Oh What a Day!

Our First Scheduled Clinic Day
Monday, April 19, 2010 evolved into the most eventful day of our trip. There were two almost empty jars of peanut butter on the table at breakfast, so after eating I donated my new full jar, took the two almost empty jars (one had a plastic spoon in it) across the road, and placed it near the trash pile. Earlier we had noticed a young boy hanging near there who took a trash sack when he thought we weren't looking. I hope he comes back and finds the peanut butter.

My second patient of the morning was a 42 year old woman named Michele. She came in stating she was about 4 weeks away from delivery of her baby, but hadn't felt her baby move since yesterday. According to the size of her uterus, she measured about 30 weeks gestation, not 36. I was afraid she may have not noticed exactly when her baby stopped moving. I was unable to hear fetal heart tones with the doppler we had brought with us. When I did a pelvic exam, I noted she was 4 - 5 centimeters dilated and there was something protruding from her cervix into her vagina. I was not able to identify exactly what these fetal parts were, but felt it was an abnormal presentation.

I went to Garlene, who is a registered nurse from Haiti, living and working in Boston, MA who happened to be here for a family member's funeral. I told Garlene we needed to get Michele to a hospital. Garlene told me "You are the hospital". Garlene told me we should deliver her here because she would not get good care at the hospital and that the patient could not afford to go to the hospital.

After much thought, I told her IF the malpresentation was legs or feet, I could probably deliver the baby. However, if the presenting part was an arm, she would probably need a cesarean section. I reminded her that another concern I had was that the baby may have been dead longer than the mother thought since her abdomen was measuring smaller than should be expected. If her baby had been dead for a long time, this increased Michele's risk for a serious bleeding condition after she delivered. Michele" blood pressure was 152/84 which made her borderline hypertensive and at risk for more complications related to the elevated blood pressure and again raised her risk for postpartum hemorrhage. Garlene agreed, maybe we should take her to the hospital.

In the meantime, while I was caring for Michele, a young man in his twenties came in to the clinic with a blood pressure of 50/20. He had a fever, abdominal pain and appeared to be in extremely ill - maybe from a ruptured appendix. Doc Eric started an IV and could not get him stabilized. After about seven bags of IV fluids, he was loaded into the back of the clinic's pickup truck and off they went to a hospital.

Since our only means of transportation was now gone, Garlene told me we should TRY to deliver Michele's baby at the clinic. I reminded Garlene I was afraid of a postpartum hemorrhage. We did not have any medications available that I could use to stop a hemorrhage. Garlene told me to come with her and we walked about one quarter of a mile to a nearby hospital. She went to the pharmacy window, explained our situation, and they gave her two vials of Pitocin which could be used to stop bleeding after delivery. We then walked back to Michele at the clinic.

I instructed Michele in how to do nipple stimulation in an effort to stimulate uterine contractions to bring on active labor. No amount of stimulation resulted in contractions. Garlene wanted me to use the Pitocin to induce Michele's labor. I was reluctant to use the Pitocin to induce labor because I continued to worry about postpartum hemorrhage. If I used the Pitocin to bring on labor, I would not have any to use after delivery if she hemorrhaged; and I feared Michele would die if this happened. Garlene then went in search of more Pitocin.

As Michele rested on her stretcher with her IV infusing, Earla and I continued to see patients together as a team. We saw one child with a temperature of 103 degrees who had an ear infection. One girl came in requesting a pregnancy test, hoping it to be positive. The test was negative and she was disappointed. Several children and adults with what I coined the "Haiti Syndrome" of headache, cough, dry eyes, poor appetite, insomnia, and nervousness were seen and treated. Many of the patients we were seeing needed to just know someone cared about them personally and would listened to them tell what was happening to them and in their lives right now.

Garlene returned with 12 vials of Pitocin in hand. I could not come up any more excuses that would please her as to why I should not deliver this baby from this woman. I began relying on my memory of protocols I follow in Alabama in a hospital setting for circumstances such as this. In addition to high dose Pitocin infusions, we gave her IV Cefazoline to decrease the risk of infection that could be associated with her carrying a dead baby for an extended period of time. After nine of the fourteen ampules of Pitocin we had and 3 bags of IV fluids, I told Garlene I was not comfortable doing more. I felt she may have a serious malpresentation and be at increased risk for bleeding and dying and needed to be in a hospital setting. So began our quest for a hospital.


"Can't Waste It on a Dead Baby"
Since our only truck had left to take the young man with the possible ruptured appendix to a hospital, we were forced to rely on the tap tap system. This is either a truck or van that is the Haitian equivalent to our taxi system. You tap on the vehicle driving by to get it to stop, then you tap once you are on it and want to get off. Hence, the name, tap tap. Garlene had tried to stop a tap tap, but they didn't want to assist us. I told her to let me try. I walked into the middle of the narrow dirt road and the next van had no choice but to stop for me. I'm sure this white woman with spikey hair was quite a sight to him. Garlene then came out and explained to the tap tap driver our delimma and asked that he "do his part". He agreed to drive us, but she had to pay him $20 to cover the lost tap tap fares he would miss out on.

The driver, his wife, Garlene, the patient with her IV in tow, her friend, and I all loaded into an old van of which the sliding side door didn't close. We were headed to the UN Hospital run by the Brazilian army. Once we arrived we had to convince the guards to let us through. They made the patient's friend get out and wait at the gate until we returned for her. We were met by soildiers in uniforms outside a tent that reminded me of one I used to see on the old TV show M*A*S*H. The female soldier said she spoke a little English. We explained our situation and her replay was, "We only do 12 surgeries a week. We can't waist one on a dead baby. You must take her to the American hospital since this is an American clinic and you are an American", pointing towards me. No amount of talking, pleading, etc. would convince her otherwise. She finally walked away from us, back into the M*A*S*H tent and closed the door shutting us out.

The tap tap driver had a vague idea of where the American hospital was located. This is actually a hospital run by the University of Miami. The driver located a break in a concrete block wall and turned our van into the narrow opening that had barbed wire on each side of the opening. We were met by another gate and guards in uniforms. They wouldn't even approach our van. A man in civilian clothes, who we must have passed as we drive in, walked up to our van, stuck his head in my side window, and said, "What ya got?" When I explained the situation, he said, "We don't have any beds or fuel; you'll have to take her to Doctor's Without Borders hospital. They are doing all the maternity patient's in Port-au-Prince." Garlene began to argue and plead with him. He began saying something like, "I've risked my life more than anybody in this truck ever has or ever will, I don't want to hear how hard this is." I told her she was wasting precious time and we should just go.

Garlene called Greg Roberts, our American host in Haiti. Greg was at a gas station near us. We had the tap tap driver take us to the gas station where we paid him another $20 and got in the truck with Greg. It was here that we got the phone call that the young man with the ruptured appendix had died in the back of the pickup sitting in a hospital parking lot while Al, one of our team members, performed CPR on him to no avail. It was a very sobering moment for all of us.

Between the American hospital and the Doctor's Without Border's hospital we passed another hospital, called Merz. We stopped and Garlene ran in. She quickly returned and said we could leave Michele to sit in the lobby all night, but there were not any doctors there again until morning. We headed towards our fourth hospital with Michele.

Overwhelmed
This hospital was referred to by the locals as the Doctor's Without Border's hospital, because it is here that organization sets up their major operation. However, we learned at this time of night, in the hospital that delivers all of the babies born in Port-au-Prince, the Doctor's Without Border's doctors had left and it was staffed by three Haitian doctors, one midwife, two aides and a janitor. The hospital sits at the edge of Sol City, the largest slum in the world. There are about 250,000 people living in this tent city slum and about 250 of them were here on this night having a baby!

I was overwhelmed as we entered the hospital. If I were blind, I would have thought we were entering an insane asylum or a torture chamber. There were gutteral moans and groans, cries and pleas for help in French. Even though I couldn't understand the specific words spoken, it was obvious what was being requested by the body language and facial expressions of the nearly 250 women here, all in some stage of birthing their babies. Michele hesitated and did not want to enter. As I patted her arm and tried to reassure her everything would be alright, I'm not sure if I was trying to convince her or me.

We were directed through a pair of wrought iron gates. I saw a row of plastic chairs and about ten very obviously pregnant women in all stages of labor. This was their admitting area.

We then were taken into a small room where a young doctor sat on a stool at the foot of 2 exam tables watching two women in labor. Both were nude from the waist down. Michele entered and said she needed to pee. There was a five gallon bucket sitting near one of the tables that had a woman on it. Michele was directed to use the bucket. Michele proceded to walk over the bucket, lift her dress, and void. No privacy, no dignity here.

Garlene and I then were taken down a hall where there wre five cubbies with women on beds and about three more women on the floor in the hall. One woman in the floor was sitting in a pool of blood. She was quiet, but looked defeated. I asked if she was laboring or if she had delivered. I was told she had already delivered. Not wanting to overstep my bounds, I reached down and massaged her uterus in an attempt to stop her bleeding. She looked into my eyes and said, "Merci". I wanted to cry, but I had sweat out any tears I may have shed. It was so hot in this hospital my clothes were drenched with sweat. Most of these poor laboring women had stripped off their clothes due to the heat and their bodies glistened with perspiration.

Turning the corner heading into another hall we saw six more cubbies and women in the final phases of the birthing process. One woman was being assisted by a midwife. A second woman was beginning to crown her infant and no one was near. I grabbed a pair of gloves and craddled this baby up as it was birthed by it's mother, preventing it from dropping about 36 inches to the floor below. A woman I assumed to be an aide then came and double tied the cord with umbilical tape and gave me a sterile knife blade to cut the cord. Garlene then brought a sheet of paper and we dried the baby and handed it to the mother. The placenta was then expelled and the janitor came and took it and mopped the floor around the new mother's bed.

The babies were taken, swaddled and laid on a counter under heat lamps that were mounted from the ceiling. I'm only assuming they had a system to identify which baby belonged to which mother, but my guess is many mother's went home with another woman's baby accidently.

Garlene then summoned me to come and see. We went to the end birthing bed where a yound scared girl lay. I could see a tiny hand protruding out her vagina. I examined her and she was dilated about 5 centimeters. The baby was premature and transverse with a arm/shoulder presentation. I managed to reinsert the arm into the mother, but couldn't turn the baby into a better position. The young doctor appeared and smiled noting I had delivered the one young mother. He told me I could deliver this one also. I told him I couldn't since it was transverse.

The young girl in the same cubbie as the mother with the transverse lie baby began to crown her infant. Again, I grabbed a pair of gloves and repeated the delivery process. The young mother I delivered said, "Merci". The mother with the premie looked at me with hollow eyes that said, "Surely, I must be in hell."

I went to wash my hands in water I'm sure wasn't clean, dried them on my pant legs that were drenched with sweat, and returned to find the premie lying on the delivery table between the young mother's feet. The baby was dead. One of the staff had gone to tell her husband.

These poor women were alone, no family was allowed to be with them. They were hot, sweating, no pain medications, no privacey, no kind words, looks, or touch. My heart was breaking for them. I didn't even have the ability to say "I'm sorry" since I don't speak French Creole.

Garlene decided it was time for us to leave. As we were walking back out the way we came a girl was in the floor, her water broke. I checked her and she was completely dilated. We assisted her onto a nearby empty bed, but were told they didn't want her to birth there so they made her get uyp ad walk around the corner to another bed. I was prepared to deliver her until the Haitian midwife said "excuse me", and took over. I felt she was trying to make a point that her way was best. She did not like that I encouraged the patietn to push. She never spoke to her patients. I had prepared my supplies to do this delivery, and the bulb syringe I had collected was missing. When I asked for another she said, "No". I stepped aside to allow her to assist the mother with her birth. The midwife used a big wad of cotton to wipe the baby's face after it was born, but did not suction out any mucous or stimulate it to cry. The baby was getting bluer and bluer, so I rubbed it's back to stimutlate it to cry and clear out the mucous. The midwife shot me a displesed look, but the young mother said, "Merci", which was all I needed.

The doctor then took us on a brief tour of he hospital. He took us to the two operating rooms. One was still bloody from a previous surgery. Their ability to clean and get the room ready for the next case was very limited by supplies and clean water. He told us that it is difficult to get surgeries when needed. Even if they have surgeons, there is a shortage of anesthesia personnel. He commented that the only way they can get anesthesia people to come is to pay them, and they have no money.

He then led us into the postpartum unit. This was one large room with about 25 trundle type beds along each side of the room. Most beds had a mother and newborn at her side. There were a few beds with a woman lying in it and a man sitting on the floor next to her. I could only assume the men were allowed to come sit with their wives if their baby had died.

The doctor asked if I didn't just want to stay and work all night. I told him I couldn't, but I would come back the next day to work if he really wanted me to. He said he ended his shift the next day at 2 pm. I asked when his shift had started and he said he worked from 8 am one day until 2 pm the next day - a 30 hour shift! When I asked him how many babies he thought he delivered in a night, he said, "Maybe 25"? I laughed and told him I had delivered 2 in less than 30 minutes. I felt sure he did more than that. Garlene got the phone number of the young doctor we had talked to most of the evening so we could check the following morning on the status of Michele. We picked up and ate Dominoes Pizza on our drive back to the mission compound. I never knew pizza and diet Coke could taste so good!

The Truth About Michele
Garlene got the telephone number of the Doctor we befriended at the Doctor's Without Border's Hospital so we could call and check on Michele. The truth about Michele was she was not pregnant. Even though she came to us claiming to be pregnant, had not had a period in eight months, had felt her baby move until the day she came to see us; she was not pregnant. The verbal ultrasound report we got only stated she did not have a pregnancy. Now, trying to piece all the information together I have come to the conclusion that she either has a uterus full of fibroids or may have cancer. Either the fibroids or cancer is growing and protruding through her cervix into her vagina and causing her pain which she had mistaken for labor. The tumor must have been flopping around which she mistakenly thought was fetal movement. As the tumor enlarged, it no longer moved about and she thought the fetal movement had stopped. Her uterus was enlaraged to approximately a thirty week pregnancy leading me to believe the "fetal" growth had stopped some time ago. Once Michele was told she was not pregnant, she walked away from the hospital without receiving treatment for her tumor. Hopefully, it will not begin to bleed and become a life threatening condition for her, or be cancerous which could be the death of her.

I have a devotional book called "Jesus Calling" by Sarah Young that speaks to me daily. On this particular day I shared the information with my team. We have talked about how difficult life is in Haiti, especially for the women who must scavange daily for food and water. Today's devotion made me think about the Israelites who wandered around for forty years and had to depend on Jesus for their manna.

Early this morning in the clinic Yancik, the clinic director, came to me and said she had two girls in labor. Even though I deal with girls in labor on a regular basis in the States, it was a very different situation here in Haiti. Especially after the incident with Michele the day before, I was afraid we would be spending our entire day again traveling from hospital to hospital. One girl was forty-two weeks gestation by her history and had been hurting all night. The other girl stated she was not hurting. I examined both girls and determined they were both about 1 centimeter dilated. I told the girl who was forty-two weeks gestatin to go to the hospital. Going two weeks past the due date puts her at high risk for losing her baby if her placenta decides to quite working and giving the baby the food and oxygen it needs. I hated to send her or anyone to the hospital after my previous evening there, but felt I had no choice. Even in it's poor state, the hospital was better then nothing in an emergency. The other girl was not in labor and not due for another couple of weeks. I told her to go home and to come back to the clinic in one week to see the provider who would be here. I told her the signs and symptoms of labor and advised her to go to the hospital should labor begin.