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.