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
