Thank You!

Hello to everyone from Oriani. As you can see from the report, November was a less busy month than October. While 1,100 patients is less than 1,500, it was still enough to keep us busy. A big change came when Carmina left at the beginning of the month. She helped me a lot in getting the clinic running, helping our nurses adapt to our way of doing things, revamping our protocols, and helping me learn to operate here. She is missed but we wish her well.

            This will be a shorter than usual update as I am tired. I was up most of the night with a delivery. The delivery went well for the mom, but the placenta separated early and was delivered with the baby. The baby wasn’t breathing. I suctioned the nose and mouth thoroughly then started assisting breathing with a Bag Valve Mask (BVM). After about 10 minutes, when I had almost given up, the baby finally started breathing on her own. When they left the baby was opening her eyes and crying. After that long I am very concerned for an anoxic brain injury. God only knows how she will turn out.

            On the 13th a 15 year old boy was brought to our house after falling off a moto. He had a large wound on his left foot. At first I didn’t think I could close it enough to suture it. But after cleaning the wound, I was able to use X sutures to pull it together enough to suture the rest. After bending over his foot for an hour, my back seemed to be hurting me more than his foot was hurting him. I had numbed it with lidocaine, but he never flinched. I asked him several times if it was hurting him and he said no. I gave him Bactrim for antibiotic prophylaxis and a tetanus booster. He came back on the 16th and 20th for check ups and dressing changes. On the 1st we were able to remove his sutures and it seems to be healing well.

            After placing several large orders of medications over the last 2 months, I can finally say the clinic is stocked with medications for 6 months. This has been my goal and going forward I will try to keep it stocked at that level. I want to thank everyone for your donations. Money donations are very important to allow us to buy supplies and pay our staff, but material donations are great too. We have received donated supplies from people in the US and Canada. Thank you for this. These are useful and often are things that we can’t buy here. We plan on going home for Christmas since the border seems to be opening. The clinic will be closed between Christmas and New Years to give our nurses the chance to go visit their families in Port au Prince. Thank you again for your support!

Tropical Medicine

Hi, from Oriani! It is already time for another monthly report. The month of October was very rainy, but now the sun has been shining for the last few days. It is good to dry out and recharge our batteries. On rainy days our batteries at the clinic do not recharge, so if we get several rainy days in a row, we need to run a generator. 

Two weeks ago we started hearing reports of numerous people from the zone below our house getting sick and some dying. We didn’t see many in the clinic. The ones that came in would complain of vomiting and with questioning would complain of diarrhea. They never looked very sick here, but people here are very scared of cholera outbreaks. The symptoms didn’t really seem to match typical cholera. Not that I have any experience with it yet. Cholera usually causes almost non stop diarrhea, from what I’ve been told and read. I had one come to our gate in the evening. She only complained of vomiting. I brought her to the clinic. While I was opening the clinic she had diarrhea in the outhouse. After I questioned her again she said she had diarrhea earlier in the day. Her vital signs were fine. Even though it hardly seemed indicated, I gave her 2 liters of fluid. I also gave a cholera dose of azithromycin and medication for nausea. I sent her home feeling I had at least helped one. The next morning I heard she had died. She was young, only in her 30s and seemed healthy enough and after the nausea medicine was able to drink almost a liter without vomiting. I was told of numerous people that died after the same complaints. They would start vomiting then some would die within a day. It's very confusing, especially without being able to test to see what disease they might have had. I did message MSPP (the health department) and they wanted me to collect information on those who got sick. Fre Willy started a list of everyone who checked in with these symptoms and everyone they reported was sick or had died and in his morning address would encourage people to only drink treated or boiled water. Clean water here is a challenge as everyone drinks from cisterns and any bush is a bathroom. (Thankfully we live on top of a hill and have a good water treatment system.) I also told the nurses to give everyone with any abdominal symptoms the dose for cholera. As of this week we haven’t heard any more reports of this disease, thankfully. Hopefully it is over and we won’t see a full outbreak.

In September I was sick for several days. I would spike a fever every couple hours and have no energy. Tylenol and Ibuprofen would barely do anything. I had no other symptoms, so it was hard to tell what it was. The next week Carmina had the same illness but she had a rash. Then Julie had it and the rash and our children had fevers for several days. Over the same time, we started seeing patients with similar symptoms. Usually just a fever. If they had a rash, it didn’t show on dark skin. One of our aides was sick for several days and felt itchy. I read a news article that said the Dominican was seeing a lot of cases of Dengue fever, these symptoms match that so it’s a good guess that's what we were seeing.  Not having a lab to help diagnose is one of the biggest challenges of working here. That, combined with the local population often being poor historians makes it a challenge to be sure of a diagnosis. All we can do is collect as much information as we can, fit it to a disease pattern, and give the best care we can. Thankfully dengue is rarely serious. Over this time we did see several patients that were more serious with respiratory symptoms. Dengue can cause pulmonary edema. One woman we kept on oxygen for several days and treated for pneumonia. This woman is a good example of a dilemma we face several times a week. She was sick enough to need to go to a hospital that can do further tests and inpatient care. When we told her this, she said she didn’t have money to pay for a ride to Fond Parisien or for the hospital once there. Ok, so we can offer an ambulance ride. Then what about the hospital cost? Do we help pay for that? That amounts to us funding a bigger organization than us with more resources than we have. And how often can we send our ambulance? These roads tear up vehicles. Parts are expensive and difficult to get. And finally if we do all this to get them to Fond Parisien and the hospital there says they need to go to Port? For this patient I was willing to give her a free ride to Fond Parisien and a little money once she got there. Then the mom came in. She kept asking for more money, and I quickly got the feeling she might not have her daughter’s best interests at heart. I decided I would offer the mom no money, but give it to the ambulance driver to give to the daughter in Fond Parisien. Then they decided not to go. We kept her for 2 days on oxygen, then let her go home. Her oxygen level was still not high enough to meet discharge criteria in the US. We told her to come back next week. She did and was doing fine! These decisions are never easy and are the most draining part of my role here for me.

I don’t want to give the feeling here that we seldom see good outcomes, so I will finish with some good stories. One of Sebastian’s Sunday School teachers came in very sick with a low blood pressure. He had a cough for several days with yellow sputum. He had fine crackles in the left lung base and ultrasound showed possible consolidation in the left lung base (please correlate clinically). We gave him fluid to bring up his blood pressure and gave him Ceftriaxone IM and Azithromycin pills. He came back the next 2 days for more IM Ceftriaxone and to see how he was doing. He was in church Sunday and back to normal.

Another story that I don’t know the ending to yet, but so far seems to be ok. I had a woman come to my gate at 3 in the morning. She is 33 with 6 children at home, one died, so 7 pregnancies. No reported complications with any of them. Her last baby was born in September. She came to the clinic one time in June with a normal prenatal check. Family said she was fine the day before until 10pm when she had a seizure. She had several more before they came to our house. She was unresponsive on arrival. I brought her to the clinic. 2 months after delivery it is very unlikely to be eclampsia, but what else could it be? Blood pressure was slightly high and her oxygen was a little low. I started oxygen and it quickly came back to normal. She started waking up, but was very confused. Then she had another seizure. This was the first one I saw and it convinced me they were real. Not that I didn’t believe the family, but seeing a classic seizure helped me decide what to do. I started the IV magnesium bolus. She went through the classic postictal phase and started waking up again, but was confused and agitated. I gave 10mg of IM diazepam to help calm her. Magnesium bolus finished so I switched to the maintenance infusion. (Insert here. Your donations helped buy a subscription to UptoDate, an excellent resource. It is our primary resource for most of our protocols here and my go to, along with Medscape for helping with medication doses and diagnoses.) After about an hour she had another seizure, so I gave 10mg of IM Midazolam. In the meantime I talked with the family about sending her by helicopter to Port au Prince. They agreed and the husband went to get money and clothes. I messaged Haiti Air. We need to find an accepting hospital prior to transport. That is very difficult to do over the phone with limited Creole. There are 2 doctors in the area from Port here to do first aid in local schools. They came by to see if they could help. I asked one, Dr Pierre, if he could call to arrange the hospitals. He did, and found an accepting doctor. The midazolam and magnesium stopped any more seizures and kept the patient asleep. Carmina came then and placed a catheter. Then all we had to do was wait on the helicopter. They came at 9:30 and took the patient to Port. Dr Pierre messaged me in the evening and said she was in the hospital and doing well. 

The border with the Dominican is slowly opening. We were able to get an order of medications several weeks ago. Along with a load from Port we are stocked for 3-6 months. That is my goal. I hope to do one more order from Port and the DR this year to keep us at the 6 month level. We are still not sure if we can cross the border into the DR. I have heard mixed messages on that. One Thursday, 11/9, we plan to take Carmina to Santo Domingo. She flies home on the 11th. This will give us an extra day in case of trouble. It is sad to lose her at the clinic. Her knowledge and experience has helped me a lot with a second opinion and updating our protocols. She will be missed and we wish her well.

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