Count your blessings

Good morning from Oriani, Haiti! It is a beautiful sunny morning here. Yesterday was market day and the village was full. We always see more patients on market days. Today, the village center was a little more quiet without lots of people setting up for market. There were 15 people sitting in the benches this morning. I’ve been noticing that as we stay open from 8 - 2 every day, we don’t have as big of crowds in the morning. Instead of everyone coming early to try to be first, they come throughout the day. The mountains are still peaceful with people going about their lives. There is plenty of food in the markets, but prices are high enough that people struggle to buy food. Our dry season wasn’t as dry as some and we had some rain in February and March. This helped people start their gardens and for weeks we could see groups of men hoeing and planting. We didn’t have people begging for water like last year and the moto wash up the street was going every day, so it seems people weren’t hurting for water. Rainy season started 2 weeks ago, but it hasn’t been extreme either with gentle rain most afternoons. Hopefully this will allow for people to have a good harvest.

It really seems like a different country from the reports of chaos and violence in Port au Prince. That does affect us of course. The “toll” charged by the gangs on trucks bringing garden produce to Port and rice and other items to market here is part of the reason food prices are high. Our agent who buys medications for us in Port was able to find some in March, but April has been too dangerous for him to travel. We are having to rely on our stocks and the limited medications we can get from the Dominican. The Dominicans’ response to the situation here is quite frustrating. While it is understandable they don’t want the chaos to spill over, they don’t seem to make an exception for humanitarian agencies. I spoke with a Dominican immigration lawyer who made some inquiries for us. He said there are no exceptions granted for humanitarian agencies. Instead we have to negotiate with local officials if we need to cross. Another issue is the gangs like to cause havoc by shutting the fuel terminal in Port, making fuel harder to find and more expensive.

The violence in Port has led to most hospitals there shutting down. I saw an article that there are only 2 still open. This makes it very difficult to know where to send patients needing a higher level of care. We had a man with wounds on both his legs that has been coming to the clinic for years for dressing changes. His chart goes back to 2021, but Fre Willy thinks he has been coming longer. He needed a skin graft if the wounds were ever to heal. But he had no money to go anywhere. In January we decided to give him money to go to Port. I told him this money was given to God by christians in the US to help people in Haiti and now that I was giving him some, he was responsible for how it would be used. In the past when I gave money there have been times when I fear the people did not use it to seek help like we wanted. So I tried to impress him with the responsibility. He asked us to pray with him before he left. He went for a consultation at Benard Mevs in Port in January. He came back 2 weeks later and said he had an appointment in February for the operation, but needed more money to pay for it. We generally don’t give money for other hospitals as it equals us funding larger organizations, but since he has been coming for years with no progress, we decided to make an exception. So I gave him more money in February for the skin graft. Fre Willy said he had stopped by in March while we were in the Dominican. They still hadn’t done the graft but he had another appointment and was going back. Now I didn’t see Benard Mevs as one of the hospitals still open. Was that money wasted? Hopefully not, but we will see. This is the question I try to understand, how to help. By helping people go am I sending them into a dangerous situation to look for help that can’t be found? Sometimes the choice is easy when I know they can find help in Fond Parisien, for example. Last week we had a very malnourished 5 year old boy come in. If it was only malnourishment, we could have taken care of him here. But he also had a palpable mass in his belly. The little hospital in Fond Parisien has surgeons that can take a look and decide if it needs surgery. A decision I am not qualified to make. So I offered the ambulance. The mom of course didn’t have money, but when I said she didn’t need to pay for the ambulance, she went to find some money and see to it her other children were taken care of. I gave the ambulance driver some money to give her in Fond Parisien and told her, if the hospital didn’t want to do an operation, to go to Love a Child as they have a malnutrition program. This time the ambulance did make it back under its own power, but barely. There is a problem in the fuel system that hopefully we can find and fix.

Friday night we had some frantic women come to our gate with a 4 year old girl. It had been raining and a large branch fell on her. They weren’t able to say where it had hit her and I couldn’t find any injury. She was not responding normally, drooling with her eyes fixed to the right, right side with reduced strength, and left side contracting spasmodically. I gave her some water and she was able to swallow, so at least her airway was ok. I couldn’t do more for her and there is nowhere to send a patient like that. We told them to go home and pray and we would pray too. The next morning they brought her again. They had found a little bump on her head, but otherwise she was fine, standing up and holding up both arms to her mom. A mild concussion? Or a miracle? Either way, thank God! Sometimes we feel so helpless here. Yesterday we had a 2 year old girl come in with second degree burns on about 20% of her body. Family said she dumped a pot of corn. They said it happened 6 days ago. Why didn't they come then? I wanted to yell at them, but held my tongue as I didn’t think it would help. We sedated her with Ketamine and debrided it, then covered it with burn cream and non adherent pads. The burns really didn’t look that bad considering they have been uncovered for 6 days. I can’t imagine the pain the poor girl was in. We gave her antibiotics and protein and vitamin supplements. She will come back every day for dressing changes. I just finished it today, and I think she will do well. Thank you for your continued support. Despite the less than ideal conditions, God is blessing us that we can continue here.

There and back again...

Hello to everyone! Well it was an interesting month. Numbers are still down, but up some from February. Our vaccination program continues to be a success, with Mis (creole for nurse) Rachelle vaccinating more than 25 children every Wednesday. With Port au Prince continuing to be extremely chaotic, it's a miracle we can continue to get vaccines. Things seem to be calming down in Port a little. At least vehicles can get in and out. Our agent in Port messaged me and said we can get some medications right now. The depot that gets our orders together is still functioning, but if they don’t have what I want, they call other depots. Many of these others have been burned. So there are some medications I asked for that they don’t have. Our agent in the Dominican is still able to import medicine for us. We have a 3-6 month inventory of our most used medications. Another challenge that the recent chaos has presented is the closure of the airport in Port. This means MFI can no longer fly from Florida. Their service is incredibly useful as that is how we get donations, vehicle parts, medical, and household supplies from the US. Hopefully this will not continue for too long as it will make it difficult to keep our vehicles running.

Speaking of vehicles. Our ambulance has presented some challenges. In January, Rosemard took a patient to Fond Parisien. On the way back it stopped running just above Fond Parisien. He called me and we spent the night towing it back. Through the narrow switchbacks above cliffs and through the river below Fond Verrette. We made it back ok, but it’s not an experience I wish to repeat. We were able to find the part we needed locally and our mechanic, Jenel, got it back into service. In the beginning of March, Rosemard, took another patient to Fond Parisien. On the way back, at almost the same spot the ambulance broke again. This time it was broke badly enough that towing was not an option. This was the night before we left Oriani to take Kelson and Taija to the airport in Santo Domingo. I couldn’t do much to help, so I sent a neighbor on one of our motos to bring Rosemard back. Unfortunately the moto broke as well. Poor Rosemard spent all night walking up the mountain and got to our yard just after I woke up in the morning. Rosemard and Jenel spent the next 2 days hunting for parts to fix the ambulance and repairing it before they could bring it back. Jenel spent 2 weeks going over the ambulance and our Land Cruiser, making sure they were both road worthy. We had to buy many parts locally. While they can be found, the price is a lot more than in the US. To give an idea, a bushing that costs maybe $30 dollars with shipping, cost $115! We spent more than $2,000 dollars on vehicle repairs. It is enough to make me despair of using our ambulance, but Jenel says it is good to go now.

Our trip to the Dominican was very enjoyable. We spent some time at the beach and visited some missionaries. We spent a day sightseeing in Santo Domingo before Kelson and Taija flew home. This happened to be right when Haiti was making the news for all the wrong reasons. Port had exploded in violence and the gangs attacked Ganthier, our line of defense here in Oriani. Because of this, our board in the US and Canada as well as local Haitians encouraged us to stay in the Dominican for another week. We spent a day shopping for supplies in Santo Domingo. Not sure what else to do, we went to Santiago in the north of the country. There the missionaries put us in touch with someone who had a house to rent. We spent 4 days there. By this time, the gangs had been beaten back from Ganthier. While Port continued in chaos, the mountains of southern Haiti remained calm. So we decided to come back. We made it back to Oriani on March 18. Everything seems as normal here, but things locally are getting more expensive as items from Port become more scarce. For example the local price for gas is almost $13.50/gallon. As long as the gangs can’t pass Ganthier or Jacmel, this part of Haiti is safe. If we need to we can leave down the south side of the mountain and cross the border at Anse a Pitres.

We didn’t really have any outstanding cases in the clinic. We did have one 18 month old girl we had to keep overnight on oxygen. She had a respiratory infection, possibly pneumonia. She was doing better the next morning and was able to go home. One of the big difficulties here is getting patients to follow up. The patient from February who had multiple thoracentesis came back one time in March. She is still retaining fluid and needs close follow up. I gave her medications for a week, but she did not come back. I gave her some money every time for food and for a moto as she couldn’t walk far. Fre Willy told me she is poor and needed money. It’s a little frustrating as we had just started making progress and I have no way to contact her.

We were closed on Good Friday, so 2 of our nurses went to Port to see family this weekend. I didn’t question them as they know much better than I do how safe it is. Another small update. Last week Rosemard was finally able to make it to Canada to be with Carmina and their new baby. He will be missed, but we are very happy for them. Well for now we can stay and will keep operating as best we can. Only God knows the future, but this country needs a miracle.

Troubled Times

Hello from Haiti to everyone! Well first thing is to address the situation in Haiti and how it affects the clinic. I’m sure you all have been reading the news, so I won’t go into great detail. The gangs in Port au Prince have been causing trouble for years making it unsafe for us to go to Port and expensive to transport medications and other supplies from Port. In the last month they have combined in an effort to overthrow the last remnants of the government in Haiti. Over the weekend the violence has escalated dramatically with attacks on the airport in Port to prevent the prime minister from returning. They have also launched concerted attacks on police stations and broke open 2 prisons releasing an estimated 4,000 more violent bandits. Port is in complete turmoil at the moment. This makes it impossible for us to buy medications and other supplies in Port. However, we were able to go to Fond Parisien Friday and buy gas, propane, diesel, and medications from the Dominican. The clinic is well stocked to go without more supplies for several months. Hopefully then the situation will have calmed down. The other effect this has on the clinic is on patients that need a higher level of care. If we or the hospital in Fond Parisien can’t help, they have no other options. This puts much more pressure on us to do everything we can here. As to our security here, the mountains remain calm and peaceful. The gangs need to pass Ganthier before they can reach Fond Parisien and the road up the mountain. So far they haven’t been able to pass Ganthier. As long as it stays like this, we are safe here. If the gangs were to pass Ganthier, we can go down the other side of the mountain and cross into the Dominican at Pedernales. The markets here still have food available. The prices are high and this makes it difficult for the poorer people to buy. There is so much need here, but sometimes it feels like there is so little we can do. And the rest of the country is in much more dire conditions, yet the international community does nothing. Pray for this country and for us.

2 weeks ago we had a 31 year old woman come in with significant swelling to her abdomen and legs. Blood pressure was a little high. We gave her medications for her blood pressure and furosemide, a diuretic, to help take off the fluid. She came back that Thursday, much worse, struggling to breathe. I told her she should go to a bigger hospital, but they said they had no money. I thought about taking her to Fond Parisien by ambulance, but I didn’t know what they could do for her. Ultrasound showed she had large bilateral pleural effusions. Over the summer we did a paracentesis to drain fluid off a patient’s abdomen. Then we sent her to the hospital in Fond Parisien for further workup. They sent her home and said they didn’t have a doctor that could do a paracentesis. Yet nurses at a clinic in the mountains could? Oh well. With that memory in mind and nowhere else to send her, I decided to try a thoracentesis to drain the pleural effusions. This involves sticking a large needle between the ribs into the pleural space to drain the fluid. The needle is withdrawn and a catheter stays in place so the needle doesn’t harm the lung. Care must be taken to avoid puncturing the lung and sterility is vital to avoid an infection. For all these reasons I was afraid to try it, but she clearly needed it. So I set up with nurses and Kelson’s help. Without ultrasound to help avoid the lung and the liver I would not have done it. I’m very thankful for that ultrasound. The procedure went well, and we drained 1,200 ml in total off both sides. Afterwards, she looked much better. She was breathing normally and able to eat. Without being able to do more of a workup it is hard to know what caused the problem. Postpartum cardiomyopathy is a problem, but her last baby was a year ago. I gave her metoprolol to slow her heart and lower her blood pressure, lisinopril to help with her blood pressure, and furosemide to help reduce fluid retention. She came back the following Monday, still doing OK. Her pleural effusions looked a little worse, but I sent her home. She lives close, so she was able to come back Thursday for a checkup. This time she was having more trouble breathing, so I repeated the thoracentesis. This time I was able to draw 750ml off the right side. After her pleural effusions were almost completely gone. We gave her the option of going by helicopter to Mirebalias. The hospital there is much cheaper than the ones in Port. They said they would think about it and let me know. However, over the weekend the gangs attacked the airport in Port and now it is closed. She will come back tomorrow for a check up.

THORACENTESIS

Last Wednesday we had an unresponsive patient brought to the clinic. He is 45 years old. His wife said he went out to the garden to take care of the animals, when he came back to the house he drank a Toro (a Haitian energy drink). Afterwards he said he had a headache, then had trouble walking and finally collapsed. He was completely unresponsive and barely breathing. At home we would have intubated him and placed him on a vent before taking him to CT. But here? I suspected a stroke. I wasn’t sure what was the point, but I set up a BVM, connected it to oxygen, and started assisting his breathing. I also had to keep suctioning him, because he had a LOT of secretions. His initial oxygen level was 5%. (Congratulations sir, officially the lowest I have EVER seen.) After a bit his oxygen level started coming up. Then he started trying to breathe on his own. Eventually I was able to stop bagging him and switch to an oxygen mask. He still wasn’t acting appropriately. Watching him, I wondered if I had resuscitated him only for him to have an anoxic brain injury. After speaking to the wife and family more, they told me he had a brain surgery in the Dominican 12 years ago after an accident. I started thinking maybe he had a seizure. They said he never had a seizure before (props to this family for the best medical history I’ve ever received here). This would make it more likely for him to have a seizure. Maybe not eating or drinking much before drinking the Toro triggered a seizure? I told them he should go to Port to speak with a neuro doctor and have a head CT. I contacted Haiti Air. They asked if the family had $400 for a CT. That’s a bargain by American standards, but a lot of money here. They didn’t. I prayed the prayer I often pray, “God, help me know what to do to help”. The patient was having violent tremors. It didn’t look like any seizure, but I decided to give him Diazepam IV just in case. This seemed to help his neuro status improve. He started talking and was oriented! I finished giving him a liter of fluids and was able to remove the oxygen. He staggered out with a man on each side supporting him. I still wasn’t sure what the cause was but gave him seizure medication to take at home just in case. I also gave him antibiotics in case he aspirated while I was bagging him. This morning he came into the clinic, walking on his own, perfectly fine! It was amazing to see! Nothing like shaking the hand of a man I almost gave up for dead to make your day. An amazing and humbling experience. Miracles still happen.

One of our after hours visits was a little boy who fell on some metal. He had a large cut on his head with skull exposed. While irrigating the wound, we could see the skull had a scratch. Kelson did a good job suturing. The boy came back a week later and the cut had healed beautifully.

We were able to take the cast off the boy with the broken leg. I just checked on him. He is walking with a limp, but able to put weight on it. I encouraged him to  keep walking, and he should do well. Thank you again for your support!

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!