Mouri

I witnessed the worst in medicine today.  The story - heartbreaking.  The medicine - malpractice.  The outcomes - pre-determined.  I alluded to a laboring woman in part one of my previous story.  She had initially visited at the OB clinic we held this past week.  18 y.o.f. G2 P1 LC0 at 38 weeks, even as her uterus was a mere 29 cm above her pubis.  Her arms were skinny, but she seemed in good spirits.  Her water had broken while I was away, so she walked to our clinic.

We put in a line, slapped on a fetal monitor, gave her an epidural, and cranked the pitocin.  Oh wait.  #WrongCountry  We moved a mattress into our procedure room, threw a couple disposable chux on it, and let her lay down.  She was posterior and firm; this is going to take a while.  Angie told her that she should walk around.  I went to bed #Exhausted.

I woke up at 4 am, like normal.  I assumed that the girl delivered and I had just slept through all attempts to wake me up.  I was out like a light #10MileHikeCuresInsomnia.  I get up and head over to the procedure room.  I hear a moan.  Sounds like she's still here.  She hadn't delivered overnight.  In fact, she hadn't really progressed very much either.  No worries.  I needed to worry about finding a way to get my mountain family to the hospital in Cajale later that morning.

My trip came and went.  The mountain kid was safely on his way to Cajale and lifesaving, inpatient malnutrition management.  I returned to the mission, anxious to see how our pregnant girl had progresses.  Maybe we'll have a new baby?

The girl was gone.  She lived about 500 yards from the procedure room in a tent towards the top of the hill.  Angie and I do a little game-planning for if/when she comes back.  Her membranes ruptured at 1500 yesterday, so we should take her to the Arcahaie hospital at the same time today.  Deal.  Get some sleep, Angie, you deserve it.

It's about 1 o'clock.  We ask the girl to come back to the compound so we can observe her and arrange transportation if need be.  She still hasn't progressed much.  Three centimeters.  Thirty percent effaced.  Station still at -1.  We call a tap-tap to come pick her up.  At first the driver announced that he wouldn't do it for the $50 Haitian that we paid him to take the pre-eclamptic woman to the hospital earlier in the week.  We told him we didn't need him then.  He was on his way.

Angie gets in the back with one of our CHWs to take our patient to the hospital.  She's been ruptured for 24 hours.  Her vital signs are stable.  But we're still concerned that her delivery will take more care that we can offer in our procedure room.

I hear a moto a few hours later and see the Angie and Gueraline stepping off.  The girl was delivered to the hospital.  The situation was explained to the accepting nurse.  The "delivery room" is a wooden slab with foot pedals.  A bucket sits under the patient with a plastic drape guiding any drippings into it.  Apparently they like to reuse plastic drapes #Sterility.  No doctors were called.  As soon as the nurse got the chance she ordered the patient to 'marche'.  We could've done that.  But, hopefully, they'll continue to monitor her progression, start pitocin, administer antibiotics if she develops endometritis, and even perform a c-section if necessary.  We gave them $30 U.S. to cover the costs of the delivery.  Apparently they don't view arrested labor as an emergent condition.

Our quiet evening was ruined when the little girl's father came up to our compound.  They told the patient she had cholera and would need to go to Port-au-Prince.  Yes, they told our patient who had zero complaints of diarrhea, was in her 30th hour of labor, that she had cholera and couldn't stay at their hospital. They gave her $20 U.S. and closed their doors.  It was pitch black outside.  Haiti is not a safe place to travel at night no matter the color of your skin.  He also told us she started to bleed.  We tell him to bring her to our place immediately.  Angie and I get to work setting up our procedure room.  I set out the stuff to place an IV.  We have 3 bags of saline solution.  We get out all the dressing supplies we can find.  The thought of performing a c-section is terrifying given our supplies, but it might be necessary.  We grab anything we think could be of assistance if it comes to surgery.  We have Solange boil us some water.  I find some glass bottles to get them cleaned out and boiled.  They may become our new IV bags.  I pray not.

We're as ready as we can probably be.  No patient.  I walk up to her tent with my head light.  She's still moaning.  And doesn't look like she's coming down.  "Nou bezwen alle".  "Tale, tale, tale."  She's having a contraction, and it looks terribly painful.  She re-positions.  There is a little blood under her.  How much blood has she lost?  Is it normal or because she ruptured?  I don't have the time or equipment to figure it out.  "Nou bezwen alle, maintenant".  Unfortunately the French for 'now' doesn't translate over to Creole.  She's slow to move, but finally emerges from the tent.  We begin our walk back to the procedure room.  She moans in agony.  Doubled over.  Another contraction.  How far apart are they?  About 90 seconds?  I try and get her to move.  She is slow and extremely uncomfortable.  Another contraction folds her over again.  Gotta move.  I take the blanket from her mom, wrap it around the patient, and pick her up.  Quickly now.

I strain to see the 'path' that has been worn to our compound, but eventually just take off in a straight line.  She's tiny, but offering no assistance in my carrying her.  I feel her slipping.  I pause and roll her higher up on my arms.  Moving again.  Quicker.  Another contraction.  My arms are sweaty and my biceps burning.  We're halfway there.  It sounds like she's saying "I don't want to fall. I don't want to fall."  I pause to re-position.  We get through the 'field' and onto the gravel of our large mission compound.  We are still over 100 yards from the procedure room.  I see if she can walk now.  One step.  Two steps.  Too slow.  I signal that I'm going to pick her up again and we take off.  Down the gravel and into the procedure room.  Angie already has a sterile glove on to check her.

She's much further along and the blood doesn't appear to be pathological.  Thank God.  We hold off on the major interventions for the time being and let her continue with her labor.  She fights any exam and prefers to lay completely supine with her legs crossed.  Probably not the best position to deliver, but we choose not to force her.  The patient communicates that the Arcahaie hospital did not give her any medicine for her 'cholera.'  We tell the two CHWs present to open up some azithromycin.  She vomits.  A lot.

One thing is certain, the community health workers we have enlisted are very compassionate.  I would hate it if I were a laboring woman and these two strangers kept petting me and throwing water in my face, but I'll be more upset if I'm ever a laboring woman.  Angie and I sit quietly at the end of the bed, observing the CHWs' 'care'.

Her extended family is outside chatting up a storm.  Her mother comes back.  She tells a story.  After an abbreviated translation we gather that the daughter "swore" against somebody.  Accordingly, the child will not come out until the grievance is cleared.  How does this happen, you ask?  She has to go back home to the tent.

The patient starts trying to get up.  Saying, "Alle, alle."  We implore her that she stay, for her safety and that of her unborn child.  Tenuous minutes go by with this exchange.  It isn't until Solange steps forward and begins leading the group in a passionate prayer that the concerns of the family are allayed.  She stays.  The mother stays.  Another prayer.  Certainly can't hurt.

We encourage the patient to find a comfortable position amenable to delivery.  She crawls around the bed, pausing every minute or two to agonize over another contraction.  The baby's father comes back for a brief moment to offer support.  Smart man, he doesn't get close enough to be swung on.  Her God-Mother also pays a short visit.  She manages to maneuver herself into a squatted stance and with the next contraction...blood.  It spills on the chux.

We move quickly.  Angie dons another set of sterile gloves and I grab the IV equipment.  She continues to writhe with every contraction and with the way she has responded to every exam we've done I know this stick won't be easy.  I prep.  Ready the needle to her left hand.  She fights.  Another contraction and she pulls away.  She's squatting like a catcher on top of the bed and using her hands to hold herself up.  I'm sitting on the ground with a needle in my hand.  The contraction ends.  I grab her left hand.  Lucky for me she has good veins.  She offers plenty of resistance to me controlling her hand.  I wipe again with another alcohol swab.  I start to engage the needle and she retracts.  I have no direction for her because I can't speak her language.  I brace and move quickly.  Flash.  Thread.  Withdraw the needle.  The blood is running.  I hook up the tubing and saline bag.  It's in.

We lie her down and help her pull her knees back.  Time to get more aggressive.  The next contraction reveals the babies head.  Angie goes to work.  Slight pressure on the head and on the perineum to help prevent tears.  The three CHWs in the room continue to encourage, pet, console.  With each contraction we encourage "pusse".

The delivery only takes about ten more minutes.  I hear it come out as Angie withdraws a tiny, blue infant.  He makes no noise and offers no spontaneous movement.  She begins toweling him off.  I grab my stethoscope.  HR of maybe 70.  No breath sounds.  She begins compressions.  We look at each other.  I state the obvious, "This is why the hospital didn't want to take care of her."  This was our concern from the beginning, but without ultrasound or doppler, we had no way to check.  I give her the two clamps for the cord.  She cuts it and we move the baby to the procedure table.  The baby gasps.  Is there hope?  The heart rate is still painfully low and I cannot appreciate any air movement with my stethoscope.

Compressions.  Faster.  My thumbs pump away as Angie assess the airway.  His eyes are under-developed.    Another agonal breath.  She opens his mouth.  My compressions are moving air in and out of his chest, but is it enough?  Angie does the unthinkable, but the instinctive.  She blows to quick breaths into his lungs.  And again.  A spontaneous movement?  Two more breaths.  I listen.  He's still not breathing.  We have no other options.  There is no neonatal intubation kit.  We do not even have a bag mask.

We call the father back and place the baby in his arms.  He cradles it with a loving smile.  We ask Solange to explain to the parents that the baby is not breathing on his own.  He's too mall to survive.  His heart is beating now, but it won't continue much longer.

We still have one patient left.  Angie calls for another push as she provides gentle traction on the umbilical cord attached to the placenta.  It is expelled rather uneventfully.  It's in tact.  I massage the fundus to aid in hemostasis.  She doesn't appear to be bleeding.  Rather, she appears to be lost in thought.  She stares off, her eyes fixated at nothing in particular on our concrete walls, but her mind elsewhere.  In a land I could never understand described in a language that I barely comprehend.

She chooses not to hold the baby.  We offer the other family members a chance to see the new mother who is soon to lose her second of two children.  The mood is not as somber as I would expect.  "Pa gen pwoblem" is what the father keeps repeating as he rocks the neonate in his arms.  Still smiling.  Proud.  He asks us if he can take the baby with him.  Of course.  We offer the mother the bed for the evening.  She declines.  Her own mother returns to the tent for a change of clothes.

The saline continues to run through her IV.  The bag is nearly 3/4 empty.  Her vital signs continue to be stable.  Her eyes continue to drift off through the walls.  Physically, it appears as if she's going to be fine.  Emotionally there is no way for me to know.  Spiritually is just as unpredictable.  Will the 'blan' be blamed for the loss?  Will the conflict of the 'swear' or some curse torment the family?  Time will tell.

In the United States, the baby would've been intubated by neonatology airway team from the NICU.  He would have been ventilated, given IV antibiotics, and incubated.  The mother would have received pitocin and cut her labor time in half.  A fetal monitor would have directed earlier intervention.  And beyond all of this, she would have had easier access to appropriate pre-natal care.  She would have gotten vitamins.  She would have been tested for TORCHeS.  She would have had an ultrasound confirming dates.  She would have been forewarned about IUGR.  She wouldn't have been told that she had a GI infection and that she needed to be treated in a hospital an hour away.

It's tough.  #KenbeLa #PaLage