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.

About Moms and Babies...

Births at the clinic last month: 5

Births at the clinic this month already: 4(+3)

Average amount of pregnant ladies attending Prenatal Day every Wednesday: 35

Pregnant ladies sent down by ambulance this month already: 2

These numbers don’t look like much, do they? When I dream of a 24-hour birthing center built next door, with a surgical suite, OB doctor, and helicopter pad, would it be worth it? I think so, and I will tell you why.

_Have you delivered a stillborn? Or a tiny blue baby hardly breathing? Or a baby with deformities? 

Have you watched a mother writhe in pain while a tiny hand with a grasp reflex is visible, trying to be born? And the mother thrashes and won’t be calmed until there is a noticeable ‘pop’ and the tiny hand turns blue and lifeless. 

Have you seen a mother not eating or speaking, depressed after she fell on the slippery rocks and delivered a dead baby a few days later?

Have you picked babies up off bloody blankets on the muddy gravel outside of a locked gate, where the mother gave birth before help could come? Or the floor of an outhouse, or a porch?

Have you rushed by two tiny newborn girls being cared for on a dining room table to find a third little triplet, en-caul, and placenta already delivered on the porch floor?

Have you looked under the blankets of a mom’s bed who was carried by people to the clinic from miles away, only to see two little blue legs already there?

Have you watched a mom, one twin already delivered, bleed out in front of you, life draining from her eyes as you futilely try CPR? And then the main question you get later is why you didn’t deliver the second twin, as now the voodoo doctor must perform magic in order for them to be buried separately. 

Have you done CPR on tiny bodies that you hold in your hands, foam coming out of the nose and mouth with every compression of the pliable chest?

Then there’s the girl who was told by doctors that she would need a hospital delivery, but refused to listen and wouldn’t tell us that important fact, labouring 3 days before she got to hospital, only to lose her baby. 

Or the lady with pre-eclampsia/possible HELLP syndrome that got past the gangs but was shunted from hospital to hospital in the dangerous city of Port before finally delivering, saving her life but losing the baby, as it was born too early. 

Ironically, as I was typing this piece, I heard the dreaded call of ‘Baby in the outhouse!’ and there was a tiny baby with a mom in pain… when we got her to our delivery room, she soon delivered another, and then a third… all too small to live with our limited resources. At approximately 6 months along, they would have been whisked off to NICU at home. But this mom hadn’t even had any prenatal care by us, never mind a Doppler ultrasound telling her she was carrying triplets. She didn’t know who the father was and had four children already.

And here I am, a cowardly hypocrite, preparing to cross a restricted international border in a time of much unrest, to get on a plane and fly over 4,000 kilometers so I can get professional prenatal care and deliver our first baby in a hospital with a NICU and operating room close by. How can I look these women in the eyes and encourage them to deliver at home if possible? It’s because the Haitian women have a better chance of getting past the gangs, if they do need emergent care, than I do. It’s because the city of Port au Prince is too dangerous for me to go to the Canadian Embassy with my baby for the needed paperwork. It’s because, as little as I know, I’m probably the most educated experienced L&D nurse within a few hours’ radius. And other reasons too.  

We tell ladies to please deliver at home if there are no problems because we don’t have enough personnel here to accommodate all the babies born in Oriani, Gwo Cheval, Marie Claire, Jadin Bwa, Oplimèt, and from zones even farther away. We aim to be available for emergencies, and we try to catch potential problems in our prenatal care. We encourage monthly prenatal visits and at least one professional ultrasound. Thanks to Vitamin Angels, we have free prenatal vitamins to give to each mom. When needed and available, our ambulance takes emergencies to Fond Parisien. 

_And the birthing center could have more departments, like a nutrition program and a designated contraceptive clinic. And the surgical suite could be used for other minor surgeries. And the number of staff could be such that the nurse who answered two or more emergency gate knocks in the night wouldn’t have to be the same nurse opening the clinic the next morning. A step in the right direction would be control of the gangs to open the roads for safer passage, and to improve the roads for speedier access to care. One can dream. 

_A big thanks to generous donors who have enabled us to offer what we can! Please keep us in your prayers. 

Carmina