Thursday, September 24, 2015

Reverence for Life

Before I write the story of the last shift, I want to first say this: There are many people who have read this blog and who have subsequently saturated us with thanks and praise, pouring us over with statements of what great things we are doing, how selfless this work is, and how we are doing such phenomenal things. While this praise does indeed lift us up and make us feel good, I want to acknowledge that we are doing nothing special, nothing requiring anything but a love and respect for life, and the heart to care. The word 'altruism' comes to mind, and there are times I wonder if true altruism exists. Don't we all do things for a purpose of our own heart and conscience? I cannot say that volunteering my time does not make me feel “good,” simply. That in itself is a selfish reason.

I've recently finished a book that was very insightful. It gives an understanding of early Haiti, how Haiti came to be the Haiti that it is. Mainly, it is the story of an ordinary man and woman, not much unlike you or me, detailing how these two individuals did extraordinary things in Haiti. This book I speak of is called Song of Haiti, which details the lives of Dr. Larimer and Gwen Mellon. The recurrent theme (and purpose of Larry Mellon and his philosophical mentor, Albert Schweitzer) speaks to what draws me to Haiti: “Reverence for Life.”

What is Reverence for Life? It is recognizing the value of all life, with the fundamental principle of morality being that good consists in maintaining, promoting, and enhancing life. I value my life. I value the life of my children. There is nothing more valuable to me than this. I see my own life and the life of my own children here. We are not so different. I value life and the right to live without pain and suffering- no matter in my own country, or half a world away. I it's because of this that I cannot have a skill that I can share and not share it, which I know will save lives and help to ease suffering.

A little girl at the feeding center

“The fundamental fact of human awareness is this: 'I am life that wills to live in the midst of life that wills to live.' A thinking man feels compelled to approach all life with the same reverence he has for his own.” -Albert Schweitzer

Our evening started off rather eventful, and not in the usual way. We rode to the hospital in the usual fashion, riding on the back of a moto. This is something that I fear dearly. The black and white logical thinker that I am, has mulled over many times the various ways that we could come into harm while in Haiti, and I've concluded that the moto is likely the #1 culprit for injury. Further add that we are most often on motos during dark hours- going to the hospital in the evenings after the sun has set, and returning in the morning, before the sun has fully risen. The darkness adds the factor of limited visibility, in addition to the dirt roads entrenched with large stones, rolling and bumping land, that further creates an unstable journey on two wheels. As we were riding to the hospital, I thought to myself, “I wonder if we are going faster each time, or if I am becoming more paranoid?” It was as if Glen read my mind because as soon as I finished my thought, he says out loud, “It seems like the moto drivers are going even faster than before!” Oh Lord, it wasn't just me. Not 1 minute after that, I look forward and see the single headlight of another moto coming straight at us, both us and him going full moto-speed, directly toward each other. I think, “Oh shit, we are going to die,” and instinctively yell out, “SHIT!” My hands fly up to grab the first thing they could grasp onto to brace myself- that being the drivers neck. As I yelled, “SHIT!” I felt my nails sink into the driver's skin. Thankfully both motos slammed on their brakes, bringing us to a halt right before collision. I am also thankful that SHIT wasn't my last word before I died. I apologized profusely to the moto driver, and even though he spoke no English, I am certain he got the gist of what I was trying to convey, as I tapped his neck and said repeatedly, “So sorry!!!!”

Our view from the back of a moto

Planting my feet firmly on the ground, I was relieved to get off the moto and walk the few hundred feet from the outside gates of the hospital compound, to the entrance of the Maternity Ward. As we walked through the hospital grounds, the sky above was thundering and rain started to fall down on us. I stopped just before the metal gate entrance to the ward, and stood there under the falling water. Even in the dark night with a deep blanket of clouds above, the air here remains thick. The cool rain felt good.

We began our night by making rounds on the antepartum, postpartum, and post-op units. These are each one room units, lined with beds on both sides of the room, each bed numbered on the wall above. The first patients we see is a mom and baby. The baby is about a week old and is being watched for a low-grade fever. The first observation is that the baby is swaddled up tightly with a thick winter blanket. It is hot as hell in here, and no one should be using a blanket, baby included. I have no doubt this is likely contributing to her low-grade fever. We take her vitals and do a full assessment. I see that the baby's diaper is full, and note that it is soft, yellow stool. Just as it should be. I help Grandma change the baby's diaper and discover that this baby girl dressed in all pink, actually has a penis. I laugh at my own assumption, because really, using whatever clothing you have is simply practical.

As we are doing our rounds, one of our favorite Haitian midwives Carmell says to us, “I will let you know if we have anyone in labor come in. I know you like to do deliveries!” I smile at that. I know she likes the help, and she is right- I do like birth.

At 9:50pm I catch a baby- a normal vaginal delivery, a healthy mom and healthy baby. As I am finishing up and helping the new mom get cleaned up, Glen listens to heart tones on another patient who is being induced with misoprostol due to severe hypertension. This mom looks terrible and seems to be very sick. Her whole body is extremely swollen, tight from the fluid that is collected in her body. Her face is so swollen that even her eyelids are puffy. I am certain she is nearly unrecognizable from what she normally looks like. Just looking at the woman is a reminder that hypertension in pregnancy is no joke. It may cost this woman her life, or her baby's life. Glen puts the doppler on and we hear clunk.........clunk..........clunk......................clunk. The baby's heart rate is in the 80s and stays there. They reposition her and continue to monitor baby. There's no oxygen available. The baby continues there, sometimes skipping beats. With this mother's hypertension and severe symptoms, along with misoprostol induction, there is no doubt that this baby has little reserve. Glen checks her to see if we are close to delivery and can somehow expedite it. She's only 3 cm. We know that this baby is not going to tolerate labor much longer. He calls a c-section. It's 9:55pm. The Haitian midwives call the Haitian OB. He's busy and can't come. He says that Glen needs to do the c-section. The midwives hang up and jump into action. Within mere minutes, a foley catheter has been placed and the patient is prepped for surgery. Honestly, I'm dumbfounded. I have never seen anything happen so fast in Haiti. There is true urgency in the room, and I have never before witnessed this in Haitian culture. Maybe I'm naïve, but this is my honest observation. Glen tries to listen to the baby again and can't find heart tones again. Is it because of a positional issue or have we lost the baby? We are all wondering the same thing. He continues to try, and nothing is heard. The clock is ticking...ticking...ticking...we wait and the minutes pass by. The Haitian OB who they previously called cannot get a hold of the anesthesiologist, and neither can they. She isn't answering her phone. Glen can't do a c-section without anesthesia. Tick...tick...tick...the minutes are ticking by, and this baby is dying with each tick. Finally, an ambulance arrives to the hospital, and in the ambulance emerges not a patient, but the anesthesiologist and a scrub tech. How interesting that the ambulance brought them to us. As we would find out, this crew is Cuban and only speaks Spanish.

So there they went, an Anesthesiologist and scrub tech who only speak Spanish, an OB and RN who only speak English, and a Haitian O.R. assistant who only speaks Creole. As Glen leaves he shakes his head and tells us that it is inevitably too late. There is no way this baby is still alive. My chest is heavy as I think that we listened to that baby's heart slow down as it gradually stopped beating altogether. I walk to the storage closet, to where Shelly was, and I ask her (as if she were more insightful than I was on the matter), “Do you think the baby is still alive???” I feel as if I am grasping at straws, wanting some reassurance that this little life is still in existence, that we even have a chance. Not just the he or she has a chance, but that yes, WE, have a chance. This life is valued. This life matters. I don't know the swollen face of the mother from any other random face of the day, and I might never know her baby, but in these fleeting minutes, tick, tick, ticking away, there is Reverence for Life.

Shelly looked at me and answered my question. “I don't know...probably not. But I hope so.”

I would walk away to another mom laying on an exam table who was pushing. I would do this delivery by myself, as Glen and Camille were likely just beginning the c-section. I couldn't help but to think that as one life blazed into the world screaming, one life was ending, coming into the world silent. That is a profound feeling. As Glen and Camille would later tell me, Glen would lift the blue, lifeless baby boy from his mom, hand him to Camille. He was certain this was a lifeless baby he was handing over, and contemplated this as he sutured this mom's very sick body back together.

I had just finished with this mom when Camille entered the room with the tiny bundle in her arms, pressed against her body. I heard her say my name, “Tara.” She called it out firmly, not exclaiming but still, making a statement.

I knew when I heard her that the baby was alive. I asked her, “Is the baby breathing?” The baby was trying to breathe, though not very effectively. The conversation between Camille and I is a blur. I took Camille's stethoscope and placed it over the baby's heart and was surprised to hear a heart galloping away; 140 beats per minute. A couple breathes of PPV and some stimulation and this baby was breathing on his own. My fingers remember what that limp body felt like under my fingers. This baby was not even two pounds. So delicate, so frail. We wrapped up this tiny, flopping body who was now making an effort to breathe, and carried him down the hall to the NICU. A pulse ox was placed and showed that his heart rate was 160 bpm and oxygen saturation was 87%. Astounding. We would leave the baby there, under the care of the NICU team. We walked away having done what we could, leaving him in the care of others who will hopefully do what the can.

Meanwhile, we do an intake assessment on a young and very tiny mom whose water has broken. She is a first time mom, looks to be about 100 pounds, and is about 28 weeks pregnant. There is amniotic fluid everywhere- the exam table is drenched, and as Camille and I speak to her, our shoes are in a sea of in her amniotic fluid. She lays on the exam table, without underwear, her legs spread. Her vulva and legs are dripping with fluid, smeared with mucous and blood. I place my hands on her belly, and see that her abdomen hardly looks pregnant. The untrained eye would likely not suspect this naked abdomen to be a pregnant belly. My sweaty, gloved hands could hardly palpate a baby. Her muscles were taut and solid, her skin and muscles from not having held a baby before. Her vitals were normal and her baby sounded fine. She was not contracting. The Haitian midwife had already completed a vaginal exam and said she was 1cm dilated. I went over to the Haitian midwife and asked if we were staring steroids, to help mature the baby's lungs. She shook her head no. I asked why. She said because the patient was already dilated and it was too late, steroids would not be useful. I felt the need to clarify how dilated this mom was, and asked again. She said 1cm. I had so much to say but recalled a good piece of advice that I had just read in the Midwives for Haiti volunteer manual...the best place for questioning something and to correct or teach, isn't in real time, in the clinical setting. This is, after all, their territory, we are just here to help, and teach by example, or when otherwise appropriate. I walked to the back room where Glen was and explained the situation. He agreed that the mom should get steroids and antibiotics. I asked Shelly how I might say this, to let the midwife know, “This is what we would do at home...” Shelly ended up doing a great job with translating this, and in the end, the midwife was very receptive to it, asked Glen the appropriate medicine and dose, and then said she would do it. [The next day we would find out that this mom would subsequently deliver her 28 week breech baby into the hands of another midwife volunteer with Midwives for Haiti. No one knew if the baby was dead or alive, and when the baby's legs were delivered. Jamie was surprised when they started to move. As I write this, the baby is alive and well in the NICU. I hope those steroids got to where they needed to go.]

We would have another delivery later in the night, and this one wouldn't be easy on use either. I wouldn't have expected anything less. The Haitian midwives were taking care of a mom in labor. I had previously told them to just let us know what we could do to help, that we were available if need be. While pushing with the mom, the midwife heard that the baby's heart rate was having decelerations. It would go from 140 to 80...70...and then slowly recover back to baseline. That's not something that we don't sometimes see. Except then she noticed that the baby began to have repetitive decels that were taking longer and longer to recover, now staying a good bit of time in the 70s and then not recovering. She asked for “Dr. Glen” to come help. At this point we were seeing baby's head at the peak of the push, but not crowning. The Haitian midwife asks if Glen can do an episiotomy, but he explains that this will be useless because the baby isn't to the perineum yet. The midwife nods in undertsanding. I see her contemplating something, and as I open my mouth to offer a suggestion, she says the same thing, but in Creole. “What about a vacuum,” we both ask? Glen looks surprised and says, “Oh, do we even HAVE a vacuum?” Why yes, yes we do. I had seen them in the storage closet. He says ok, and a vacuum is retrieved. He puts it on, mom pushes, and he assists her pushing with the traction of the vacuum. A baby girl is born, screaming.

All in all, a busy two days...reminding us and revealing to us in new ways, how delicately precious life is.

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