About Moms and Babies...

Births at the clinic last month: 5

Births at the clinic this month already: 4(+3)

Average amount of pregnant ladies attending Prenatal Day every Wednesday: 35

Pregnant ladies sent down by ambulance this month already: 2

These numbers don’t look like much, do they? When I dream of a 24-hour birthing center built next door, with a surgical suite, OB doctor, and helicopter pad, would it be worth it? I think so, and I will tell you why.

_Have you delivered a stillborn? Or a tiny blue baby hardly breathing? Or a baby with deformities? 

Have you watched a mother writhe in pain while a tiny hand with a grasp reflex is visible, trying to be born? And the mother thrashes and won’t be calmed until there is a noticeable ‘pop’ and the tiny hand turns blue and lifeless. 

Have you seen a mother not eating or speaking, depressed after she fell on the slippery rocks and delivered a dead baby a few days later?

Have you picked babies up off bloody blankets on the muddy gravel outside of a locked gate, where the mother gave birth before help could come? Or the floor of an outhouse, or a porch?

Have you rushed by two tiny newborn girls being cared for on a dining room table to find a third little triplet, en-caul, and placenta already delivered on the porch floor?

Have you looked under the blankets of a mom’s bed who was carried by people to the clinic from miles away, only to see two little blue legs already there?

Have you watched a mom, one twin already delivered, bleed out in front of you, life draining from her eyes as you futilely try CPR? And then the main question you get later is why you didn’t deliver the second twin, as now the voodoo doctor must perform magic in order for them to be buried separately. 

Have you done CPR on tiny bodies that you hold in your hands, foam coming out of the nose and mouth with every compression of the pliable chest?

Then there’s the girl who was told by doctors that she would need a hospital delivery, but refused to listen and wouldn’t tell us that important fact, labouring 3 days before she got to hospital, only to lose her baby. 

Or the lady with pre-eclampsia/possible HELLP syndrome that got past the gangs but was shunted from hospital to hospital in the dangerous city of Port before finally delivering, saving her life but losing the baby, as it was born too early. 

Ironically, as I was typing this piece, I heard the dreaded call of ‘Baby in the outhouse!’ and there was a tiny baby with a mom in pain… when we got her to our delivery room, she soon delivered another, and then a third… all too small to live with our limited resources. At approximately 6 months along, they would have been whisked off to NICU at home. But this mom hadn’t even had any prenatal care by us, never mind a Doppler ultrasound telling her she was carrying triplets. She didn’t know who the father was and had four children already.

And here I am, a cowardly hypocrite, preparing to cross a restricted international border in a time of much unrest, to get on a plane and fly over 4,000 kilometers so I can get professional prenatal care and deliver our first baby in a hospital with a NICU and operating room close by. How can I look these women in the eyes and encourage them to deliver at home if possible? It’s because the Haitian women have a better chance of getting past the gangs, if they do need emergent care, than I do. It’s because the city of Port au Prince is too dangerous for me to go to the Canadian Embassy with my baby for the needed paperwork. It’s because, as little as I know, I’m probably the most educated experienced L&D nurse within a few hours’ radius. And other reasons too.  

We tell ladies to please deliver at home if there are no problems because we don’t have enough personnel here to accommodate all the babies born in Oriani, Gwo Cheval, Marie Claire, Jadin Bwa, Oplimèt, and from zones even farther away. We aim to be available for emergencies, and we try to catch potential problems in our prenatal care. We encourage monthly prenatal visits and at least one professional ultrasound. Thanks to Vitamin Angels, we have free prenatal vitamins to give to each mom. When needed and available, our ambulance takes emergencies to Fond Parisien. 

_And the birthing center could have more departments, like a nutrition program and a designated contraceptive clinic. And the surgical suite could be used for other minor surgeries. And the number of staff could be such that the nurse who answered two or more emergency gate knocks in the night wouldn’t have to be the same nurse opening the clinic the next morning. A step in the right direction would be control of the gangs to open the roads for safer passage, and to improve the roads for speedier access to care. One can dream. 

_A big thanks to generous donors who have enabled us to offer what we can! Please keep us in your prayers. 

Carmina

Keeping On...

Hello again from Oriani. It seems like only a short time since the last update, but already a month has passed. Our numbers are similar to last month at a manageable level. MSPP (the Haitian Health Department) sent a nurse to us for several months to oversee vaccines. It is good to see a little bit of activity from the government, even if it is minimal. She is busy on Wednesdays, our prenatal and vaccine day. One Wednesday she vaccinated 49 children! Other days of the week she doesn’t have much to do. Last week we printed flyers for her. She went to all the churches in the area to let people know to bring their children. There are anti-vaxxers here too, unfortunately. She will talk to parents with children waiting to be seen. Some will come to get their shots, others refuse. I’ve asked but so far haven’t got an explanation of why they refuse. Carmina suggested she go to schools to pass out her flyers, but she says school children are too old. After the child is 3, they refuse to vaccinate them. We told her that there is no medical reason for this, but that is their policy, so that’s what they do. 

Vaccination Day! Photo by permission CHC

After several months of trying, our clinic was accepted by Vitamin Angels. They are a non-profit that provides prenatal vitamins for pregnant women. This is huge for us as we see a lot of pregnant women and prenatal vitamins are very expensive. They provided us with enough for a year from a warehouse in Kwa de Bouqet. They also provide Vitamin A for children to prevent complications from malnourishment. They also give Albendazole (a dewormer) for children. We are thankful for their support. Everything helps. 

Vitamins

It is rainy season here. That seems to be the respiratory season too, just like at home. If you look at the report you will see we saw a lot of patients for respiratory conditions. Most are just flu-like symptoms. We give Tylenol and cough medicine and encourage them to drink a lot. Most Haitians seem to be chronically dehydrated. Some require supplemental oxygen and we occasionally keep them overnight, if we can’t wean them of oxygen. The 2 year old from last month came back. His father said he started having some difficulty breathing after lunch, so he carried him up the mountain to our house. He got there about 8 pm. Thankfully he wasn’t as bad as in August. So I gave him an inhaler and prednisone to go home with. I gave him a ride home in our landcruiser. It was about a 20 minute drive down the mountain. I made sure to praise him for not waiting to come. Maybe I did too good a job encouraging him, because they came back 2 days later as the boy still had a cough. I reassured the dad  and told him to continue the medications.

September Report

Nebulizer treatment Photo by permission CHC

The challenge of what to do with sick patients doesn’t get easier. We can tell them they need to go to a hospital, we can even get them to Fond Parisien or sometimes arrange a helicopter. Then what? They are no longer in an area they have contacts. They don’t have money to pay the hospital and we can’t help them. Sometimes they go and we hear they did well. We had one woman who had the end of her thumb partially torn away in an accident. I splinted it as best I could and told her she needed to see a doctor. She went to Port and they were able to fix it in place. She has been coming here for dressing changes until it is time to go to get the pin removed. Other times they simply refuse to go anywhere. We had a man in his 20s with abdominal pain. Ultrasound showed free fluid (sound familiar?). He was still able to walk. We told him he needed to go to Fond Parisien immediately. They assured us they would go right away. The next day we were told they didn’t go and he died overnight. Someone said they trusted the devil (Voodoo?) more than they trusted us. Saturday we had an unconscious patient brought to the clinic. She had had stomach pain starting last night. Her blood pressure was 73/32 (almost dead). I immediately started an IV and fluids under pressure. Further examinations didn’t show anything. Abdomen was fine, no free fluid. She had no other complaints than the stomach pain. I think it may have been a heart attack. There is no way for us to confirm here. Her blood pressure did improve with fluids, but immediately started to drop when they finished. We told the family she had to go to Port immediately. Initially they said yes, so we started trying to arrange a helicopter and find an accepting hospital. Then after they had time to think about it, they changed their minds. Only one person can go with the helicopter. Then they are alone in the most dangerous city in the western hemisphere. We could try to do more, but with nothing we could treat it would only delay the inevitable. She would not have lived long enough to take to Fond Parisien. So we sent her home and she passed away later in the day.

The border closure with the Dominican has had severe consequences for Haiti. A lot of food and other goods come from the Dominican. Many Haitians work in the Dominican. Most humanitarian organizations still working in Haiti rely on bringing in supplies from the Dominican. We do too. Half of our medications come from the Dominican with the other half coming from Port. I have been trying to keep the clinic stocked for 3-6 months because of how uncertain these supply lines are. We were going to the Dominican every month or so to buy supplies and groceries. We will be ok for a month or 2, but if the border doesn’t reopen, then what? Is it even advisable for us to stay with the worsening condition of the country? This area is secure, for now, but that could change too. Please pray for Haiti and for us.

    This is an excellent article on how the border shutdown and gang violence are affecting health care in Haiti. The hospitals and clinic in Fond Parisien are currently our only higher level of care we can access.

https://www.miamiherald.com/news/nation-world/world/americas/haiti/article279900234.html

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