Day 3- The Doctor's Perspective

Our first day at the hospital was met with much anticipation.  We had toured the facility yesterday, but really couldn't get a good feel for how it would run.  And nothing...nothing, could have prepared us for what was the reality of the day.

8:30 AM and we walk into what can easily be described as a circus.  People standing around in the 'hallways,' patient's lined up in rows of four beds, with up to 8 moms in a room.  All rooms are open to air, both with windows in the back and a door and windows up front.  The wards are supposedly divided into antepartum and postpartum, but it soon becomes obvious that each ward is just a free for all.  No chart racks with big letters saying Dr. Elrod or IWW.  No such thing exists.  There are some lose papers in a manila folder that apparently are the patient's charts. 

But, that was not my task at the moment.  I was to meet with the Medical Director, a surgeon.  My interpretor, Emanuel and I go up to the Administration office.  We sit and wait.  And sweat.  It has to be 90 by 9AM and the humidity is horrible.  All the patient's are subjected to this heat with rarely a portable fan seen.  Imagine to my surprise when we walk into the Medical Director's office, a GUSH of Arctic cold air!  I have found heaven.  I could live in this place.  He was obviously a man of status.  The air conditioning, a Blackberry (I haven't seen a smartphone here except ours) a crisp white button down with cuff links and a gigantic diamond ring with several metal bracelets.  A very pleasant man who expressed his gratitude for us coming to help out in his hospital.  Now, for you hospital folks, or doctors, you know how hard it is to get credentialed at a hospital.  Months and endless amounts of paperwork.  I sent nothing. I showed up and claimed to be a OB/Gyn and I was treated like one.  A bit scary, but refreshing. 

After our meeting, I meet with the OB doc of the week.  The usual doc is taking vacation.  We then start to make rounds.  Our first mom was sent from her clinic because she was extremely swollen and was measuring much larger than her stated 26 weeks.  The doctor asks me to run and get the Sonosite from the clinic.  Thank GOD for the gift of a Sonosite.  It might not be a great ultrasound, but it's at least something and would come in VERY handy today.  I start scanning this mom and almost immediately find the answer.  She has twins!  Both appear to be about 26 weeks and both are alive.  And that's it for rounds on her.  The doc doesn't make a note, just walks to the next person.

The next is the mom with severe preeclampsia at 26 weeks that Tara mentions in her blog post. They had her on mag, but her blood pressure got better, so they took her off and she hasn't felt her baby move since yesterday.  Tara and Liz couldn't reliably find heart tones earlier.  I ultrasound her and I don't find them either.  This mom has an IUFD and will need to deliver.  But, the baby is breech.  The doctor and the midwives argue about what to do, induce or section.  No decision is made and won't be made by the time we leave for the day.  Again, no notes, they just move on to the next waiting person. 

Next are two postpartum moms that have also just had IUFD at term.  So, now we are up to three moms with intrauterine demise in the span of 2 days.  I fear that more are yet to come.  It seems common place here.  There aren't special arrangements made for these moms.  No special sticker on the door to notify the staff and visitors that there has been a loss.  No separation from the moms that are there caring for their babies in the next bed.  Nothing.

In the next bed, a mom that had a postpartum hemorrhage and got a blood transfusion.  Blood comes from the Red Cross that is just next door.  Next a 16 week teenager than just started bleeding.  Well, just as in they are just getting to her, but she has been there for hours.  This baby is fine.  No problems with the placenta, so we move on.

As much as I detest charting and writing every little thing down, I'm stunned and shocked by how little is written.  I'm not sure how anyone knows what is going on. 

Finally, back to labor and delivery.  I have heard from Tara that there is a mom that's 8 cm, another that's 7, and another with ruptured membranes. I help her with a beautiful birth, no tears, skin to skin, delayed cord clamping...the works.  And the mom was utterly apathetic.  We had to repeatedly encourage her to hold her baby for fear she would not hold it and drop it. 

That mom delivers on a 'bed' that is a 3x5 exam table with a thin pad, covered in a plastic drape and the few towels she brought.  No real way to deliver but on her back.  So, that's what we did.  Meanwhile, in the bed in the same room, with a birdseye view of all of it, is the mom that was supposed to be 2 months along that is miscarrying.

After the birth, I finally get asked to see her.  I ultrasound her and see lots and lots of clots and tissue in the uterus.  I find a speculum and a ring forcep and by iPhone light, get out a huge amount of retained products.  You could tell she had been bleeding pretty significantly.  Again, no real emotion is displayed. It is traumatic as an experience for her, but the real trauma is the reality of neonatal and maternal death that Haitians are all to familiar with.  She is lightheaded when she stands, so she will eventually be moved to postpartum for observation.

Another antepartum mom.  This one with known twins.  She came in at her due date with a little pain, but not labor.  The want to know the presentation.  They are vertex/vertex.  She's not in labor now, so we may get to help with twins before we leave.

All throughout the morning there had been wailing from another birth room.  Tara had briefly told me that the mom was 7-8cm when she first checked her at 9.  I checked on her around 11:30 and thought she was 7-8cm with a swollen cervix.  I THEN happen to notice the scar on her belly.  She had had a c-section in the past and was laboring here without any monitoring.  What a concept?  Anyway, she continues to moan and I feel like she should be complete by now, but at 1:30 I check her again and she is still 7cm and even more puffy cervix. 

I pull the doctor aside and ask him if he happened to know about this VBAC mom here.  No.  He wasn't aware.  He goes in a checks behind me and she's....7cm.  He calls a section.  The events that transpire at this point are amazing.  I can't say I've seen anything like it.  The nurse aides and midwives begin a seemingly well rehearsed series of events.  A 16 guage IV is place by Liz, our American volunteer from New York.  Her pubic hair is shaved with a 10 blade!  And a mighty close shave it is, I might add.  A foley catheter is placed by first cleansing with a dilute solution of betadine that they made on the spot and poured over her perineum.  The foley get up is a foley and a bag.  The fluid to fill the balloon is drawn off of the patient's IV bottle.  But not through a special port, but a needle is simply stuck through the plastic bag and fluid drawn off.  No alcohol prep, just pop and we have fluid for the foley.  IV antibiotics are started, ampicillin and gentamycin.  Then, I really thought I had seen everything, when they bring in a bucket of fluid.  Nothing added to it, just water.  And they wash her feet and legs with water.  This whole process takes a good 30 minutes.  Surgery then comes to get her.  Anesthesia doesn't see her.  No nurse is asking her if she wears seat belts in the car or is she learns best visually or verbally.  She moves to the gurney, is covered in a white sheet and is whisked away to the OR. 

The doctor asks if I'll stay and help.  'I'll do it, if you'd like!'  I didn't think he would actually take me up on it.  I should point out that also during the day I did see two moms that had had c-sections.  Both were vertical and one went up beyond the umbilicus.  (this particular incision headed due north from her symphysis, but after the curve around the belly button, it took a decidedly north by north west trajectory-not sure why, but it wasn't straight)  This mom had a previous Pfanenstiel incision.  I think this made the doctor a bit nervous.  So off to the OR we go.  Normal routine, get on some scrubs, put on a hat, a mask and some boot covers (actually, I forgot the boot covers and Liz put them on for me.  Thanks Liz)  We scrub with normal brushes, but with an aide pouring water over our hands. It was special.  In the OR we put on reuseable gowns and double gloved. 

No time out.  No fire risk assessment.  The patient was already draped by the time we were in there, so I couldn't honestly tell you it was her except I didn't see anyone else back there and knew she had gone into that room. 

The scrub tech hands ME the scapel.  OK, it's go time.  I was a bit comforted to see a Bovie in the room.  Too bad it wasn't hooked up.  A bleeder on the fascia I have to tie off.  Other than that, it was an easy section.  I missed doing my ritual sprinkling of the Intercede at the end.  We get to skin and he wants to close.  3-0 Chromic subcuticular.  Well thank goodness for that.  I thought it would be much worse.  Not the best closure I've ever seen, but it will work.   

My first Haitian baby...boy!

A quick moto ride back to the house, another quick moto ride into town and we have a nice glass of Rum and Coke to finish off the night.

Tomorrow, we head 2 hours away to do a mobile clinic and teach.  Not really sure about what, but I think we will make do.

I was thrilled to be a part of this process today.  I was sad that fetal death is obviously so common here that emotions are constantly guarded with this almost-expectation.  That really makes me sad. How can we change this? 

Until tomorrow....