Some are repeat patients. Also, we lack testing and the ability to definitively diagnose patients, so treatment and diagnosis are based on the patient’s presentation.

An interesting thing I have noticed in health care is how often you see similar patients during a day or a week. For example, the first week of July started Sunday with a 23 or so year old woman came to my house on the back of a moto. She was complaining of right lower quadrant abdominal pain. It had started the day before and had significantly worsened during the day. Very concerning for appendicitis. I told them they needed to go to Fond Parisien right away. I took them to the clinic and gave her a shot for pain before they headed down on the moto. She went to the bathroom before they left and had a lot of blood in the toilet. I asked the man with her to please give me an update when they got back but haven’t heard anything since.

A day later we had an older man come into the clinic very weak with lots of diarrhea for 3 days. He was so dehydrated I had to do an ultrasound IV. We gave him 3 liters of fluid. Concerning for cholera but unable to tell here. I contacted the cholera hospital in Fond Parisien and they agreed to take him. Rosemard took him in the ambulance. I heard later they didn’t think it was cholera but took care of him anyway. Two days later, when I got up, I saw some people standing in the road in front of our gate. I hadn’t heard knocking so wasn’t sure that they wanted to see me. The clinic was open that day so I looked for them, but they weren’t there. That evening we were at Rosemard’s for supper and they came to the house. They hadn’t come to the clinic during the day and instead went to a local that does some level of medical care. This man was very sick with significant abdominal pain. An ultrasound exam showed free fluid and air in the abdomen. By this time it was after dark and Haiti Air doesn’t fly in the dark. We started fluids and antibiotics and I sent a message to Haiti Air to get him on their list in the morning. Unfortunately, but not surprisingly, he passed away during the night. The following night I had a young man come also with abdominal pain and feeling very sick with diarrhea for several days. Why didn’t he come earlier when the clinic was open? I couldn’t understand their reply. I took him to the clinic. Ultrasound looked fine to me. I gave him fluids and antibiotics. The next day we left for the Dominican for a shopping trip and to spend a day or two at the beach for some R & R. I heard while we were there that he had passed away. Situations like this always make you wonder, did I do everything I could? Did I miss something? What more could we do? God only knows. All we can do is the best we can with what we have.

We tell some patients they should seek care at a bigger hospital. That’s indicated in the referral to other hospitals. Many times patients can find their own way and often aren’t sick enough to need to go right away. We use the ambulance if they need to go right away, but can’t find their own transportation. Saturday a man propped up on a moto came to our house. He had fallen out of a tree and hit his head. He was not making sense and not following commands. He had blood coming out of his ear and nose. Definitely not good! It was already evening, but I messaged Haiti Air to see if they would fly. They said the clouds were too thick over Pic La Selle, but they could fly in the morning. That often happens in the evening. We spoke with a man who said he was the son and said he needed to go to Port au Prince. They agreed and said they would go right away to Fond Parisien and find a taxi to Port. These taxis pay the gangs not to be harassed and Haitians can get through. Meanwhile the patient started to become combative. Not a good sign in a head injury patient. I told them to stop by the clinic and I would give him a shot to put him to sleep. Having a combative patient on a moto did not seem like a good idea. I gave him a dose of ketamine. They propped him up on a moto between the “son” and the driver. Then they asked about our ambulance. I went to find Rosemard to see if he wanted to go. He came and got the ambulance, then we headed back to the clinic. Now the crowd was a lot bigger and they were crying that the patient had died. I checked for a pulse and breathing and found both. I showed the “son” how to feel a pulse and explained that the patient was only sleeping due to the ketamine. They loaded up in the ambulance and headed out. Several hours later I got a call from Carmina. Apparently when they got to Fond Parisien, they didn’t want to go further. They didn’t have money and they were too scared and wanted to come back to Oriani. Then the “son” said he actually wasn’t family. Rosemard took them to Chris pour Touts, the small hospital in Fond Parisien. They offered to keep the patient until morning when the “son” and companions could find transportation to Port. They refused. So Rosemard brought them back. In Fond Verrette they decided they were hungry and discovered they had money for supper. So they stopped for food. Rosemard dropped them off at the patient’s house. This is a story that just gets worse the more I think about it. Since, we wrote up a small contract to give to future patients and families. It explains that the ambulance can not go past Fond Parisien and will not bring them back. Hopefully that will help in the future.

Sunday I was at the clinic with an old man who couldn’t pee. A simple fix with a catheter. On the way home we were met by yet another person propped up on a moto. She was young, had been fine in the morning, and I smelled alcohol. My ER fake meter was pegged. I asked if she had been drinking. They said no. (Funny how some things are just the same as North America). So I did an exam. She moved to pain, flinched when I flicked at her eye, and made herself comfortable on the exam table. Vital signs and sugar were normal. I told them to take her home and let her sleep. By this time more people showed up including her sister who finally said she had been drinking. The many people showing up every evening gets very tiring. I’ve heard that people with money wait until we are closed because they don’t mind paying our after hours fee so they don’t have to wait. Should it be more? Also, we see patients coming from beyond Fond Verette and Thoitte. They pass the bigger clinics and hospitals because we are cheaper, or they didn’t get help there, or we are white. Truly some tell us that! We try to explain we are just nurses and these clinics have doctors and more resources than we do. Should our prices go up? Should we charge for medications? We are here for the poor people of the mountains and want them to come if they need help.  Often Fre Willy in reception hears people say they can’t pay. We trust his judgment and he gives discounts to those who need it. But it's becoming too much for our staff and resources. Thankyou for your prayers and donations. They are very needed and appreciated. 

The 2 year old boy we treated for a burn last month has healed well. He has some scarring and loss of pigmentation, but healed without any infection! We gave him juice and protein shakes for the first week, since he wasn’t eating well. His appetite returned after that. His parents were very diligent with follow-up appointments and it’s good to see positive results.

CHC photo posted by permission