Kurrant Part 2

At ServeHaiti I've been incredibly spoiled with a touch of the U.S. luxuries I'm very accustomed to.  They are outfitted with solar panels that charge a battery throughout the day, a wind-powered generator and then the traditional fossil fuel powered generator.  Most of the time I have wi-fi access while I'm in the clinic, which is helpful.  It's one thing to not be able to communicate with the patients, but then factor on the fact that I can't even access my medical resources to help with treatments and I would be basically worthless down there.  

But the ServeHaiti clinic is the exception, not the rule.  When I was doing my surveys a common request was for "kurrant".  If you want electricity in Haiti you have to buy a generator and then the fuel to run it.  Needless to say, most people just do without.  So, if you have one you can be big dog on the block, charging people a day's wage just to charge their cell phone.  Can you imagine what it would be like for there to be zero power #WalkingDeadStyle?  Complete darkness.  No street lights, just the occasional stray moto headlight zooming down the gravel road.  It just seems unfathomable for anyone to expect a country to develop, or rebuild after a series of major natural disasters, when there is no water security or electricity for the people to use.  #RantOver

Puerto Rico to the East, Domincan Republic, and then Haiti.

I think I fall asleep around 10 pm.  I had an alarm set for 1030 just to get the jump on my hourly checkups.  Fortunately, or unfortunately, the neonatal resuscitation table has a sensor that will detect the surface temperature of whatever is underneath it.  And anyone who has worked with these darn things can tell you, they’re a fickle lot.  Even if the baby is there and is at a normal temperature the alarm may still sound.  Well our baby isn’t quite back to normal temperature, so sure enough the alarm sounds.  1015.  Almost.  Guess I can cancel my hourly alarms.  I get up, hit the reset button and take a quick listen to her heart and lungs.  Stable. 

Suddenly the room is filled in darkness.  The oxygen machine begins alarming.  The resuscitation machine lets out an awful howl.  There is a faint beeping heard in a far off room.  The power went out.  This is new.  Since my time in Gran Bois I’m not sure I ever dealt with a power outage.  I swaddle her with the blankets and begin some breathing assistance with the ambu bag.  Dad and grandma come back in to check on her.  “Fils cop bay tete?”  “No, pa capab.”  She just wasn’t breathing comfortably enough for me to suggest her to try and breastfeed.   Maybe when we get power and she can get her oxygen back.  Yeah, I didn’t try and tell him my thinking cause that would have been a communication nightmare. 

I hear Prophet’s name called out and then about five minutes later the power kicks back on.  Hallelujah, I’m not sure how much more of the mindless bagging I could take.  I turn the table and oxygen back on.  While I’m awake I give her a little more IV fluid PO.  She actually does a great job with it.  Breathing?  Labored but stable.  HR?  110s.  Back to bed.

Thirty minutes later the resuscitation table alarm sounds.  No problem.  Check on her, things are looking good.  I lay back down on the bed and just as I’m falling back asleep, the power goes off again.  I turn off the oxygen machine and the resuscitation table, cover her back up in blankets, and watch.  She’s breathing okay.  This time the power is back up in short order.  Machines on.  Still stable.  Back to bed. 

Another table alarm comes and goes without incident.  And then the power goes off.  Three times for those keeping track at home.  I turn off the machines and lay back down.  I don’t really know what else to do.  This is the time when you start to question whether your effort is misplaced.  Is it really worth me staying up all night for this patient?  No one else certainly seems like it's worth it.  I must’ve drifted off because I was startled awake ten minutes later when dad and grandma came back to check on her.  I get up.  She’s blue again.  Her body is limp.  Her respirations are infrequent and irregular.  And her HR is 15. 

I take off the nasal cannula to ensure that the mask gets a good seal and deliver two rescue breaths before starting CPR, pumping my thumbs where there already is significant bruising.  30:2.  30:2.  Five cycles and a pulse check.  Still 15.  No respirations.  The flashlight in my mouth offers the only light in the room.  My skin glows in the dark down here, but to watch her chest for movement I have to have the light.  What am I missing?  Neonatal sepsis?  Is she so early that her lungs aren't developed?  Did I give her a pneumothorax with my first rounds of CPR?  What's her blood sugar?  Medicine is much more fatiguing when your questions outnumber your answers.

My jaw is sore.  My mind is tired.  My spirit is exhausted.  And then I feel the vibration in my pocket from my phone.  I’m sure everyone has had the phantom vibration syndrome, where you constantly feel like your phone is going off.  Well, I’ve had that too, but I was certain this was legit.  Not sure how though.  I haven’t had service or Wi-Fi since I’ve been here.  I mean, I’ve been connected to the router, but the connection to the internet has been down since before I arrived.  Maybe, just maybe, in some strange twist of fate, my phone is connected to the internet and I can look up a formal flow sheet for neonatal resuscitation.  Maybe Youtube how to intubate a neonate with a tongue blade and a straw.  Anything to change the impending outcome.  I pull out my phone.

Calendar notification.  Two days until “Bedica’s birthday.”  I fumble as I try to quickly resume compressions.  My hopes dashed and what a crushing blow.  Her lips and eyelids are a faint blue hue.  Grandma has already left the room and only dad is standing there to watch this white man beat up his newborn baby girl.  Ten minutes past the hour and I’m done.  I look at the father and can’t imagine that I would want to keep seeing the same trauma inflicted on my baby girl.  The outcome isn’t going to change.  Not without epinephrine, atropine, IVFs, an incubator, and a real NICU team.  A family medicine resident in his second year that is terrified of sick neonates cannot win this battle with a flashlight.  I stop.  I swaddle her in her blankets and carry her to her father.  I don’t even know what I would say if he spoke English.  “I’m sorry.”

Kurrant Part 1

The silent vibration against my thigh was an unfamiliar sensation over the past few days.  I have been without 4G, 3G, 1G and wireless since I arrived in Haiti.  So even while the mindless banter in my group texts is likely ongoing, I have been completely removed from it.  Leaving my phone truly silent.  So naturally, I checked to see what may have gotten through.  The message was simple, but the timing could not have been worse.  “Bedica’s Birthday is in 2 days”.

 

Honestly, the date hadn’t crossed my mind when I was booking my travel dates.  But at this moment I couldn’t even take any time to grieve or contemplate the message I had just read.  I was in the middle or trying to navigate a resuscitation effort on a newborn girl.

The delivery came in the middle of the night prior.  During clinic we probably see ten to twenty obstetric patients per day which means the hospital delivers upwards of fifty babies a month.  This patient had seemed innocuous enough.  She was considered term as our dates had her at >39 weeks gestation.  Common practice is to induce in the office to ensure that they deliver at the hospital and not at home, miles away.  So I placed cytotec intravaginally and told her to marché.  Her labor curve went into the evening.  She ruptured approximately 6pm, but didn’t make much progress initially.  We opted to go to bed and I set my alarm so I could check on her every hour.  About midnight I went and found her complete and ready to push.

It didn’t take long and we had a baby girl.  There was no delivery team, so I scrounged for the clamps and scissors.  I have been advocating for the nurses here to do “skin to skin” but it hasn’t caught on yet.  But, I’m by myself so baby goes immediately to momma’s chest.  Towel dry for stimulation.  She isn’t crying. 

I’ve been through this before.  In fact, this happened last time I was here.  I grab the baby and carry her over to the resuscitation table.  This time I find an infant bag-mask and begin some positive airway pressure.  It takes some time, but eventually she starts coughing and crying.  Whew.  Happy sounds.  She’s still working a little harder to breathe than I would like, but sometimes you just have to take what you can get.  I replace her on mom’s chest and try in my best broken Creole to tell her that “the baby isn’t breathing great, so we need to keep watching”.  And with that I head to bed.

My alarm goes off in my ears an hour later and I walk down to the post-partum “suite” to find the nurse getting the mom situated in a bed and the baby with supplemental oxygen flowing by nasal cannula.  She looks more comfortable wrapped snuggly in her blanket and wearing her pink toboggan.  Her breathing still looks a little labored, but improved since a couple hours earlier. 

I check in on her throughout the next day.  They turned off her oxygen around lunch time and mama was happy to report to me that she was breastfeeding well for her.  I sneak a peek under the swaddled mess of blankets and see her resting comfortably enough.  “Thank goodness” I think to myself.

It was shortly after dinner that the Haitian resident flagged John, my interpreter, to grab me.  There was a patient he wanted me to see.  I thought maybe another mom was about to deliver and he wanted to let me know, but we bypass the delivery suite to the recovery beds.  He points to the far bed and I know immediately.  I go check on her.  She’s limp.  She’s tachypneic.  She’s turning blue.  I grab her and bring her to the delivery room where the neonatal resuscitation table is.  Thankfully, the bag mask is still out from when I used it to deliver her approximately 18 hours prior to now.  I try my hardest to pace my breaths, but they say in times of distress we often tend to over-ventilate.  We pump too hard too quickly.  Go big or go home, right?  #NotAGreatStrategyInThisSituation 

The nurse lugs in the suitcase sized oxygen machine from the inpatient rooms.  I ask if there is a way to hook up the oxygen flow directly to the bag mask.  Nope.  Alright, we place the three-size-too-big nasal cannula into her nares and I try to continue to provide any sort of positive airway pressure that I can.  She’s dry.  It doesn’t take a chemistry panel or even an advanced degree to recognize that.  The Haitian resident calls for Dr. Leo and Dr. Ulysse to come examine the baby.  Dr. Ulysse quickly is able to secure an IV in the baby’s right hand #MadSkills #CubanTraining.  The nurse brings a bag of IV fluid.  I’ll take anything at this point.  “How much does she weight?”  “2.3 kilograms.”  That’s 2300 grams for those of you playing at home.  And that’s her birthweight.  Something is amiss.

I pass off the bag mask to John and he’s doing a wonderful job.  For the next twenty minutes I’m on my phone, with no internet access mind you, punching away on the calculator function to figure out how much fluid to give and how fast to give it.  Maintenance is 8 mL/hr.  Dang.  That’s not even a mouthful of spit.  Okay, we need to “bolus” her like 20 mL twice.  I grab the IV tubing wheel and roll it until I count one drop every 3 seconds #OldSchool.  Now.  Antibiotics. 

Neonatal sepsis is treated by “Zosyn” in our hospital now - because we can.  If you’re taking a board exam the answer for treatment of neonatal sepsis is ampicillin and gentamycin.  I’m gonna go out on a limb and assume we do not have Zosyn here.  I ask the nurse for ampicillin and gentamycin for IV use.  No ampicillin.  Penicillin it is.  #AlwaysSettle 

I didn’t realize how difficult it can be to be a pharmacist until this very moment.  I mean, I always find it super annoying to have to figure out how much of an oral suspension for a kiddo to take to get the appropriate dose of medication.  Now I’m reconstituting penicillin, figuring out how many thousands of units this baby needs to receive every six hours, and how many mL that would be  #MathIsHard  The answers for those of you playing at home are 115,000 units which equates to about 0.14 mL of the reconstituted penicillin.  Now I have to do the same to figure out how much of the gentamycin to give her.  #FML  In order to keep things simple I took a piece of tape and wrote the drug and dose on it and put it on the syringe I used.  Unfortunately the IV tubing we were using didn’t have a port for me to administer additional medication.  Screw it, I.M. it is.

I resume my position manning the bag mask.  Minutes feel like hours.  Her little lungs fill with each pump of the bag.  Suddenly the nurse points to the IV fluid chamber.  It stopped flowing.  Her little R hand was swollen up to twice its normal size.  Our IV had infiltrated.  A wise man once told me that subq fluid still got fluid into the system, and in this situation I was going to take what I could get.  But the nurse pulled the IV catheter before I could say anything.  Dr. Ulysse was able to come down and place one in the other hand in short order #LikeABoss  We continued our resuscitative efforts.  This time I paced out the fluids to one drop every 8 seconds. 

Needless to say, pumping away on an ambu bag for a long period of time can get monotonous.  Even with trying to count in my head and stay gentle with the amount of pressure I create, it’s easy to for me to get distracted.  Time is crawling and there is no end in sight.

The Haitian resident places his hands on her chest and comments, “Li fret”, indicating that he thinks she’s cold.  I look down, feel her chest, and immediately grab my stethoscope.  There’s good reason for her to be cold; her pulse was at best 20 bpm.  Her hands were already blue.  0.14 mL of the reconstituted penicillin.

90.5 is what her axillary temperature measured.  Before the thermometer even alarmed I had started CPR with rescue breathing and chest compressions.  I cycle as fast as I can.  Occasionally she opens her eyes and a spastic movement squeezes enough air out of her chest to make a squeal.  Cycle after cycle and I feel like I’m getting nowhere.  I check for cardiac activity and can’t detect anything that seems like it would offer perfusion.  And so I continue.  I spin her around because up to this point I was operating with her head towards me and feet away from me.  With her feet towards me I can wrap my hands around her torso and use my thumbs to compress her chest.  I can also visualize chest wall expansion with each breath.  Bruises are already setting in from my trauma.  And we just lost our other IV.

The Haitian resident, recognizing my fatigue and dwindling faith, points to the wall and offers simply, “Nou gen epinephrine?”  I’m not even sure what I would be giving it for.  We have been resuscitating this girl for an hour now, what good could it possibly do? 

The patient’s father and grandmother walk into the room to me doing compressions and rescue breathing.  I’m not sure if it was the look on my face or if they caught a glimpse of their little girl on the table, but you could see the despair in their eyes.  Why not?  “Please give me the epinephrine.”

Hmmm, I have a 3 mL syringe with 0.5 mL of solution in it.  There is a piece of tape with “Epinephrine” written on it.  No dose.  No concentration.  Nothing.  And nobody knows.  Well, I don’t have an IV or an endotracheal tube, so at least the route of administration isn’t in question.  I grab her thigh and plunge the 18 gauge needle into the muscle.  I push the plunger.  No carefully planned amount.  Just push the plunger.  And then resume compressions. 

Minutes pass by.  Why not?  I grab the other thigh and empty the rest of the syringe.  Tick tock.  Tick tock.  I listen with my stethoscope.  Wait a minute, that heart rate is improving.  I stop with compressions and resume rescue breathing with the ambu bag.  I see some more purposeful movements in her arms and legs.  She’s even offering some of her own breaths.   

I continue supporting while the Haitian resident continues to stimulate in the hopes of producing a cry.  I take another listen.  108 bpm.  Dr. Leo swings back by to check on the baby.  We tell him we lost our IV again.  He turns to the family and tells them that the baby may not make it through the night.  And with that he is off.  We’re gonna do what we can without an IV.  I stop with the rescue breathing and see how she does on her own.  All things considered it isn’t awful.  She has a little accessory muscle use, but her rate is hovering around 70.  I set the bag down.  We replace the nasal cannula as I had removed it when I started with compressions.  And I stepped away. 

Her next doses of antibiotics were due at 1255 and 0255 a.m. My phone was set.  She needed some sort of volume, so we attempted to have her breastfeed.  It went okay for a few minutes.  She didn’t really latch, but her mother was able to express some milk manually.  8 mL an hour is her maintenance, so if we can do that intermittently I would call that a win.  Still, she quickly tired without the supplemental oxygen, so I placed her back on the resuscitation table.  That’s the only place in the hospital with a radiant warmer, and her temp was still low 90s.  She still has the bag of IV fluid hanging on the pole beside her.  Why not?  I open the tubing and let a little trickle into her mouth.  She immediately does her best to latch onto the end of the tubing and begins suckling at it.  #FluidIsFluid at this stage of the game.  She gets about ten drops before she starts coughing.  I’ll take that all day, every day, and twice on Sunday. 

New resolution, wake up every hour, see if she can take some expressed breast milk and then supplement with the IV now PO fluid.  This is going to be a long night. 

I head upstairs.  There are still several people in that room, and for most of the resuscitation there was a mom of a different baby still being cleaned up from her delivery.  Right now our little girl is holding her own.  Her heart rate is stable.  With the 4LNC in she’s breathing much more comfortably.  She has some purposeful movements in her arms and legs.  Not much more you can ask for given our situation.  I don’t have telemetry to give me a constant update on her heart rate.  I don’t have a pulse oximeter to assess her oxygenation.  I don’t even have an IV to give her the parenteral nutrition and fluid she so desperately needs.  She was only 2.3 kilograms, meaning that even if she were a 37 week baby she would be close to SGA.  How certain can we be of our dates in Haiti?  Did we induce a premature baby?  Questions that will never be answered.  Problems that won’t be resolved.  We have a second year family medicine resident trying to care for an NICU baby.

I grabbed a sheet and several blankets – it gets cold in the mountains at night – and head back to the delivery suite.  We don’t have any women in active labor, so I’m calling dibs on the bed.  Yes, the same beds that have been covered by more blood, poop, and amniotic fluid than I’d care to count.  I plan on posting up there for the night.  My syringes are ready to go.  I plug my phone into the socket; alarms are ready to go.  Let’s do this.