Thursday, April 18, 2013

Day 19...A Silver Lining

Our next to last night at St. Therese started just as every other night shift. We meet our translators, set down our stuff in the call room and get a feel for what is happening. Tonight, it's obvious we have just missed something. There are blood trails from the birth room to the 'shower/bathroom' as a mother had just given birth and was getting cleaned up. We find out through the translators that the mom had delivered twins. One had survived, the other had died. Apparently, the baby had been dead for some time.

Now knowing the Haitian way things worked, I looked for the baby. I knew I would find it. The cardboard box. And there it was...parked inconspicuously in the corner, a cardboard Lactated Ringers box. Curious, I open it and confirm what I had figured. No bags of LR IV fluid, but instead the body of the deceased baby was unceremoniously placed in a box and left in the corner. There it would stay, too. It stayed there throughout the night. Patients came and went. One woman was there to be evaluated for bleeding. She kicked off her shoes and stepped up on a step stool a mere 6 inches from the box. She never knew what lay beside her. Her baby was fine and she was sent home. But others came and went and still the box stayed.

But, that seems to be the way it's done. It happens so frequently here.

We check with antepartum to see if anything needs to be done. The midwife brings over a woman with preeclampsia that has been 'induced' but it has failed. The term 'failed induction' here has a completely different meaning than what we use. This particular mom had been on the antepartum unit for at least 3 days. She was admitted with high blood pressure and 3+ proteinuria, about as good a definition of preeclampsia here as you are going to get. There isn't a way to do a 24 hour urine protein, a full CBC with platelets or a chemistry panel. So, it's blood pressure, urine dip, and symptoms. The first morning she had 25 mcg of cytotec placed. The next morning she had 50 mcg of cytotec placed. In reading her chart (in Creole) it is apparent that during that time she had been given apresoline, both as an injection and as a drip, methydopa, hydrochlorothiazide on multiple occasions. But it all seemed random, as I've found most orders here to be. I have at times quipped that doctor's orders at home are merely 'suggestions' because good nurses will do what needs to be done, regardless of what I write. Here that couldn't be more so the truth. There aren't parameters to do A, B, or C if the blood pressure is high. There are no orders to repeat the Cytotec if she isn't contracting. No orders to repeat the blood pressure meds if the first hasn't worked. It just seems that if the next midwife happens to round and find something askew, then it might get addressed. Otherwise, it might sit for another day. And so it goes...

When this mom got to Maternity, we did our initial intake. Her blood pressure was 220/120. She had bags of fluids hanging. LR, apresoline in LR and magnesium in LR. All were running at some apparent random drip per minute rate. The Haitian OB happened to be there and I expressed my concern to him. He asks a few questions. Do you have a headache? Not now, but earlier, she says. Do you have any pains? No, just a few contractions. He looks at her sclera, presses on her legs to look for edema and then says that we should work tonight to try and get her blood pressure down, and if we are not able to then she could be sectioned in the morning when he comes back in. That's not reassuring! I am not exactly comfortable with this plan at all. But, I can't do a section on my own here.

The midwife on last night has to be commended though. She does a stellar job. Actually, probably one of the best I've seen. She takes and documents her blood pressure and babies heart beat every half hour, all night long...which may not sound like a lot, but without an automatic blood pressure cuff and continuous electronic monitoring, meant she was bedside nearly constantly throughout the night, manually taking pressures and listening to baby. It doesn't come down much at all, until I decide to just take matters into my own hands. I rummage through the cabinet and find Labetolol. I tell the midwife to give her 200mg orally. Her next few blood pressures are the best of the night, but it doesn't last all night. By the time we leave in the morning, her blood pressure is back up to 190/110 and we heard from the next shift that she did end up getting a section. None too soon in my book.

The other patient we triage last night had come in from 2 hours away, from a town called Thomasique. She had possible premature, preterm rupture of membranes. Tara is doing the evaluation. She is gathering supplies to do a speculum exam. There are no fancy tests to prove rupture of membranes. No nitrazine paper (although apparently that is here occasionally) no Amnisure, no fern testing, no fetal lung maturity on pooled fluid. A speculum exam is the best that it gets.

Just as she is about to start, the power goes out! And everyone pulls out a phone and shines a light. Tara is able to find one of our headlamps and she continues on with her evaluation, mostly in the dark. Yes, the fluid leaking appears to be amniotic fluid. Damn. This is not a good situation here.

On the wall, behind the midwife's desk are a list of protocols. There is one for preterm rupture. It looks reasonable. I bring the midwife to the desk and point at the protocol. THIS is what we are going to do, ok? She needs dexamethasone 6mg every 12 hours for 2 days, ampicillin 2gms every 6 hours for 2 days, gentamycin every 24 hours for 2 days, then amoxicillin for 5 days. All of this plus or minus tocolytics, nifedipine or magnesium depending on contractions. It all seems reasonable.

I go over and over and over this with the midwife. Yes, yes...I can give the ampicillin and gentamycin. OK, but what about the dexamethasone? 'I'll get it' was the response. Hours later, I ask if everything was given. Yes, yes...I've given the ampicillin and the gentamycin. Ugh. Who knows if she got or will get the medicine? And the ampicillin, will it be dosed every 6 hours? Doubtful. There just isn't a mechanism to force a reminder that meds are due at 8 and 2 or 6 and 10. There's no such thing as a MAR and verbal hand-offs are nonexistent.

The rest of the night was uneventful. A somewhat restful night. We have one more day shift followed by a night shift left before we depart. I have seen some things seemingly get better even since we have been here. The midwives seem much more prepared for birth now. Pitocin, instruments, and ambu bag are readily available more often. But, so much is left to fix. And it all seems to boil down to follow through and initiative. Patients need to be triaged and have a plan developed and followed through. There should never be an 'induction' for preeclampsia here that is a single dose of Cytotec daily. That shows lack of follow through. Either she needs to be induced or she doesn't. If she does, then follow-up after that first dose.

As a final note, I should mention a patient I first saw on Tuesday. She was brought to my attention by the midwife on antepartum rounds. According to the midwife, she had come in from a village the night before with a cough and the midwife thought she had a 'respiratory' issue. The patient had been given a slip for labs, but hadn't done them yet. Apparently, she thought her sister could go do the tests for her. I do a quick obstetrician's assessment and ask a few questions and listen to her lungs. The right side sounded awful. I knew it was beyond my scope, so I found the internist making rounds. At that point, I felt like the idiot medical student, because she grabbed the chart and found out that she had actually been on the ward since the Friday before, so now day 5 on the ward and no internal medicine consult. She read through the chart and saw that she was started on erythromycin. She asked more questions and found out that the cough had been ongoing for 21 days. She had night sweats, weight loss, but no dyspnea on exertion. She agreed with my physical exam at least.

She needed a PPD, a sputum culture and a chest x-ray at a minimum. We went to radiology to see if we could beg to get a chest x-ray. As it turns out, they had one film left. Then the argument got to whether or not they had a lead vest for the pregnant patient. Nope. They had A vest, but it was for the technician and couldn't be used on the pregnant patient. Fine. The radiation from a single x-ray is miniscule and likely less than we get from walking outside on a daily basis. This was a battle we weren't going to win. Oddly enough, the x-ray was taken with the mother AND the technician unshielded. Ugh. There is NO accountability here.

An hour later, the internist pulls out the film. We don't need a lightbox. She has a consolidating mass in the right upper quadrant. TB until proven otherwise. The PPD and sputum test will be two days. She goes back to antepartum ward, supposedly with a mask, but that's all the precautions she has.

The next day she is a little better, and her ppd is starting to indurate, but it's too early to read. The next day, she is gone. Whisked away to the TB ward to be treated there. What could have been two days of exposure to a room full of pregnant women ended up being nearly a week, because a plan wasn't made and the proper people weren't consulted. Looks like I'll be getting a PPD when I get home.

I hope that all of our emotions and feelings have translated through this blog as a true testament to our time in Haiti- depicting not just the negative...because even with the negative- hurt, loss, frustration at a chaotic environment and lack of system, there is still good. There is a silver lining. The hospital itself, the midwives, and the facilities have apparently gotten MUCH better over the years. We can see that the midwives trained with Midwives for Haiti are the brightest and the best that they have. Last night I saw one truly have follow through and take vitals and document vitals regularly. There is some obvious critical thinking going on. In the patient with the preterm rupture, I had told the male midwife, a graduate of last year's class, that he could give nifedipine to help calm her uterus. When he took her blood pressure and found that it was low (normal-low, 110/60), he questioned giving the meds. That made me proud. I know he's going to do good by his patients. So, there is a hope here. Certainly, a few things need to be changed, but as time goes, the students from Midwives for Haiti will begin to exercise the change that they are taught and improvements will be made- in the hospital, and for maternal and neonatal health in Haiti.

1 comment:

  1. I have enjoyed reading about your journey. I pray that I may be of some help one day. Thank you.