Gwo Tet De

“He’s blue guys.  And not crying.”  They continue with drying/active stimulation.  “He’s got good tone” the other resident responds.  Looks kinda floppy IMO, but I’m not manually checking him.  You know how they always tell you that good communication is key in high intensity situations?  Well, that is definitely true because I felt like with the language barrier we couldn’t communicate what we were thinking and what we needed to do.  Seconds seem like hours as we are waiting for any signs.  Finally, we each grab for a cord clamp.  I guess our thought cycles synced up.  Clamp.  Clamp.  Cut.  She grabs him by the shoulders and carries a floppy, blue baby over to the neonatal resuscitation table ServeHaiti recently provided to the clinic.  Sidenote: I was actually here the day the docs brought it down.  They were so proud.  Certainly seems like a great idea…Until it’s not useful.

We place him head towards us, face up.  “Do we have any suction?” I ask as she is bulb syringing his mouth and nose.  She’s getting some yellow gunk, for sure.  “You see it” she responds.  “Stethoscope?”  Fortunately there is one hanging on the wall, because none of us had brought ours in the delivery room.  We hadn’t needed one all night.  This was obstetrics.  Who needs a stethoscope?

I place the plastic diaphragm on his chest.  #HolySh!t That doesn’t sound normal.  Let’s try the other side and hope it’s better.  More normal, if he were an athlete.  FWIW heart rates in the 50s are not good for newborns.  “Oxygen?” the other resident asks.  Our nurse tries to hook up the one in the room, but it isn’t working.  “Any mask?”  No.  Of course not. 

I do the only thing that comes to mind.  I start compressions.  I have flashbacks to a premie that Dr. Angie and I delivered in Arcahaie.  The thought crosses my mind to give mouth to mouth rescue breathing like she did, but I’m already fighting with their hands while they place a nasal .  My face getting involved would just be too many moving parts occupying the same space. 

About now I try and stretch to the far reaches of my memory.  As an intern in family medicine at Wesley we go through tons of certifications.  And rightfully so.  As the family doc we could literally find ourselves in most positions where those different class and certification skills would be necessary.  Give me an adult code blue and I’m good.  ATLS?  I probably wouldn’t be the worst at it.  But here I am trying to remember my neonatal resuscitation program.  And it’s not going well.  All I can remember is PPV, which we didn’t have.  So next best thing in a bradycardic infant who is hypoxic is chest compressions, right?  Where’s my iPhone?  There needs to be an app where you take a picture of a patient and it magically tells you everything to do. 

I keep mashing away.  Every now and then he gives me something to work for by moving an arm or leg spontaneously, as if fighting the pain I’m surely causing on his chest.  I pause for heart rhythm identification.  Oh wait, no ekg leads, no O2 sat monitor, just me and a plastic stethoscope.  “Well, the funny sound seems to have gone away.  He’s hinting that he might try and breathe on his own, but still not very consistent with it.  And his heart rate is still low for an adult.  Resuming compressions. 

His eyes open and no longer appear lifeless.  I can hear the occasional grunt from his mouth and nose, which are now turning pink.  #PositiveReinforcement  His arms and legs are offering more signs of tone.  And we finally have the nasal cannula in place, powered on, and all done without unplugging the resuscitation table…again.  BTW, did anyone bother to calculate APGAR scores?  No?  Okay.

You can see the bruise.

I replace the steth on his chest.  Please be normal.  Please be normal.  It is!  Good, brisk heart rate without any murmurs.  He’s pink.  Moving spontaneously and with slightly better tone.  His respirations still leave a lot to be desired, but without deep suction or PPV I’m without any other options.  He’s gonna have to cough and cry it out.  Already a bruise is developing on his chest where I did compressions.  I talk to the Haitian doc about need for antibiotics and extended stay.  At Wesley he would have been a special care admission at the very least, but likely an NICU.  Course, he probably might have been intubated at the onset.

#WardrobeFail x 2

And it’s events like this that make it ever so clear why it’s nice to have a team.  The whole while we were working on the baby the mom sat there unattended.  And then when we were comfortable with the baby we turned our attention to mom for her repair.  I’m used to continuous nursing care and monitoring; this was incredibly painful for me.  I didn’t even offer to sew.  All I could do is retract (ain’t no way I’m gonna do my first third degree perineal lac repair without direct instruction) and watch from across a bed as the infant retracted away. 

But to bring the longish story to an end, he’s doing much better.  He and mom were recovering in the next room when I checked on them a couple hours later.  He was pink and breathing fine.  I still hope they decide to do 48 hours of observation if not also IV antibiotics.  He went through so much those first minutes of life that it’s worth an extra 24 to make sure he leaves the hospital healthy.  Heck, they're all GBS unknown so they should all stay for 48 hours.  But you try telling that to a Haitian family that needs to get back home to take care of the rest of the kids.

#NewbornSelfie

As a stateside update to this story, I was recently involved in an emergent cesarean section for fetal distress.  Turns out there was a placental abruption and the newborn was basically cut off from the maternal blood supply.  Thank goodness we had an operative staff and neonatologist on site.  It simply became a matter of me stepping out of the way and letting the specialists do their jobs.  The surgeon dropped off a floppy, gray baby into a functional resuscitation table where four hands began drying/stimulating.  The neonatologist got a deep suction catheter ready and suctioned about 6mL of cloudy, thick secretions..  One of the nurses auscultated for cardiac and breath sounds.  PPV was applied to help with oxygenation.  Slowly but surely the baby was weaned to room air.  There were three surgeons controlling the hemorrhaging uterus and closing up mom’s abdomen.  The entire team worked like a well-oiled machine and the outcomes reflected it.  Sometimes it’s easy to think we overkill our preparedness in the United States, but when something like this happens it’s crystal clear why it is so important.

Gwo Tet Un

I was getting impatient.  I had woofed down about a half portion of my evening meal.  The eleven year old that swings by the clinic to mooch actually scoffed at the amount of food on my plate.  Talk about being made to feel like a punk.  But I had done this because the last two of our laboring women were theoretically about ready to deliver.  The first was a primip who was term and being helped very gently along so she could just go ahead and have her baby at the hospital.  The other was a G3 who one might think would be a pro at this stuff.  They both took forever.

Maybe it’s because I didn’t get to go to La Fite.  Maybe it’s because they kept saying something to me about the ‘blan’ but I had no clue what it was.  Or maybe I was just ready to get some more food, but I’m sure I was wearing my impatience on my face.  And my co-workers can attest that I would never do that at Wesley.

We deliver the multip, finally.  I can only imagine what the heart tones would have been doing because she came out swimming in thick meconium and a cord around her neck.  Baby transitions okay and we actually do some skin to skin.  A full hour is too much for them to handle here, but I tried my hardest to institute a change.  Ten minutes in and I see that they’ve already pulled the baby off mom so they can tie the cord and clean her up.  And forget about four hours of recovery time in the delivery room because she was immediately told to walk back to the back “post-partum” room where two other new moms had already claimed the best beds.  No Jacuzzi.  No flat screen TV with touch screen, on demand movies, and food ordering service.  I’m not exactly sure how the ServeHaiti can compete for these pregnant women when they aren’t getting pampered properly.

But now we turn our attention to the primip.  She had come in yesterday during clinic, but hadn’t technically hit active labor until about 3 pm today.  But when they live miles away over a couple mountains and a terrain that even a moto can’t traverse your only option is to keep them around till they deliver or basically guarantee that they deliver at home and you hope to see mom and baby within the first week.  So she got to “maché” around the compound all day and night.  But now, she was our only remaining pregnant patient and she was close to active labor.  The pit is running.

Keep in mind these women are unblocked.  There is no epidural taking the bite out of their pain.  They scream, they pray, they sing and squirm in every way possible to try and distract themselves from the pain.  Because of this though, I have to fight every urge to check her and figure out where the hell we’re at.  Do I have time to finish my meal?  Ugh.  It’s painful.  And normally I’m one who is hands off of my laboring patients.  I finally get up the nerve, or lose the battle to my impatience however you want to look at it, and check her.  Complete and +2ish.  Perfect.  Let’s ‘pusse’ this baby out.  Yes.  That is Creole for push.  And yes.  That is said repeatedly, at louder than playground voices, during active labor.  #KeepAStraightFace #IDareYou

She seems like she should be a good pusher.  I feel like all Haitian women seem like they would be good pushers.  I’m not sure why and I’m not sure if that’s racist.  But I feel like that’s a compliment?  My apologies if someone is offended by that assumption.  Making good progress.  Baby is crowning.  Finally, I can see the end of my work duties.  I mean, I’d hate to violate hours. 

Then he’s still crowning.  Still crowning.  She’s unblocked but damn we’ve been at this for a long time.  I apply gentle stretching forces with my gloved hands to try and facilitate the path.  With the next push I insert my finger into her rectum.  Gross, I know.  But I was going to try and hook the baby’s jaw and pull him forward.  I couldn’t reach it.  This kid’s head was huge.   We try and doppler for heart tones, but she waves us off as another contraction hits.  She’s running out of gas. 

At this point the Haitian resident and I discuss our options.  We have no surgeon, or operating room, or sterile surgical supplies.  We have no vacuum or forceps.  Alright then, good talk.  It’s either we push him out or we send her on a four hour drive in a massive downpour to Port-au-Prince.  We talk episiotomy and get the scissors to the bedside.  I try and offer some push coaching, but who the hell am I kidding.  My botched attempts at Creole probably add to the confusion.  Fortunately for me the Haitian resident speaks a little English and she and I have been practicing languages with one another throughout my time here. 

With the next push I reach as far as I can.  I find his jaw and thrust it forward.  Every OB in the world is probably like, wtf are you doing.  And they’re probably right, but in the situation it seemed like the most reasonable recourse.  He comes out.  And, yeah, massive tear.  And he too is followed by a pile of meconium.  I pass him up to the patient’s abdomen so we can start cleaning and skin to skin.  I take a peak at the tear we are gonna be repairing still waiting to hear a cry.  

I hear nothing.  I take a peak up to her belly.

He doesn’t look good.  

Takotsubo

A heart is a terrible thing to waste.  Songs are written about this very fact on a daily basis, and I’ve been known to listen to a T. Swizzle heartbreak song before.  In the hospital setting, we go to great lengths to either confirm or “rule out” a primary cardiac issue when someone presents with anything related to the chest: pain, shortness of air, cough, and even nausea.  We get stat EKGs, troponins, chest x rays, and an ICU admission with telemetry all because someone comes in and says, “Ya know, my chest kinda hurts.”  Because we’ll be damned if we’re the one doc who misses a heart attack.  And even with all that…we… miss… heart attacks #Whoops

I’d like to think that when I’m finally put into the position where I’m the one making the calls that I’ll use a little more clinical judgment than I’ve seen a few of my practicing professionals exhibit.  But, when that time comes am I going to allow myself to “miss the heart attack” or will I order those two extra tests and sweet talk whoever the hospitalist is into watching them for 24 hours?  Even if it’s 99.9% likely a pec strain they suffered while trying to do P90x for their first exercise in six years. 

I say all this because day one on the job in Haiti we had two patients come into our clinic with chest pain.  I’m not sure if they were well known or not, but Dr. Leo seemed to know who they were and what they’re history was.  First thing was first, we had a brand new EKG machine from the states… Better use it (Allows us to upcode their visit!!).  So I figure out how to affix leads and get the first patient set up.  Ten minutes of button mashing later we have a printout of the limb leads.  Perfect.  Couple more button mashes and the precordial leads print too.  Now what…  Myself and two of the other docs look at it kinda perplexed.  I called it sinus tach with probable partial bundle branch block.  However, the Haitian resident was calling it atrial flutter with a 2:1 conduction.  It’s nice in American life to turn to your super friendly cardiologist and say, “What the hell is going on here?”  It’s also nice to have the machine auto calculate all the intervals, the rate, and even offer a preliminary diagnosis.  Not so much here.  So I do the next best thing.  She had a medical record chart.  In the chart was an EKG performed about a year ago by a doc in Port-au-Prince on a machine that offered a preliminary report.  By in large the tracings looked similar enough to where I would call it unchanged.  #ProblemSolved #InternMedicine

The story behind her heart problem is a little more curious.  She’s 43 and 4 months post-partum.  Her chest pain and dyspnea started 2 months ago.  I’m no ECHO expert, but even I saw a giant heart when I placed the sono to her chest.  Peripartum cardiomyopathy is rather rare, but sure seemed like we had a rip-roaring case of it here.  And with her massive ascites, it almost looked as if she were still pregnant.  I placed a paracentesis catheter, blind mind you with a regular IV kit #Improvisation, and we drained 3 L out of her abdomen and started her on heart failure medication. 

The second patient was 13 years old and had florid heart failure.  Her heart murmur indicated this was also a structural problem with one of, if not more than one, the valves.  Again, I’m not an ECHO-ologist so I couldn’t point to the aortic valve and say that is massive regurgitation, but clinically the management is likely going to be the same.  Refer to Port-au-Prince should she or her family ever gather enough money to: 1. Send her there.  And 2. Pay out of pocket for any test or treatment they offer.  Not likely going to happen.  So we’re stuck managing what is likely a surgical problem with medication.  Fortunately, @TheDrSinclair had just given a baller lecture on the medical management of heart failure.  And thank goodness that we actually had all the meds.  I didn’t realize how insecure basic medications were to the Gran Bois clinic until this trip.  After a quick check in with my OB consult on call to ensure that nothing too different was required in the post-partum period we were squared away with both patients.

As the patients recovered in our inpatient unit I started thinking about how I saw them walk up to our clinic.  Yes, they were both using a moderate amount of assistance, but still.  They both had nasty heart failure and had hiked from their homes to our clinic.  I can’t say it’s a La Fit kind of hike, but I know for damned sure that it’s more than the flat two miles my lazy ass would have to walk to get to work every day.  And we’re in the mountains.  I’ve been dyspneic ever since I climbed out of the truck.  I don’t know how these people do it.  Basically the patients pass a stress test on their way to the clinic #CardiacRiskStratification  

As an aside, we started blood pressure medicines on an 82 yo m today in clinic today who’s pressures were 180s/110s.  This was the first time he had ever come to the Haitian clinic.  His chief complaint: a rash on his back.  He left his appointment with an ACE, a diuretic, and some hydrocortisone cream.  I’m just thinking to myself, “He could run circles around 90% of America…I’m not sure he needs a daily pill.”  You can follow him on Twitter at @Im82AndIHikeMountainsOnTheReg.  But this just goes to show, whether in Haiti or the U.S. we physicians are sometimes guilty of not seeing the forest through the trees.