Thursday, April 11, 2013

Day 12- Learning as we go...

We worked the nightshift last night. I've come to really enjoy the nightshift at St. Therese Hospital. It's a cool reprieve from the intense sun of the day. It's quiet. It's personal in comparison to the chaos from the sweaty, compacted, disjointed day shift. There are no students to teach. Just Midwives to teach...midwives to set an example for. One on one time to show, explain, work and be intently watched. I feel as though it's just as much needed. And probably even more needed.

As we triage patients, speak to them, touch them, explain things to them as we go, and collaboratively make decisions, the midwives watch us and listen as we go. There is no doubt in my mind that this makes a difference. Maybe not just because of Glen and I, but cummulatively, with the next group, and the next group, and so on...if we continue to build on this, THIS will continue to set the path for growth and skill, which will lead to improvement of care and better outcomes for mothers and babies.

Last night we arrived at the hospital in a dark, torrential downpour. We were soaked, trying our best to manuever through the flooded ground and then careful not to slip on the flooded, slippery sidewalks within the hospial. As I walk the corridors, I am now on the look-out for cat-rats, as the last nightshift we worked, I had the displeasure of seeing a rat larger than Ina May, the Midwives for Haiti house cat. Now, I can handle quite a lot- put me in a hostile climate of an environment, with limited medical supplies and resources, take away running water and readily available clean water, my protein rich diet, and work me like a mule- that's ok. I'm down for it. But the thought of crossing paths with a cat-rat in the wet darkness of the hospital pushes me to my limit!

As we walk by the antepartum unit I briefly see a group of people gathered around a bed, but I don't think to stop and investigate. We arrive on the maternity ward, set our backpacks down and get our supplies in order. We have learned to carry everything we might need on our bodies, in a pack around our waists. Yes, a fanny pack. Ha.

We had been there a few minutes and a midwife walks in and goes straight to the back counter. It didn't even register with me that it was a baby in her arms. She says something in Creole. Our translator says, "A baby was just born on the antepartum unit." And then next, "She says the baby is not breathing." It's apparent that the midwife either does not know what to do or does not want to do it. She is continuing to stimulate, but I already know we are in secondary apnea. I have a hunch that this baby has likely been stimulated for 2 minutes+ and it obviously needs more than that. I immediately go over and see a blue, limp baby. I say out loud that we need the ambu bag. There is not one in sight. Glen darts to go get it from the back and comes back with one in about 2 seconds flat. The midwife says no, it's dirty. She doesn't want to use a dirty ambu bag. In the heat of the moment I say, calmly, but directly, "A dirty ambu bag is better than a dead baby." Later I wonder if I could have said it in a better manner, but at the time I just wanted to get the point across.
She says nothing and continnues to watch. Glen and I open the baby's airway and start to bag. I listen to the heart rate and it's pounding need for compressions. Well isn't this a treat tonight. No compressions! After several minute of bagging, the baby begins to breathe on its own. I have Shelly, our translater, plug in the warming pad. I scoop the baby up and hold it in my arms to keep it warm in the meantime. Baby is flaring and retracting so I put it on oxygen. The baby calms down and doesn't seem to struggle as much in my arms.

The midwife asks if the baby is a boy or girl. I haven't a clue. I was a bit preoccupied. I tell her I don't know, but as soon as the baby is stable, we can look. In other words, it's really irrelevant at this point.

A couple minutes later the other midwife asks me how much baby weighs. I really have to bite my tongue with this. I smile and say that I haven't weighed baby yet, and as a general rule of thumb, we shouldn't worry about things like weight and measurements until baby is stable. She nods her head.

The peds resident arrives to assess things and see if we need help. We are a bit unsure of our abilites. I explain that honestly, I have no idea what I'm doing. And yet here I am, stablizing a 4 lb preemie. How long can he be on oxygen? How do I know when to take him off? Once he's stable, then where do I take him? Ah! It's funny really. Funny but not! She leaves us to continue doing what we're doing.

Glen goes to lay down and I stay on baby duty. I watch him like a hawk. Literally. I'm sitting above on the dirty counter, gazing down on him. I turn my roaming data on my iPhone on and I 'Facebook' in between taking vitals. I do this for a good hour and then decide that before I take him to his momma, I need to do a test run without the oxygen.
Preemie baby boy in his surgical towel "cloth-diaper."
My view from the counter top, as I monitor baby.

He's doing better, with some intermittent flaring. It's now been a couple hours after birth and he has yet to meet his mother, let alone have skin to skin or nurse. I start to worry about his blood sugar. Again, I have no idea what I'm doing. Well...I do, kind of. I am a trained and licensed midwife. But  prior to coming to Haiti, I had never cared for a premature baby. Never even seen one, actually. I decide he's stable enough to go see mom for some skin to skin and hopefully some suckling.

I swaddle baby and so very carefully manuever through the dark, wet corridor of the hospital. I sit and talk to the young mom, who is accomplanied by her parents, and explain that her little guy has had some problems breathing but I would really like them to be together and see how he does. We put him to the breast and he nuzzles in and falls asleep. His flaring has subsided. We sit for 10 minutes to make sure he is stable, and then I feel semi-comfortable leaving him. I tell the mom and grandparents that they need to make sure he stays skin to skin with mom, stays warm, and does not begin to breathe quickly or make noises when he breathes. I explain what nasal flaring and retraction is. They nod and veralize that they understand and promise to come get me if he starts to struggle again.

The baby lasted 30 minutes with mom and we ended up taking him to the peds unit. I felt much better at this point. As of this morning, he was still on oxygen but doing fine.

The rest of the night included a D&C done in the L&D room for a girl who was "2 months" pregnant but having severe cramping and bleeding. Glen scanned her and saw nothing in the uterus, but the unpassed tissue still in the cervix. Keep in mind there is no anesthesia for this, no pain medicine available. I felt bad for her, but I was glad that she came in and we were able to take care of her and monitor her, in case of hemorrhage.

The filthy room with a toilet (a toilet that is not actually functional, just a place to catch your pee)- which smells so bad, the air is thick with the scent it makes it difficult to breathe- is locked. Rather than go outside like I have done every other night without hesitance, I squat inside the storage closet and pee in a bowl. My lovely interpreter takes my bowl and dumps it out for me. Anything to avoid the cat-rats.

We complete our shift with me catching a healthy baby, with no complications for baby or mom, and Glen doing a c-section. One of the midwives assists me with the delivery and is good help. I am impressed with her forethought, her interaction with the patient, and her attention to getting heart tones. Immediately after delivery she asks if she can take baby away to weigh him. I smile and say that the best warmer is on mom's breast, and weighing baby can wait. She nods her head and says, "Ah," as though she is processing this for the first time.

A healthy, term baby boy, born OP.

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