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

WHAT NEXT?

I have not found a place where life and death, survival and ‘thrival’ hang so precariously in the balance as in this country of Haiti, and this last week has been no exception. The closure of the border by the Dominican president over a group of Haitian farmers trying to irrigate their drought-plagued land has affected everyone. Commerce is grinding to a halt on certain items, among those medication, fertilizer, and food. Banking and travel are going to be severely limited if not almost impossible, as the road to Port au Prince is hot with gang activity. What do we do? There are still blessings: gardens are being planted, rains are plentiful, cisterns are full at the moment. 

The clinic numbers seemed to have leveled out and we see around 60 to 100 people a day. I had a lady who hadn’t been to the clinic since 2016, according to her chart. Her nonsensical explanation to this was that she heard the ‘whites’ were back, so here she was. 

A lady gets carried up on a bed. The husband seems frantic, telling me she’s not talking, not eating, not drinking for three days. Others inform me that no, she has been getting nourishment. She says words to us. I dig deeper… only three days? She looks a lot sicker than that. Ok, about 9 days, with the last three being much worse. Ok… I ask what the leaf doctor gave her, tricking them into admitting they tried him first. A pill and a syrup, they tell me. Then he tells me they come from far away, and everyone listening bursts out laughing as he says Oplimèt, the area right next to Oriani and not considered far at all. Jonathan establishes an IV with the help of ultrasound, as her veins are pretty flat. Blood test shows HIV. I test the husband, who also has a non-healing dermatological condition on his chest. HIV positive. We explain the malady and put them in touch with the Croix-des-Bouquets TB and HIV clinic for the much-needed anti-retrovirals. It may be too late for the lady. 

A mom silently labours as she waits for her prenatal consult and delivers almost as soon as she’s called into the consultation room. The quietest Haitian labor I’ve witnessed, I think! She doesn’t have a name picked out for her girl, so when Nurse Vitanie fills out the certificate we start suggesting. The mom rejects one suggestion of Roselande but takes my suggestion of Daphlinka (my go-to for naming baby girls here). I tell the mom she can give her two names, and suggest her name, Jackline, for the middle name. Mom seems quite enthused. Another bonus: she’s sitting on a hard bench, breastfeeding the minutes-old newborn as we discuss this. I have high hopes for this baby!

I am seeing a patient in my room when Sè Papi comes in with a bundle. Look at this baby, she says. A tiny baby, dead of malnutrition. We ask the mom when she had died. While she was waiting for her appointment here today she says. Yes she had gone to Forèt clinic with her. They said she was malnourished. Did she give the baby any milk or breastfeed her? No. She was a month old. The mom has a very flat affect and quite a few children at home. I add a piece about postpartum depression into my prenatal course.  

Vitamin Angels donated prenatal meds, vitamin A, and albendazole, so we are working on rolling out a program where we try to keep better track of dewormer and supplements for children under 5 and continue pushing prenatal vitamins on all pregnant and breastfeeding moms. One old wives’ fable I’m trying to quench (one of the many!) is that taking prenatal vitamins will make your baby big and therefore make labour more painful. 

MSPP, the national health care authority, has sent a vaccine nurse to help us for 6 months. Wednesdays are her busiest days, so in the meantime she helps out in the consult rooms and the pharmacy. 

And coming up in November, the Lord willing, there will be a vacant position for a nurse. However, with the indeterminate DR border closure, will there even be enough supplies and funds to run a clinic at that time? This is a day-by-day adventure like none other, this Oriani clinic life! Please pray for us and the people we are here to help. We don’t know the future, but we know Who holds the future.

THE CIRCLE OF LIFE

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

Successes, Failures, and Near Failures?

Many inspirational quotes for success and failure say success is personal, not the outcome, and failure isn’t the end… but in the medical world, I beg to differ. Success is a good outcome, and failure can mean harm or death. I think we all have ‘what if’ thoughts, and here, in a remote, low-resource medical setting, it’s often difficult to not ruminate on the failures, as they feel like your fault.

As Jonathan and I are doing a paracentesis in one room, a twin is born in the outhouse. The other nurses and aides situate mother and baby in our delivery room and encourage her to push. When I get there, I see the second twin’s placenta has come out before the baby…how long? Time to get this little one out. But mom seems stalled with pushing and the baby is high, albeit with head presenting. I find a vac-assist device and start pulling, worried this mom will have to go down for C-section if we don’t get the babe out. After a few good pulls, mom pushes, and a little blue girl is there. Not much sign of life. An occasional heartbeat. The rest of the staff encourage me to start CPR, which I do. Not much improvement, and I think of how hard life is for babies here, never mind tiny preemie twins, and a possible hypoxic brain injury? I talk to the mom. I tell her she has a beautiful girl, and she should name her and her sister. She can always tell her little girl she has a sister in Heaven. Surprisingly, the mom comes up with two names, Mirlandy and Mirlandia, and specifies which is for which. She is calm as she leaves. 

The paracentesis: liver failure, ascites, jaundice from? hepatitis? in a young lady. Came to us twice and we took off 6 liters each time before they went to Fond Parisien. FP hospitals said they couldn’t help; she needed a bigger hospital. So when they came back and asked us for help getting her past the gangs to one, we managed to get Haiti Air Ambulance to fly up. It was lovely to see Larissa again. And know that our patient would be getting the care she needed at last. 

P.S. Word on the street 6 days later is that she died. Likely only a transplant would have saved her. What ifs crowd into my thoughts. 

One of the youth boys came in with a 4-day foreign body in his eye from grinding metal. I did my best to remove it, first with a swab, then a plastic wand, and, finally, a needle tip (yes, this stuff is scary, but can be effective). Sadly, the little speck of metal had started getting embedded into the eye and I only got a piece off. Some research later, I found that the eye clinic in Roche Blanche was operating, open Monday to Friday, as per their website that had the date of 2023 on it, and I told him to rush down there (past the gangs) as fast as possible. Off he went. 

The next day I had another eye injury come in. Well, I thought I knew where to refer. Tried to pull up the website again and what also came up was a letter saying that they were closed due to gang activity since November, not to refer patients there, etc. I was horrified. I immediately called the youth boy. No answer. Asked his family. Yup, he went down right away yesterday, and we haven’t heard from him since. Oh, one of the nurses said, yeah, that area is full of gangs. What had I done? Had I unwittingly sent him to his death?

A few long hours later my phone rings; the youth boy calling me back. I’m so sorry, I blurt out. I thought they were open and here I sent you into gang territory. No problem, he said. They were open. Took out the foreign body. Gave him a follow up appointment. Everything went well. Whewwwwwwwwwwww!!

We changed up our system here a bit, and it is more streamlined. With the central pharmacy, we now have the aides doing weights, vitals, etc. This frees up the nurses for more time with each patient, and more efficiently spent time. The results were immediately noticeable. The other day there were about 100 patients, and with 2 nurses we were done by 230. Pretty amazing. Our receptionist feels the pressure, though, and says he doesn’t have as much downtime now. 

In my prenatal class I am adamant that they should not drink ginger tea in pregnancy, especially in the third trimester. I repeat, cajole, reiterate, make them repeat back to me, show pictures, hand out pamphlets, act out problems graphically, to what avail? A young girl comes to us. First baby, cramping. The nurses check her. Not dilated. The next day, again. I take one look. Ginger tea? Yes. And she has attended my class. 3 cm dilated. Later in the evening, the family has been to Forèt clinic (which has a real doctor) and sent home, and they are back. 4 cm. We can’t help this, it’s the ginger tea. By this time, they say they want to go to Fond Parisien. Sure. If we get a driver and they can pay the ambulance fee, do they want to go? Oh, no, they aren’t ready. Next afternoon they are wanting an ambulance ride but through all the back and forth with multiple people and discussing the price, we eventually don’t hear from them again. 

A sister in the church gives birth on Friday, but I only hear about it Sunday afternoon when they come with the baby (mom still at home for the obligatory 14+ days) and say it isn’t breathing well. Looks like a baby boy peacefully sleeping, no nostril flaring, no respiratory distress. But when they went for further assessment to Jonathan’s, they say the baby hasn’t had any milk at all since birth, as he won’t breastfeed. What? This mom has raised 6 other children; how does she not think nourishment is important? And she came to prenatal class too, at least once. I talk A LOT about breastfeeding and formula preparation there. 

Maybe I’ll have to stand on my head next prenatal class. Note to self: practice handstands. Or maybe someone who already knows how to do handstands wants to come in my place. I plan to leave for Canada in November, to put my Prenatal Class knowledge to practical use. The Board says I can leave if I find a replacement. So help me out here! Haha. -Nurse Carmina