Thursday, April 4, 2013

Day 4/5- A Day and Night Shift at the Hospital

Today started like any other, we got up, had breakfast and headed off to work. That is the last bit of normalcy we had for the day. We get to the hospital at 8:30 and the local OB is looking for me to help in surgery. Not sure what we are doing yet, I eagerly follow him in anticipation of what is to come. It turns out to be another cesarean, this time for the mom (a midwife herself) being 42 weeks and not yet in labor. That part is a little sad to me, since we would have at least elected for an induction, if not continued waiting. But, without good antepartum testing, it might be the lesser of two evils.

I am finding that antepartum testing is really never done. There is no such thing as a routine NST or a BPP, or twice weekly testing. It simply does not happen and likely would take a huge undertaking for it to happen. I'm not sure why, but my guess is that it boils down to resources and man hours. There are just too many moms for the staff and the clinics. With wards full of moms, both antepartum and postpartum, there isn't room or time to do testing. I should note here that some moms are simply at the hospital because it is too far from home to come in labor. These moms will essentially stork nesting at the hospital from 34-36 weeks until delivery.

They clearly do the best that they can, but there seems to be a lack of urgency, a lack of protocols, a lack of organization. For instance, the second mom I sectioned today. She was 'induced' with cytotec for preeclampsia. The induction 'failed' and so they just stopped and waited for the doctor (or me) to round and decide what to do. I'm not sure how many doses of cytotec they gave, how often they monitored blood pressure or baby during the induction, but I don't see quitting and waiting in our standard treatment for preeclampsia. But, what do you do with 25 patients and 3 midwives? Clearly, they are understaffed.

I digress. The first section ended without a hitch, this time I got to close the skin. (Those that know my style, know that I take pride in closing the skin.) I stroll back to Maternity to find Tara and Liz. I poke my head into the delivery area and see a lifeless baby getting 'stimulated' by the midwives. Clearly, help is needed. Liz has that experience and Tara needs that experience. I rush to grab them both and then help get what I can to help. I honestly did not expect this baby to survive. It looked to be 32 weeks at best and probably no bigger than 3 ½ pounds. I had no way to know how old the baby was when they started, could be 2 minutes, could have been 20. Apparently, the mom suddenly delivered in the antepartum ward and the baby was taken to maternity for resuscitation. Almost immediately they started chest compressions. No PPV available, so they bagged the baby with room air. No such thing as CPAP or nasal cannula. By some miracle, they got a heart rate back and the baby started to pink up. It was cold and floppy, but it was breathing and pink. No such thing as a warmer, either. Eventually a warming blanket is found and Liz suggests wrapping the baby in a ziploc bag for added warmth. I found the pediatrician (who has finished her first year of residency in Ireland) and she says that what they have done is as good as it gets. She does arrange transport of the baby to a more advanced hospital. That will take hours to get and hours in transport and according to our interpreter has a very high likelihood of death for the baby enroute. No NICU transport team exists. Again, it's the best you can do. I know that without Tara and Liz, this baby would have died within minutes. Sadly, this baby may die in the next few days as it is.

Tara still providing oxygen after a successful resuscitation

All this before 9:30! At 9:45 I go see the severe preeclamptic I mentioned earlier. Tara had rounded on earlier and found her blood pressure to be 180/115. (Although, I swear someone told me 2210/120 at some point) She had been 'induced' for severe preeclampsia but failed. She is massively swollen, big belly and has headaches. She needed delivery and urgently. I find the attending and give him the scenario and we call a section. I wish I had stuck with my gut feeling when I examined her. I thought she was breech, but didn't verbalize it. We were going to section anyway, so it really didn't matter, but it would have been good teaching moment for the midwives that were trying to induce her all night.

Off to the OR

We get into the OR, again with a difficult time finding scrubs and again with the personal water pourer as I scrub. (Jake...that will have to be your new job title!) I miss my scrub techs today. I get into the OR and I am handed my towel and gowned. And then left to glove myself. Frustrating! I am truly spoiled. And by spoiled, I mean that I am ELATED that this section is being done in the OR with air conditioning!!! I'm embarrassed to always be the one who constantly has to gesture for someone to wipe the sweat off of my brow. No cool points for me!

Then the doctor points to a large ring forcep like instrument and I'm handed three folded 4x4s. He points at the belly and makes a swiping motion. I guess I'm doing the prep today. (When was the last time I prepped???) A three part prep that ends with copious amounts of betadine. Seems reasonable. I have now affectionately termed these sections the '5 lap, no bovie' sections. They have 5 laps and I don't dare ask for more. There is a bovie in the room, but it hasn't been hooked up yet. There is no time-out, no fire risk, no preop count, no count during the case and no count at the end of the case. On one hand, it's refreshing to not have so many check boxes, but I miss the safety of the counts. It may seem overkill at times, but I can't imagine not doing counts at all! Well, I can imagine it, because that's the reality here.

And just like my Leopolds and instinct told me, this little guy was breech (a surprise to the attending) and severely IUGR for a baby at term. He's whisked away by the midwife and that's the last I see of him.

I come out of the section and head back to Maternity. I find Tara and Liz all smiles. I look and see a mom breastfeeding twins.

Minutes after delivery and both are nursing!

Guess what? These two delivered twins, vaginally and NOT in the OR!! Liz had her very first catch ever and Tara got to help with her first set of twins. Baby boys did great. It wasn't without a little uh oh moment, though. Liz catches the first baby and has some help getting baby untangled from its cord from Tara. She tells mom to take the baby and immediately baby goes to breast. They are preparing for the placenta when grandma chimes in that the ultrasound said there were 2 babies! Thankfully, Tara and I had talked about what to do with twins and she did a perfect job.

The twin mom had done great, started breastfeeding right away, got her Pitocin right after birth and had a rock hard uterus he whole time, but just as she was about to get up she gushed and gushed. The head midwife swept her for membranes and got a few. She got cytotec rectally and ergotamine IM and all calmed down. THIS was the result of the bleeding.
Lack of staffing prevents rapid cleanup
This doesn't change for hours, even after the patient left.
And sadly, this is how the room stayed for hours, even as the next patient was laboring and ultimately delivering. This is how the bed, room, and floor stayed. To say that this is not the most hygienic place, is an understatement.

We then find ourselves caring for a 17 year old mom having her first baby. She is complete just as the twins were delivering. She lays on the bed in the same room pushing as the other mom is delivering. 5 feet at most separate their beds. Thankfully, she takes a bit to deliver. Intermittent monitoring for labor and as she is pushing, the heart tones are in the 80s. I'm not too concerned yet. It's pretty common to see them drop as the head hits the perineum. But mom isn't giving the best pushing effort. Listen again...even lower. Listen again and this time it is clearly lower than 60. I look at Tara and we know what needs to happen. An episiotomy is truly needed. This baby is compromised, and we are already facing a resuscitation that we are ill-eqipped for. I know she does not want She spends a bit trying to figure out mentally exactly how much to cut...a little, a lot, 2 cm, 1cm? I told her to cut the tight band and she would be fine. With the next contraction, she cuts and with the next push we have a baby. Right up to mom's skin and a bit of stimulation and baby immediately perks up and does well. Whew...we've already seen how tough is to resuscitate a baby here and I wasn't looking forward to that again. It could have been much worse. In the end, Tara's first episiotomy was about 4mm cut, but it did serve it's purpose and she delivered quickly after that band was gone. Tara asks if I would like to do the repair. I numb her up and do the quick repair.

He turned out pretty good. All smiles for a healthy delivery

I talk to the OB doctor, who happened to just walk in, about what his routine post section orders are and am very surprised to find that his ONLY pain med given after section is diclofenac. As I recall, this is something similar to Motrin. Wow...I can't say this would fly with the majority of my post section moms. These moms are clearly tolerant of pain with birth.

Next, I'm asked to scan a mom that is sent in for induction for a 'threatened demise.' I question what they mean by a 'threatened demise' but I don't get a good answer. She hasn't had a formal 20 week scan, they didn't do one in the clinic, and the local midwife doesn't see much wrong. I put on the transducer and find a baby that is clearly alive. Tons of amniotic fluid, but nonetheless alive. With the limited scan I can't tell if anything looks abnormal. Maybe the chest is a little small, but that's all I can easily see. Without my intervention, the local midwife would have done as she was told and induced a seemingly healthy 26 weeker, leading to its certain death from the prematurity. I presume that if that had happened, they somehow could have justified the 'threatened demise' because it did in fact happen. I don't pretend to understand.

I'm confused when I'm asked 5 minutes later to scan a mom with a demise. 'The same mom?' 'No' I'm told. A different mom, but again 26 weeks without heart tones. Immediately I can tell the baby is dead. There's a tremendous amount of scalp edema and fluid surrounding the abdomen. The head is a lemon sign and of course there is no heart movement. I take the time to show the midwives and Tara and Liz the ultrasound findings. I want Tara to be prepared for how this baby will look if we are able to be at that delivery. 10 minutes later the midwives come with orders from the OB. 50 mcg of cytotec vaginally. I try and discuss with the midwives that 50 mcg is the dose for a live baby and an IUFD can stand to have a much higher dose, 200 or 400 even wouldn't be unreasonable. But, they insist that's what the doctor ordered. So I put in the generous part of the 50 mcg tablet. I will see her later in the night and place 100 mcg, but that still hasn't even begun to start her labor. And she's essentially left by the midwives overnight to sleep in a room of moms and newborn babies. She was very sad and very emotional at the loss of her baby.

And that is how the day shift ended. A very eventful day, full of challenges, new skills, honed skills in the face of adversity and the beginning realization that I may not be able to change much in the way things are done, but I need to keep making suggestions and be available to the Haitian providers to support and answer questions.

Home for a quick bite to eat and a nap because we have decided to do the night shift. We rest from 3:30 to 7, or at least I do. Tara is up early working on her blog from yesterday. She's hard-core. I needed my beauty sleep.

As I'm waking up I realize that it is pouring buckets and buckets outside. It is a torrential downpour. Our first rain in Haiti and a much needed remedy to the dry, dry roads. I panic a bit because I hadn't gotten our clothes off the line from laundry day, but find out someone was nice enough to do it for us. Thank goodness.

A quick cold shower, a bit of dinner and we head off in our rain gear for the night shift. We were lucky to be able to take an SUV to work this time. I wasn't looking forward to a moto in the rain! It's amazing how good air conditioning in an SUV feels with this heat.

We get there just before 8. Maternity is a ghost town. Our interpreters seem to be running late. We break out the laptop and put in Season 1 of Glee that we borrowed from the house. The intro starts and the interpreters arrive. We stash away the laptop and that will be the last we see of it for the night.

Off we head to make rounds. We split up and Tara does the normal moms and I do whatever they ask of the high risk moms. The first, I am told, is a mom with severe preeclampsia that is being induced with cytotec. I take her blood pressure.....yes Susan and Tonya...I CAN take a blood pressure, I just don't like too. Did you not read that part about me being spoiled? Anyway, her blood pressure is 142/76. Not bad for a severe preeclamptic. I look and see that she is on an apresoline drip. Interesting. I haven't seen that done before. Then I put my hands on, this baby is tiny!!! It feels like a 2 pound baby. I tell the midwife that I have to ultrasound her. I grab the Sonosite and find her to be just that, 26 weeks and 1128gms, just over 2 pounds. I think I got a little firm at this point. I tell them that they have to stop her induction and if they want her delivered that she has to go to somewhere that can care for this baby. As it is, an induction here and this baby will most certainly die. Or, you could try and manage her blood pressure here until she is further along. Either way, you are risking mom or baby or both. It seems to be a lose/lose situation, but I knew at that moment that I did not want this baby born on my shift. One preemie is enough. Afterwards, it seems that the midwives were not correct, maybe they hadn't been inducing her, but just managing her blood pressure. This is getting old. Why doesn't anyone know who is being induced and who isn't? I guess they are going to wait for morning to see what the local OB has to say.

Scanned a set of twins for presentation. Breech/vertex. Thankfully, not in labor.

Evaluated a 14 weeker with lower abdominal pain that the midwives termed a possible abortion. She wasn't bleeding, had pain with urination and pain over her bladder. Baby looked and sounded good. Exam was benign. She got to spend the night with us because they didn't have a lab to run a urinalysis to see if she really had a UTI or not.

Evaluated a term mom in labor. She was 6cm and had been 6cm for Tara hours before. So, the local custom is very much that they stay hands off as much as possible. Vaginal exams are not frequently done in labor, to reduce the risk of infection. Intrapartum monitoring is done intermittently. Though intermittent monitoring is not a strictly every half hour event as we diligently practice, and with the high number or intrapartum deaths I've seen, this is something that needs to obviously be addressed. They get moms up and tell them to walk and come back when they feel the need to push. It is sad to say, that in this night we checked 3 moms in labor. This one that was 6, another that came in 7cm and delivered at 1am and another that came in 2cm and delivered at 6am. I can not actually tell you where the mom that was 6cm went!?! We looked in the halls and in the other units, but I couldn't pick out her face if I had to. I'm sure she's fine and maybe her contractions just stopped, but that gives a whole new spin to Harold Johnstone's saying in my residency...'if they can walk in labor, they can just walk home.' I'm not sure where home is...I hope it was close.

Finally, the event that made me so incredibly thankful for a hospital full of resources and doctors of every specialty. It was about 11pm and we had just finished our rounds on the ward. Tara was off with her translator still on the antepartum ward and I was about to kick my feet up and relax for a bit. After-all, it was still early in the shift and we had 8 hours left to go. I myself have no interpreter handy when up walks a tall, thin man, struggling to carry the weight of a near lifeless looking woman. Her body fell limp in his arms and I could hear from across the room that she was having a very difficult time breathing. Her wheezes were audible. He took her to the back and put her on the table. She could barely breath, she couldn't open her eyes and she was in a lot of distress, gasping for breath. The man didn't know if she was pregnant, and if she was, how far along she was. It turned out he had just been the one to bring her in, he wasn't even related to her. Her husband would come later.

Tara steps in and grabs a quick set of vitals. BP is 90/60 and pulse is 60 and faint. Respirations are over 40 breaths per minute. I do a quick sono and find that she's 18 weeks and baby looks fine. I tell the midwife repeatedly that she does NOT belong in Maternity. Her response was, let's start an IV and run some fluids and if her respirations don't come down to below 40 we can get some oxygen. How about some oxygen NOW!!!!! Better yet, how about let's get her to the ER.....NOW!!! Emmanuel, my translator, goes to the ER to see if they would take her. No, no no, they say...she's pregnant and they will not provide care to a pregnant womab. Of course. So, I go with him to plead my case. It falls on deaf ears. It turns out that the ER doc is a first year resident. No wonder he didn't want to see a pregnant woman!

The Chief of Staff, a general surgeon, happens by on a walk around the hospital. I stop him and say that we have a very sick asthmatic on the ward and ER won't take her. I offer him my stethoscope so he can assess her and maybe he will be compelled to get her treated. Surely, the ER doc will listen to the reason of the Chief of Staff, right? No. He looks at her, rattles off some things in Creole, that is translated as 'you can borrow the oxygen from the ICU' Gee, thanks. She can't move air, so I'm not sure how oxygen will help. Tara and I then pull apart the store room looking for anything that might help asthma; terbutaline, prednisone...ah ha! We found a Ventolin inhaler. I guess it's better than nothing and certainly can't hurt. I try my best to time her shallow, ineffective breathes to the puff and after 4 puffs I decide that that's enough. She does seem to be a little better, or maybe it's my imagination. She's still tight, wheezy and crackly. She's going to run out of gas here soon if we don't get her help.

My last resort is to call Carrie, our coordinator here at Midwives for Haiti. I ask if there is any way to get in touch with Palav, the American Internist she introduced us to on Monday. After 5 minutes, she calls to say that Palav is on her way. I have a bit of hope now that this woman might survive the night.

Palav gets there, assesses her, pulls a pulse ox out of her bag and agrees with my assessment. (I'm learning that if it's a tool you think you'll need, you need to always carry it with you.) She, Emmanuel and I take off for the ER. She tells the ER doc that he needs to take the patient in the ER. He doesn't know how to use the nebulizer, but she knows he has one on the unit. So, instead of him taking her, we take the nebulizer machine instead. Palav writes a script for Salbuterol, normal saline and predinsone. We get it filled in about 4 minutes and then head back to Maternity. She starts the first neb treatment and gives me instructions for what to do overnight. Ultimately, she got two treatments back to back, takes her 50 mg of prednisone and within a few hours is nearly clear and is sleeping peacefully. By morning she is clear and not laboring at all. I would call that a win.

It was a challenging day and a stressful night. All in all, I DO feel like we helped out today. There is no doubt in my mind that without us here at this time, that the baby would have died in the morning and the woman would have died in the night. No doubt whatsoever that we made a difference.

There is so much left to do and so much more we can teach...but for now, it's time for a nap. As we walk away and leave the hospital and the events of the night behind, exhausted and yet proud at the work we were able to do, we look up at the sky and are greeted by a new day with this...

The sun rises for another day in Haiti.


1 comment:

  1. Dear Dr. Glen,
    I am Rick O'Connell's Mother, also a NICU RN. 4 years ago I too, spent some time at Orphans International Orphanage there in the Bombardopolis area of Haiti. The work that you and your wife are doing is truly needed and so appreciated by those precious people! You have the LUXURY of a "HOSPITAL" we had a deteriorated dirty shack, one bulb syringe....horrific, inconceivable conditions.
    Please know, daily PRAYERS are ASCENDING as you continue this labor of love. God Bless you all. Raytha O'Connell