Obstetrical challenges…

One of the things you notice most about Haiti is the sheer number of kids running around. It is a young nation demographically.

_2100278
Kids (the same everywhere!)

 

So one of the spin offs of this notable fact is that there is LOTS of obstetrics. Now most is done out of hospital (with no prenatal care as we know it and no technology) and some is excellently done in hospital either by midwives or Haitian doctors with no involvement by visiting teams. This leaves the challenges …

_2130459
Cooperation

The usual things like multiple gestations, hypertension in pregnancy, failure to progress are all there, but full blown eclampsia with seizures and maternal and fetal compromise is common in Haiti. In fact on the cupboard door in the emergency room of the hospital is an excellent eclampsia protocol; all the nurses and docs working there are very familiar with the management of this problem.

Resuscitation of baby
Resuscitation of baby

On our first night in LaGonave we were called in to do a section on a lady who wasn’t progressing but had now thick meconium, indicating the baby was stressed. All our purchased drugs were locked in a room (since we were only meant to start the following the day) and we hadn’t yet done a careful inventory of what equipment and drugs were available in the OR – this changes from trip to trip and varies based on local drug availability and what other teams had left behind. As an aside it is interesting to note that medications are purchased in Port au Prince at retail pharmacies, with the buyer shopping around for the best price. There is no wholesaler that deals with the hospital as happens in Canada or the States. At any rate there was no functional anaesthetic machine and there were no paralyzing drugs to facilitate a general anaesthetic. Baby had to come out quickly and after a brief attempt at a spinal mom was put to sleep with ketamine. Chris had the baby out in a flash -amazing how quick these experienced OBs can be when necessary – but baby required resuscitation. He was intubated and hand ventilated. Thankfully after 3 hours the breathing tube came out and baby continued to do well.

_1040064
Helping a little one

And like a set of bookends, our last case was also an obstetrical emergency. The mom, who was 30 weeks along, came in with seizures and initial tests suggested meningitis and not eclampsia. But after a day of improvement with antibiotics she started seizing again and now she was obviously in full blown eclampsia and required an emergency cesarean section. One of the changes with eclampsia is that the clotting of the blood can be impaired (making a spinal anaesthetic unsafe) and unfortunately there was no way of measuring the platelets and clotting of the blood. So even though she was a thin woman who would have been an easy spinal, we chose to put her off to sleep. By now some paralyzing agent had been found and she was put to sleep, intubated and ventilated. She was kept asleep with IV meds as we had no functional machine, and again we ventilated her by hand. Mike and Aneal helped with the anaesthetic and then Mike moved to the next room to resuscitate the baby (Mike had just given a spinal for a patient with appendicitis, and Ravi had just finished the surgery so he was running). Once again in spite of the relative lack of resources, the teamwork between the Haitian nurses, the missionary physician, and the visiting team made the best of the situation. As we left the island on the small Haitian sailboat the next morning the news was good – baby was doing OK and mom was improving.

_2150853
Last case!
_2130449
Ravi and Peter in the OR

Homeward journey begins

Quick post mainly to upload photos.

We are in a guest house in the hills above Port au Prince (here it is said the richer you are the higher you live on the mountain). The boys are playing 45, with Peter again adding rules as the game progresses – I’ve dubbed it the Darwinian game of cards as the rules seem to evolve with the other players’ abilities…

I’m sitting listening to the banter and working on some images.

School yard
School yard
_2150762
Girls playing
End of the meal at school
End of the meal at school

A great deal has happened in the last few days, both medically and culturally. This trip seems to have had more down time than others but when we look our case load it has actually been a busy time in the OR.

Mikenson (translator and super organizer) and Peter
Mikenson (translator and super organizer) and Peter

The main surgical highlights include the cases done in our last evening on LaGonave – an appendectomy under spinal and a caesarian section under general complete with the resuscitation of the baby. Strange how the first case we did the night before our official start and the last case we did the night after our official end were both complicated caesarians complete with anaesthetic and neonatal challenges (in fact these cases were the most challenging for me over the entire trip).

Last case!
Last case!

Outside the OR a walk up a ravine to the source of town water, a trip to a school and amazing orphanage, and motorcycle tour up the coast to some small villages were among the many exceptional experiences we enjoyed on this trip.

Down from the source (ravine walk to WISH water source)
Down from the source (ravine walk to WISH water source)
Pensive girl
Pensive girl
Meal prep
Meal prep

Keep an eye on the gallery link as I try to add more photos as permitted by the internet gods…

Women and men of the knife

So this is maybe not the best title, but what else can I call the docs, nurses and other professionals who are here to do surgery? We have to use something sharp…

First evening at Ortlip before traveling to island
First evening at Ortlip before traveling to island
_1040003
Sunset at Ortlip with the island of LaGonave in the distance

Almost everyone on our two teams has been here before – from New Brunswick come some of the surgeons and family docs, OR and ICU nurses, a pharmacist and a lab tech; from Ontario an anaesthetist and general surgeon, ER and OR nurses, and a very useful son! Only 3 people of the 20 are newcomers to Haiti.

Similar Haitian boat to the Wesleyana which carried us to the island
Similar Haitian boat to the Wesleyana which carried us to the island
Patti, Aileen and Sophie in the OR
Patti, Aileen and Sophie in the OR (2 veterans and one newcomer…)

In our team the three surgeons, Peter (urology), Chris (obgyn) and Ravi (general surgery) are wonderful folks I’ve worked with before on these trips, and Ravi is a good bud with whom I had worked for many years in New Brunswick before we moved to different places in Ontario. His son Aneal was up to my knees when I first met him, but now stands taller than me and shows me his rear tire when we dirt bike together! He’s a great kid, like his older brother Avi who was on a trip here with us 3 years ago. Aileen is our enthusiastic organizer, an OR nurse from Fredericton who has come to understand the Haitian way very well – without her knowledge and connections here we wouldn’t be able to work effectively. Already much time is spent just getting around and managing the most basic logistics and without smoothing out these aspects of the trip we’d be spinning our wheels most of the time instead of doing surgery. Patti and Laura (mom and daughter) are friends foremost and excellent nurses as well. I first met them in Petit Goave weeks after the earthquake and was astonished to find I would be working with them 4 years later when I took a job in Ontario! Heather is an ICU nurse from Fredericton who was with the first of our two teams and who chose to stay on for the second stint with us. She is unflappable and she and Laura run a very safe and tight recovery room (along with any other odd job we can think of giving them!). Finally my good friend Mike, who practiced anaesthesia with me for over 10 years, had decided to join us at the last minute to “pass gas” with me, and with that addition the reunion of our first team to Haiti in 2010 was complete – then the first trip for all of us and the seed that led to the following 6 years of work in Haiti – introducing many people and teams to LaGonave and other areas and producing a strong cadre of volunteers that will fill many teams to come.

What we share in common is is the ability to roll with things, to improvise, and to deal with heat and constant sweat (and not fuss when the internet dies!). Everyone can come up with creative solutions, and jump into the jobs they aren’t trained for but are just now needed for. Its an energizing way to work.

Not only are day to day problems discussed (which anaesthetic technique, surgery now our later, how to manage without that necessary piece of equipment…) but big thinking is done about the future as well. For example, in my sphere one of the big issues is the lack of functioning anaesthetic machines. We are starting to network and brainstorm to get for this hospital a British made anaesthetic machine that is designed for “austere environments” – safe, simple, durable, easy to maintain, and equally important – inexpensive.

Together we remember some of our shared stories, and together we will create new ones.