Questions and Some Answers

Hello from Oriani. We are still here and still working! Numbers continue to be down from summer, with the exception of after hours calls. Those still come in. I met with the local board to discuss this and see if they had any ideas. They have heard of people not coming to the clinic because they are afraid they cannot pay. Our prices are still very low compared to other clinics and we help people whether they can pay or not. They recommended we have a meeting with local pastors and other leaders to discuss this and encourage people to come to the clinic regardless of their ability to pay. Over the summer we had people coming from long distances past other clinics and hospitals because we are cheap. This was straining us to keep medications in stock. We are here to help the poor people of the mountains, not people with resources that come from Croix de Bouquets, because they don’t want to pay for medications. In November we started charging a small amount for medications patients take home from the clinic. Medications such as prenatal vitamins donated to us are provided free. This doesn’t cover half our costs for medications, but we thought it might encourage people not to drive past other clinics to come here. If patients say they can’t pay, Fre Willy and Fre Roosevelt in the pharmacy can make the decision to give medications free of charge. They are locals and know the needs of the people. It’s hard to know what the proper balance is. I hate asking people to pay, but we felt it was necessary to not take business from other clinics. Pray for us that we can have direction for this.

One afternoon I was catching up on work at the clinic and Kelson was out front. He heard a commotion at the gate and called me outside. I was met by a mother carrying a 7 year old boy covered in dirt with blood running down his face. He had been hit by a moto in the market. We brought him inside and started assessing and cleaning him up. The blood on his face was from a small wound above his eye. His left lower leg was deformed and appeared broken. I closed his wound with a suture. We put a splint on his leg and told them they should go to Fond Parisien for an Xray. They said they would but the next day we heard they had gone to a leaf doctor instead. They live close to the clinic so we went to their house to check on him. The leaf doctor had removed our splint and put on some sticks and some concoction that dries almost as hard as a cast. But it was too tight and only several inches long, so it didn’t provide proper support. We asked if we could put it into a cast. Mom agreed, so we went back to the clinic to get supplies. I gave him a shot of morphine. We tried to align the bone as best we could and put on a cast. We gave him some ibuprofen for pain and encouraged him to try and walk on it. I just checked on him, he is doing well with only 3 weeks to go until we remove it.

            Sunday morning a landcruiser came to our house. In the back was a woman unconscious with deep rapid respirations. We met them at the clinic. Oxygen was normal with good air movement in her lungs. Her sugar read hi. So, DKA. I remembered the first patient I had here in Haiti. Very similar presentation. It was before the clinic opened so all we could do was give her some fluids before they took her to Fond Parisien. There the hospital sent her to Port, where she passed away. Remembering that I decided to do what I could for her here. I had tried for months and finally got regular insulin and IV potassium and magnesium. I started 2 IVs and started giving lots of fluids with IV insulin every hour. With DKA and IV insulin low potassium is a big concern. We can’t check potassium levels here. We bought a new monitor last fall so I placed her on telemetry (on our new monitor) and placed a catheter to monitor fluid output. I gave her potassium in the fluids. I know this is a big risk, but what choice is there?

I checked with the helicopter, but they were out of service. I kept giving fluids, insulin, potassium, and magnesium, wishing I knew what her levels really were. She had significant ST depression on telemetry, which can be caused by low potassium. It was interesting to watch the ST depression slowly correct with treatment. I stayed at the clinic all day and all night. This clinic gets COLD at night in the winter. The nurses gave me breaks to go eat. In the morning, she was awake, still breathing a little fast, but able to sit up and talk. I stopped giving IV insulin for a few hours but her sugar started going up again. So we continued with insulin and fluids. Kelson came and watched her for a few hours for me so I could go sleep. I went back to the clinic after lunch. The patient was doing much better. A urine strip had shown a possible urinary infection, so I gave her antibiotics for that. Ideally, she would go home on insulin, but here that is impossible. So I gave her diabetic pills, and hoped for the best. We told her to come back at the end of the week for a follow up. She was brought back to the clinic on Wednesday, unconscious, with a sugar of 444. We started IVs, fluids, and insulin again. I contacted Haiti Air. They were on another flight, but said they would ask the pilot when they got back if they could fly. Meanwhile I started calling hospitals and doctors in Port trying to find a place that would accept her. This is a frustrating process. Finally found one that said he would. Haiti Air got back to me and said they would fly. Their dispatch called the doctor to confirm he would accept the patient. He said he couldn’t anymore, but gave the number of another doctor who eventually said he would take her. So I notified Haiti Air. Eventually they got back to me and said they could no longer come, but we could try in the morning. So I messaged a doctor in the little hospital in Fond Parisien. He said to send her there. So I talked with the family and they agreed. Wozema took them in the ambulance.

The next afternoon, I was told she had died in the hospital in Fond Parisien. So many questions. What could we have done different? Should I have sent her Monday after she was stabilized instead of sending her home? Should I have kept her overnight again? Could I have done a better job of stabilizing her? Why is this country such a mess?

            We have had Mis (nurse) Rachelle here from MSPP (Haitian health department) to do vaccines. She has been here for 6 months and has done an excellent job of keeping vaccines on hand, keeping up with childrens’ vaccines, and filing appropriate reports with MSPP. Her contract with MSPP to be here ended at the end of January. I’m happy to say she agreed to continue under contract with the clinic. This is possibly the most important service the clinic offers, and I’m happy to have her continue.

This is a picture of the baby that was resuscitated here in the clinic in November.

Thank you for your prayers and support. I am always happy to hear from anyone, so feel free to reach out. God bless you all!

Bon Ane! (Happy New Year)

Happy New Year to everyone! Thank you for your support. We couldn’t do it without you. Your support means a lot to us! Know that you are making a difference in a lot of lives here in the southern mountains of Haiti.

Sorry for the late update. We have been very busy with travel and visitors. We left Haiti on December 7 to spend time with family and friends. We weren’t able to leave through Port au Prince since the roads are blocked by gangs. My understanding was that the border was open to people with American and Canadian passports but not to Haitian registered vehicles. Carlos, our DR contact, met us at the border to help us out. Everything went smooth on the Haitian side. The Dominicans were having problems with their computers but eventually let us through. We came back into Santo Domingo on December 27. We had some difficulty at the border and weren’t able to cross into Haiti until the 29th. My brother and his family came with us. It was good to have them here and show them what we do. Visitors are a good morale boost. My niece Heidi came with us too. She will stay here to teach our son Sebastian who is starting kindergarten. On the 3rd of January we took my brother and his family back to Santo Domingo to the airport. They flew home on the 5th. We also picked up my wife’s cousin Kelson and Keith’s cousin’s daughter Taija. They volunteered separately to come help for several months with whatever we have for them to do. Maybe now I can finally get our supplies better organized and caught up on the many small projects I have been falling behind on.

We came back to Oriani on the 8th. Our staff did a fine job of keeping the clinic open in our absence. The clinic closed December 21 and opened again on January 3. As you can see from the report we are seeing a lot less patients over the last month or two. I am not sure why this is, but I have some ideas. Dry season started in November and this coincides with the drop in patients. As you can see, we are seeing a lot less diarrhea and respiratory conditions. Maybe the dry weather is healthier. Maybe not having so much runoff into cisterns helps them have clean drinking water. Also with the gardens not producing, maybe they have less money and think they can’t come to the clinic. This is what Fre Willy tells me when I ask him. I keep telling him and Fre Roosvelt that if people can’t pay we will help them anyway. But maybe that stops them from coming? I hope not.

In November 2 young doctors from Port au Prince came to the area. They were teaching first aid classes in local schools. They borrowed some supplies from the clinic and we gave them some money to help with expenses. One of them, Dr. Pierre, expressed interest in working at the clinic. He worked in the clinic for 3 weeks on an unofficial basis, overseeing the nurses and helping me rewrite some protocols. After some deliberation we offered him a contract. He returned to Port for Christmas and to discuss it with his family. Unfortunately for us he declined. He said he was interested and wanted to come, but his family didn’t want to move to the mountains and he didn’t want to have to pass the gangs to go see his family. Very understandable. It did open us to the idea of hiring a doctor, but who knows what the future holds. Maybe it is something we should pursue.

P.s. I asked Fre Willy about the baby that was born not breathing the first of December. They live close to him. He says the baby is doing well. Thank God.

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.