Kriye

I don’t always sleep well when I’m in Haiti.  I don’t say that to complain, but as a mere statement of fact.  The beds are not luxurious, but they are a thousand times better than what most of the Haitians we are serving sleep on.  It is difficult to control the temperature; the city can smother you with heat and humidity while the thin mountain air can leave you chilled.  As I’m older I feel more aches and pains, which seem to be magnified with poor quality sleep.  And then there are the noises.  


Typical noises in Haiti can be Kampa music from a distant discotheque (Club Affeksyon is one of the best named ones I’ve visited).  The bar could be empty, but that won’t stop the owner from dropping dope beats through the aux cord ALL NIGHT LONG.  If it isn’t the beats, then sometimes it’s the ‘baaaas’.  I laugh at the customs form when re-entering the states as is asks if you’ve been on a farm or handling livestock.  Have you been to Haiti?  Anywhere but the city is agriculture and livestock.  Roosters, goats, pigs and dogs all like to make their presence known at all hours of the night.  Sunrise be damned.


On the morning of 9/17, though, there was different sound… a ‘kriye’.  We had had some deliveries the day prior, but none of the newborns had been noisy up to that point.  There were two pediatric patients in the hospital.  But, again, they had not made much noise in the days up to this point.  


I couldn’t sleep.  It was LOUD.  And it had been going on for over an hour straight.  So, I got up. 

She was outside the hospital… sitting in a chair… and she couldn’t have been older than nine months.  Her hair was in braids.  She had a dress on.  I looked around and there were several adults using the outdoor water supply to wash off their feet as they changed their clothes.  It was, maybe, four in the morning… maybe.  #EverythingBeforeSunriseIsFourAM I picked her up and I think the sheer shock of my whiteness plucking her off the metal folding chair stole her voice.  She stared.  I bounced.  Silence.  Perfect.


Her mother finished cleaning up and came and grabbed her.  About that time, she started crying again, but I at least satisfied in my mind the source of the screams.  I was up for good at that point, so I went into the post-partum suite to check on the moms and babies we had delivered.  When I passed back through the lobby of the clinic, I saw the little girl, her mom and her brother laying down on the bench to hold their spots for the day’s clinic appointments.   


I don’t personally see as many patients in the clinic as I used to.  I mostly go to observe clinic flow, provide resource support, trouble shoot and offer an occasional “this is how we would approach x/y/z in America”.  On this day I was observing in clinic when the mom brought her young boy and girl in to see Dr. Leo. Once again, my pale skin must’ve scared the little girl, or she was tired, or she was cold, or she was hungry because she immediately started screaming… no…crying – scryming?!?  I tried to hold her, but that was unsuccessful.  John, however, is the child whisperer and was able to bounce her around the clinic enough to keep her content.  


She wasn’t the patient.  Her brother was.  His body was skin and bones and his face looked beleaguered.  He was, himself, a child, but you could tell that he carried so much responsibility at his young age.  The little girl looked nine months.  She was fifteen months.  The mom’s concern was that the young boy had been coughing for over two months.  He was timid and often parroted what his mom said when Dr. Leo would ask a question.  Suddenly, Leo recognized the mother.  He confirms her name and turns to me, “we diagnosed her with TB last April.”  Yes, Tuberculosis.


She had gone to “the city” as a 16 year old.  According to Dr. Leo, she met a man and got pregnant.  As is all too common a tale, the man left her without concern for the well-being of his child or the child’s mother.  She moved back to Gran Bwa this past March.  She lives with her mom and tries to work as a seller in whatever market she can create an opportunity.   Even in better economic times, there are not a lot of opportunities in rural Haiti.    


I can’t say that I’ve seen a high volume of TB patients during my time in Haiti.  It isn’t the easiest thing to test for, so I may have started the work-up on some patients with breathing/coughing complaints that would eventually lead to a TB diagnosis.  However, we have a 20 year old mom of two with a known TB diagnosis.  The older child is here for a cough lasting two months and looks emaciated.  The 15-month-old has powerful lungs but is clinically malnourished.  Everyone needs treatment and fortunately there is a State sponsored clinic in the area with a TB program.  Yay! 

Jocelyne had been in treatment since her diagnosis in April.  One might think the system would take care to ensure close contacts did not contract this deadly bacterium, but alas here we are.  All we need do now is send our young man down to the clinic on a TB day to undergo sputum testing and enroll in the treatment program.  And fortunately, September 17^th was a TB day!  We tell the mom to hurry, pack a quick sack with a little food for the trip, and grab a moto to take her to the clinic building.


This would’ve been too easy.  The protests, or #Manifestations, had started in Port au Prince and somehow had found their way up our peaceful mountain. Crowds flooded the city streets to burn tires and generally disrupt commerce.  Not with plans of violence, this time, but to cause a scene and be heard.  The same was true in the mountains.  Young men, and possibly women, set up “road blocks” along the one road that went up and down the mountain.  Jocelyne was stuck.  She couldn’t reach the clinic to get her son started on his life saving medication.  She returned to the clinic and they had to wait.


This is one of many “road blocks” this poor, young family is going to have to deal with just to treat this disease.  I mentioned earlier that when I found them originally, they were cleaning up in the water supply outside the clinic.  They had hiked several hours in the mud just to get to our clinic.  They had brought a change of clothes to ensure that they were clean and dressed well to see the doctor.  If I’m sick, you can bet that I’m rolling up to my doctor’s office wearing sweatpants and bags under my eyes.  

Several days go by and finally the mountain road opens.  They were stuck at our clinic the whole time.  I have difficulty with the clinic being treated like a soup kitchen, but in this situation even Scrooge would show compassion.  Charity is, to me, a very delicate and difficult act in Haiti.  With nearly every trip I have people offer to personally give me cash so that I can deliver “whatever they [Haitians] need.”  I always go into a trip not knowing what I will encounter.  Where will the money be best used?  This time, it was clear.  I spoke briefly with our Haitian social worker - who had already recorded as much information about this family as he could - and I told him that I had money to support this young mother and her two children.  I felt that we should buoy them as they tried to fight through poverty to treat tuberculosis.  The clinic will always do what is necessary to take care of patients, but I wanted Jean Louis to not have to worry about the funds coming from somewhere else.  



Their story isn’t finished.  Unfortunately, it is one lasting several months with frequent long trips to refill their anti-TB medication.  It is one lasting several years to fight through the cycle of poverty to have a sustainable income.  But I do think we offered this family a new chance at life.  For those that gave this trip, thank you.  Jocelyne and her young family have an opportunity to pursue life they would not have had without your gifts.  I cannot thank you enough.

Akouchement Lakay

Since the @ServeHaiti Instagram post caught a fair amount of attention I thought I'd give the writing thing another shot.

I had returned to Haiti after being whisked away in a helicopter just two months earlier #Manifestations.  I'm still getting the feel for this whole Medical Director thing, but if it gets me into the beautiful country more then I support it.  ServeHaiti is piloting a new data collection program that will (hopefully) allow for near real-time information to be easily organized and analyzed.  We do (I say 'we', but it's definitely got nothing to do with my actions) amazing work in Grand Bois, but it's really hard to say those things without objective information.

That's why I'm here though.  Help introduce the program.  See it in action.  Troubleshoot early problems.  And obviously to work on my tan.  #BeachSeason.



The first day was great!  Abby and I were able to get the selected #CommunityHealthWorkers to the clinic and give them their "new" device.  And by "new" I mean four-year-old, generously donated, tablets running Android platforms.  But that's definitely #HaitiNew.  Even Dr. Leo and Jean-Louis (JL), our hospital social worker, were in on the fun.  The plans are to have our childhood malnutrition program data recorded, our pharmacy inventory, and then track the work of our community workers.  Abby was able to walk everyone through the sample templates so they could familiarize themselves with #Collect.

The following day we were off!  John, Abby, JL and myself hopped on motos and headed East!  Or North!  Or... I really don't know my directions when I'm down there and often feel like I'm going in circles.  Probably explains why my "short jogs" end up with me getting totally lost.  Riding on a little moto is exhilarating.  If you're able to pry your eyes away from the fractured, mud-gravel-dirt road directly beneath you and look outward over the sharp cliff to the beautiful mountains and valleys you'll wonder why more people don't tourist here.  Then you hit a rock, fishtail, and think WTF WHY AM I NOT WEARING A HELMET.

An hour into our ride we stopped at a crossroads to pick up another of the CHWs.  It was around 1030 but already the Caribbean sun was putting in work.  Silianette was out handling some local community meetings.  The plan was to pick her up and head to the far reaches of the Grand-Bois territory to see data collection in action.  I was pumped.  I was promised some good hiking.  The sun was out so the guns were out.  Fixing to be a great day.

Until



We're walking back to our motos Silianette tells me, quite plainly, "there's a woman in labor over there'".  They wanted "the doctor" to check on her.  When I get to the house I see this young woman laying on the floor, holding her pregnant belly, and another young woman sitting behind her so that she has somewhere to lean.  She was term.  First baby.  She had been seen in the clinic for her prenatal visits and had not had any known complications.  Her contractions started at 0400 that day.  WHAT?  G1P0 contracting for only 6 hours.  Give me a break, take two Tylenol and sleep it off.  I tell John that I'll make sure she isn't too far dilated, but that I think it'd be safest for her to take one of our motos back to the clinic and deliver the baby there.  6 hours.  G1.  #Laughable.  Silianette was able to grab some gloves from her house out of her CHW supplies.

"Okay, I'm going to need to help you up into this bed so I can check your cervix" doesn't really have great direct translation into Haitian Creole.  I think John basically said, "Get in the bed he's going to check your uterus."  Message delivered.  We help her climb off the floor and up onto the elevated mattress.  "A little pressure annndd…."  Oh boy.  My body language said it all.  Completely dilated.  Bulging and tense amniotic sac.  Still 0 station, but at this point I can't send her on a moto.  "We're going to be having this baby here".

I look at my surroundings.  Slabs of tin peppered with holes are over my head.  Around me is a network of sticks and branches held together with dirt.  The floor is dirt, tamped and swept smooth.  A straw mat and blanket are still on the ground from where mom-to-be had been sitting.  A child walks in carrying a plastic chair offering me a place to sit.  A neighbor picks up my backpack and sets it on a table in the adjoining room.  Clear off the schedule, we're gonna be here a while.

I step outside to discuss the plans with Abby and Jean-Louis.  I have hand sanitizer, my stethoscope, and Silianette's meager supply of nonsterile gloves.  Abby is quick to snap me out of my thoughts and keep me to task.  "Yes, we need a razor blade, two pieces of string, and boiling water."  Sure enough, within an hour Abby had sourced an unused razor blade and two eight-inch pieces of string, boiled them, and scooped them up each with a fork so that they could be kept sterile...ish.

Photos courtesy of @servehaiti on the gram

For anyone who has not had a baby it's a lot of misery and waiting.  I didn't know when my training might be helpful, but basically I was sitting around talking and thinking.  JL and Abby did take one of the CHWs to head off and start the data collection.  Silianette stayed close, but took the opportunity to survey some of the nearby houses.  John and I stayed in the house and learned about our 20 year old patient and her soon to be 0 day old son.  The father of the baby had left shortly after they learned of the pregnancy.  She had a strong support system including a sister whose toddler was absolutely petrified of me and a grandmoun who has had several of her own children.  A midwife may or may not have been notified, but was not nearby.

Her contractions started before the sun came up that morning.  Apparently, 4am is generic for "before the sun comes up".  It could have been 8pm the night before for all we know, but we know it wasn't light out.  I'm so used to having my patients walk in saying, "I started timing my contractions last night at 715 pm but they were only 12 minutes 32 seconds apart then, so I didn't come in, but then this morning at 2am I felt one that was extra strong, and I thought my water broke, but maybe I peed a little, anyways the contractions are 10 minutes apart and my doctor told me to come in if my contractions are less than 10 minutes apart. *breath* So, how far am I dilated?"  #FirstWorldProblems

I encouraged walking, but she didn't have the strength for that.  She tried to eat, but got sick.  We treated some water and flavored it with Mio.  That went down okay.  She was breathing through her contractions and cycling every 2-4 minutes.  Noon comes and goes.  I have a few breakfast bars in my backpack, so John and I each eat one.  A few of the kids running around outside share another one.  I ask to check if she's made any progress, but she really hasn't.

I manage to break her water.  Clear fluid.  Hopefully this show can get on the road.

And this is where the panic and worry start settling in.

I set my phone out and play some music.  At one point I had a "Push a Baby Out" playlist with Salt-n-Peppa, TLC, and Bieber, but I had to settle on whatever my Spotify favorites were.  I look at my patient and the emptiness in her eyes.  I look at my arms and my whiteness just glows in the dark hut.  If this delivery does not go well I worry what this might due to the trust and relationship our clinic has with the community.  Will I be blamed?  Will the clinic be blamed?  Such little control with so much pressure.

Another hour passes with her pushing with every contraction.  I try to tell her not to push, conserve her energy.  But you tell that to an unblocked pregnant woman and see what happens to you.  I check again and get a sense of position.  The baby is LOP and asynclitic.  We try the floor again on all fours to see if that's more comfortable for her.  Yes, the dirt floor.  Her prayers start flowing.  It's all rapid Creole, but I've heard them enough times to get a sense of what's being said.

She gets back into the bed.  I check and we haven't made much progress.  With her next contraction she pushes and I try my damndest to turn the baby's head using just my fingers.  I have no way to assess fetal heart tones so every moment she's still pregnant is just taking years off my life.  And yes, I know they aren't sound science, but when you've trained having that information most of the time then not having it is anxiety-invoking.  Back to the floor.

Progress!  We've delivered hair!  I get to make the joke that all his hair slowed him up!  It gets about as many laughs as you would expect.  She's tired and over it.  She makes slow and steady progress with each contraction now.  The baby's crowning.  Her pushes are near continuous, but she's running out of steam.  I have her family help support her legs as I kneel on the dirt floor heart pounding.  "Please God, healthy baby.  Please God, healthy baby."

The head delivers and he's facing left.  Shit.  Tight nuchal cord.  I grab for it and try to tell her not to push.  I can't clamp and cut.  It's tense.  I don't think it would allow us to deliver through.  With my second quick sweep with my left hand the cord slingshots from around his neck.  Oh thank God.  Head down.  Shoulder.  Back up.  Grab the legs.  POOF!  Baby boy followed by a pile of poop.  No screams.  No tone.  I grab the string and fumble through tying my long-forgotten surgical knots near the boy's umbilicus.  Then another knot a few centimeters away.  No time for theatrics.  Grab the razor blade and put the business end against the cord.  Saw away.



Separated, I turn to the bed behind me.  My internal clock is both at zero seconds and a thousand seconds right now.  Towels.  Dry.  Stimulate.  I throw my stethoscope down... *bump * bump *bump * bump... right about the rate of a catchy pop song, so probably 120 BPM.  That's good.  Still don't see a lot of chest rise.  I tell John to continue to vigorously dry the baby with a fresh towel as I tilt his head.  No suction bulb, of course.  Stethoscope back to the chest... same pace.  No movement.

Seconds.  Minutes.  Who knows.  I don't know about NICU attendings, but anytime I find myself in this situation I feel like I'm all alone and I have zero concept of time.  Stimulate the body.  Support the airway.  Pump the legs.  I'm almost about to lift him by his heel and slap his but when suddenly he sputters out series of coughs.  Quite possibly the most beautiful sounds I've ever heard.  I let out an audible sigh.





He's breathing.  His skin slowly pinks up.  And here comes the crying.  I swaddle him and try to bring him to mom.  She's not having it.  Sister grabs him up and the rest of the family swarms her.  I kneel back at mom, still on the ground, and twirl the umbilical cord around my right index finger.  It comes easily.  Seems to be intact as I inspect it on the straw mat.  I'm not sure why but I do brief exam for lacerations or brisk bleedings.  For real tho, what am I going to do?  She has a small side wall laceration, but no deep perineal laceration.  I apply a piece of gauze and hold pressure.

It's done.  We have a crying baby.  We have a mom who is standing up to put on underwear.  We have an excited family rushing into the "delivery room".  As I walk out the sun still hits my eyes.  It's 4pm.  I have John give Silianette instructions so the mom and baby will follow-up in the clinic tomorrow.  Instructions if she has any further bleeding.  Encourage her to breast feed as much as her body will let her.  We say our goodbyes.  Eat a small amount of the food they offer us.  But the rain is coming and our moto driver wants us to get back.

Near perfect timing, Jean-Louis and Abby arrive at the crossroads at the same time we do.  We course back across the Haitian landscape as storm clouds gather overhead.  Back at the clinic we pay the drivers and find our food waiting for us on the dinner table.  The rain falls as the sun fades away.  The raindrops echoing off our tin roof with authority.  The rain is welcome to the drought-stricken area, but I can't help but think of that tin roof sheltering that brand new baby.