:: Yeesh in Haiti ::

my 5 week trip to Tabarre, Haiti

Meningite — April 24, 2018

Meningite

Bon soir zamis! Today rounds were cancelled as there have been 2 neonatal deaths this week from meningitis and the unit has been racking their brain as to what the common factors were. One of the babies was born with some signs of compromise and went straight to NICU. The other baby was vigorous and thought to be in good health until he began seizing the day of discharge. I don’t know if there is a common etiology between these two babies or not– I mean they were low risk and both born to primips (women who are giving their first baby) with no known medical problems. In any case, one thing we do in the US is GBS prolphylaxis. All pregnant women get tested at 34-36 weeks for GBS (a common bacteria that if colonizing the genital tract could cause neonatal infection) and if positive they are treated with penicillin (or an equivalent) in labor. This is impossible here. Many of these women never have a single prenatal visit and present for delivery and are “presumed to be term”. I can’t even count how many times I’ve come across that reading through my dossiers. Michoutas and I were discussing our frustrations of the recent occurrences and throwing some ideas around. One thing she said was being considered was a clinic at St. Damien for pregnant women in the 3rd trimester so they can regularly screened for hypertensive disorders which are so prevalent here and GBS. Also, screening for domestic violence is crucial here. The overwhelming majority of the 150 charts I have gone through thus far have screen positive for IPV, which we know can escalate during pregnancy. The problem is that many of these women do not want to seek care. There is a lot of myths and passed down legends on pregnancy and childbirth that are impossible to debunk. These women would prefer to deliver at home with the old woman who lives down the street and delivered all the other children on the block. I don’t know if any of the above would have changed the outcomes but I think they are good ideas.

I’ve heard many myths from the maternity team regarding deliveries and postpartum. For one, elders in the family beat new mothers with palm fronds after delivery to help with milk let down. OUCH! (I know some of my aunts were subjected to the same beat down after their deliveries). Also, there is the belief that they need to stay insulated and cannot cool off postpartum to preserve their pelvic organs. Moms cover themselves from head to toes with blankets and sit on a warm bucket. The warmer the better. Mind you it is 95 degrees out and humid as heck. I swear I can see the equator from my bedroom window. Also no sex for 3 months. I’m cool with that since none of the women here leave with contraception. They receive counseling but they have to wait until outpatient. I wonder how many of these women follow up? The cultural differences are incredible.

Remember Dina (other favorite 11 year old)? Her father has become very ill. He cannot walk and is having fevers and headaches. I’m concerned he may also have meningitis but there is a serious issue with access to healthcare here. Even if there is a nearby hospital, the cost is horrendous and you will wish you died when all is said and done if you don’t have the means to afford it. So he has been laying sick for 3 days now. I even offered my services (trying to expand my scope of practice to men, ya know?) but he needs antibiotics and an LP which I cannot do. It is very hard, Dina has been crying and I wish there was some way to help. Unfortunately the healthcare system in Haiti is severely underdeveloped, there is no insurance, rules, or regulations to protect the patient. So incredibly frustrating.

Side note, I am feeling much better from my illness yesterday. I got home from work with honey tea waiting for me and concerned friends and family. Still not 100% but definitely functional!

Montezuma’s revenge — April 23, 2018

Montezuma’s revenge

Sorry, Yeesh in Haiti team, I know I’ve been MIA for the last few days, I have been a little distracted, will possibly discuss more at a later date. In any case, I had a fantastic weekend and came back to work this morning. Yesterday, I hung around the house with my favorite 11 year olds who for the billionth time brought me some mangoes they picked for me off the mango tree in the yard. For the last week or so the water pump at the house has been broken, from what I understand, the water pump is an apparatus to pump water throughout the house for bathing, toileting, etc I have therefore been bathing from a bucket of water that gets brought up to my room every night. This is all fine and well, I can deal with only washing the essentials but it gets tough when the toilets cannot flush and you cannot wash your hands! I have gone through 3 bottles of hand sanitizer already. In any case, I pride myself on being very easy going and have just been doing as the romans. I have been being very careful with what I eat and drink so as to not get sick but I slipped up. Thomas brought me FIVE MANGOES that he picked for me yesterday and brought it for me to indulge in a big bowl of water. I did not even think to ask where he found this scarce resource and instead pigged out on my mangos inadvertenty drinking some of the water. Well now as one would expect I have gotten some sort of GI bug (hence the title of this post). Nausea, abdominal pain, vomiting, and diarrhea. GREAT, I got travelers diarrhea aka Montezuma’s revenge as I recall from 2nd year of medical school! Thankfully I have some prophylactic azithromycin that I took on the onset but I am still very uncomfortable. I know this may be TMI, but hey, most of you are health care professionals, you get it!

Yesterday I rode a tap tap (an open taxi where multiple people pile in to get around) to the supermarket and bought some groceries. Lugging all of it back up the hill with Madleine was no fun but still a great experience! Last night, I threw a party for Lolo’s (the driver) 62nd birthday! He was not present but hey is that a requirement? I taught my new friends how to make microwave popcorn (THEY HAD NEVER DONE IT BEFORE!) and we ate haitian creme (ice cream), drank wine and prestige all night, all in the name of Lolo! (haha all I need is a reason to have a celebration). At the supermarket, I bought him a cake and insisted we sing and eat it for breakfast this morning before he dropped me off to work! I don’t think they can handle me here!

This morning since I am so ill and running to the bathroom q 20 mins, I am going to go home a little early. ( I don’t know that that is a much better option since the toilets dont really work but I will figure it out). To my pleasant suprise, I had a visit from a friend from back home today, Miss Cooper, one of the postpartum nurses from back home! She’s been reading the blog and is here visiting family for a few days and stopped by the hospital this morning to give me some chocolates and say hello! Wish I wasn’t feeling so crappy so we could’ve grabbed lunch and chatted more. Thank you Miss Cooper, I’ll see next month at home. SBUH ❤

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Miss Cooper, postpartum nurse from SBUH who is in Haiti for a few days and came to visit! Thank you for the chocolate and the support Miss Cooper.
Death, dying, dead — April 19, 2018

Death, dying, dead

I feel like this has been a recurring theme since I arrived here. Today I found out that my consult from last week, the 11 year old with vaginitis passed away this morning. She had a brain mass and hemiparalysis and suffered from a brain herniation this morning before being able to be transferred out for neurosurgical intervention. My heart is so broken for her mother who continues to walk around the hospital in the dress her daughter last wore. Everywhere I look I feel like there is death. A patient we’ve been following with pre-eclampsia with severe features had an IOL at 34 weeks and also suffered from a neonatal death. Chart after chart, I read of neonatal deaths during my research. I’m drained.

Thankfully, amongst all the despair, my dearest friends back home gave birth to their new healthy baby girl!! Congratulations Tom and Jenny. My heart is filled with happiness for you both and I cannot wait to meet her.

Nineteen — April 18, 2018

Nineteen

The number of mosquito bites I have right now, but lets get down to business. Today was a day dedicated to research. More dossiers. I have gotten through 100 charts which is great! I am getting so much faster and having a lot fewer questions. I went through about 30 charts today and only had 2 questions for Madame Phillippo.

I spent the day with the ladies down in archives, they are so distracting they invited me out to Jacmel on May 1, apparently a national holiday in Haiti where no one goes to work. I asked if I could get the key to the archives so I can come in and read charts instead! In any case, I told them I would think about it. Then there is the constant plume struggle. I think my pen gets “borrowed” about 50 times a day!! Sheesh, you would think if you worked in medical records you’d bring a pen to work!

Afterwards I went to newborn nursery to visit a baby we delivered. The mom left the infant on the bed and eloped. He is the cutest, sweetest, little boy. I went down there to talk to him and hold him. Thankfully there is a long list of people interested in adopting him so he should find a home. I hope it is a good one.

Next I ate lunch in the restaurant in the cafeteria. I had bannane peze, poulet frites, pickliz, and couronne. All this and tip cost me 200 gourdes. That is a little more than 3 US dollars. It is insane. I also dined with a little chicken (see photo).

Bonjour~ — April 17, 2018

Bonjour~

I feel like I’m in a scene from Beauty and the Beast walking into the hospital every morning…Bonjour, Bonjour, Bonjour, Bonjour, Bonjour, Bonjour! It is raining Bonjours~ I really like it. Everyone is so friendly and nice and as you walk by each staff member, patient, or office, you hear a cheerful, “Bonjour!” or “Ou te byen domi?” (did you sleep well). People in Haiti are very much interested in your sleep patterns. I do not think they would approve of the sleep schedule of a resident physician in the US (or the majority of our population for that matter). The Haitian people are very simplistic, for the most part, it is easy living here. The stresses and tribulations we perseverate on the US are irrelevant here.

Today, I went to rounds with the team, or as they call it in creole, tournee. There was a patient who came in overnight in labor and ended up with a cesarean hysterectomy and an infant mortality (she had a uterine rupture- RARE!!). That was the hot topic this morning during rounds. It was like a mini, M & M, however I think some reflection after such a morbid event is warranted. The mother was stoic, not a single tear or word. There are huge cultural differences here when it comes to obstetrics and infant morbidity and mortality.

Today during rounds, I again tried to keep up and follow best I could, when the Doctor presenting turned and asked me, “What do you do when you have a 28 weeker with abnormal dopplers?” I perked up, and mustered all the words I could in creole to explain our management of premature infants with abnormal fetal dopplers. Everyone nodded and it sparked a discussion on the contrast between Haiti and us. This is what it is all about, a mutual learning and respect for each other and our different practices. I find that everyone here is very open to hearing and learning about my western ways and I am more than intrigued to learn and see how they manage patients.

I got an update on my GYN consult on the ER from last week. Looks like she has a brain mass and that is what is causing her right sided paralysis. She needs a CT scan prior to seeing neurosurgery but they cannot afford it. Ugh, so frustrating. In our ER everyone gets panscanned for no reason at all! I hope it works out.

After rounds I went back to my Dungeon down in the archives. So archives is down on the first floor near the pediatric ER. The walk to archives every morning is brutal. Seeing the dozens of children lined up in the scorching sun, crying, screaming in pain, malnourished, and some without even pants or diapers completely breaks my heart. I smile and say Bonjour to each of them every day as I walk by.

“Today, give a stranger one of your smiles. It may be the only sunshine he sees all day.”

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My pile of dossiers (charts) to go through. Love the people in the archives department, they take good care of me! (even help in translation when I’m struggle busing)
Cabrit — April 16, 2018

Cabrit

Today was a great day. I powered through a lot of charts and finally got to ask them to pull some more for me because I finished what I started with!

This afternoon, Madame phillippo greatly wanted to begin the in service for the new electronic fetal monitoring machine. We went through all the accessories and I taught her how the use it. She was blown away by the fact that you can have both maternal and fetal heart rates show up on the strip at the same time. She was also blown away that you can get the pulse, FHR, Toco, Spo2, and BP all at the same time- things we take for granted. We have dozens of these machines at home. Now they have one. I’m happy I was able to see the looks on everyone’s face during the explanation though. It was priceless.

After the in service I went to lunch with Sasha where she and other residents who rotate at St. Damien stay- Villa Francesca. While there I got some great news, I got my first fellowship interview invitation :D!!! YEYYY. All the ladies in the archives department were very excited for me, one gave me a mango :). Accepting this invite was mission impossible from Haiti but it all worked out!

When I came home the Franklins were equally as excited about my “bonne nouvelle,” but all I could hear was “BAAAAAAAA” coming from the back of the house. It was a goat! (cabrit in creole). I named him Baaa. Madame Franklin says he’s for dinner tomorrow 😭.

Sigh, a girls gotta eat.

Jacmel, Petit Goave, and Furcy — April 15, 2018

Jacmel, Petit Goave, and Furcy

I had one of the best weekends of my life. I explored Haiti with mom, auntie carine, and new friends – Endrick, Pierrot, Pascale, Valerie, and Josay. First beginning on Saturday we took a 6 hour ride to Jacmel. Driving in Haiti is BANANAS. I have seen 2 street lights since I have been here, there are no stop signs. It is a complete free for all and I am suprised I have not seen more accidents on the side of the road. In any case, once we escaped the city madness and traffic, it was the most beautiful scene I have ever seen and pictures cannot do it justice (feel free to peruse below). We rode all the way up the mountains of Haiti to the beach at Jacmel, Raymond Limbe. The water was so beautiful and perfectly clear. We ate lunch there- fish and conch that was freshly caught from the sea- and then went to Petit Goave. This is my favorite city thus far. It is very quaint and homey. It wasn’t as populous as Port-Au-Prince and Tabarre. It was quiet. We stopped by a hospital and looked around and then toured a nearby hotel. These types of establishments are very different in Haiti, but beautiful in their own respect. Due to the distance traveled, we got home very, very late. I stayed up telling my friends at the house back in Tabarre all about my adventures and show them photos.

Today we went to Furcy. Another ride up a beautiful mountain on an unpaved, rocky, narrow, road. Furcy was absolutely amazing, we ate and drank at Ranch Le Montcel, a restaurant on a balcony. We then toured the 13 acres of land. There were animals, fruits, vegetables, and cabins there. They are completely self sustained given there is no easy access to markets or a city (I.e the several hour ride up the side of a mountain on a road made of rocks). It was about 50 degrees up on the montain which was a nice break from the 95 degree weather in Tabarre. My new friends are great, they are young and similar in age with me so I am hoping to get to explore Haiti more over the next few weeks with them!

Marasa — April 13, 2018

Marasa

Sorry about the late entry, I wrote it earlier but there was no power, so to keep entertained we danced Kompa in the backyard (or I learned how to dance Kompa in the backyard rather) and talked. It is so beautiful here when there is no power. It is so quiet outside and you can see every star in the sky. Zetwal. So glorious, I could sit out there all night.

Today, I skipped rounds to begin my day bright and early in the archives so as to not get into the same dilemma I had yesterday. I got through about 10 charts and entered as much data as I could before heading up to see MadamePhilippo (head of nursing) to help me out. She sat with me and went chart by chart for the 10 I went through to help me extract more data and clarify things. The acronyms in Creole are what get me. Also the handwritten charts can be challanging. So it took no time at all sitting with her and discussing the charts and having her clarify things for me. I was able to gain some insight into how they manage patients. For one, I came across several charts of pre-term deliveries but the patients did not recieve Magnesium for neuroprotection (to decrease risk of cerebral palsy). I was able to speak to Madame Philippo about this and she had no idea this was even being performed. It is apparently expensive though so this practice will likely not change. We spent a lot of time discussing the charts and I would teach her names of disease processes in English and she would explan it in Creole. For instance, I kept coming across, PAW,  in the chart, apparently this is the active stage of labor. Would have never have guessed that in a million years. So hopefully I get faster going through the charts.

I am easily distracted so once I finished speaking with Madame Phillippo, I went to check on the patient from yesterday and the fetal echo she was awaiting. To my suprise, the cardiology team got to her first thing this morning to perform the echo. Seeing the report was my next task. I went back to the cardiology department waited for them to finish speaking to a patient and verbally asked for the report… IT WAS NORMAL! Great news. I trecked back up to maternity to let the nurse and doctor know. No patient’s were in labor so I met my friend Sasha in the peds ER (l’urgent in creole) to complete my consult. It was for a 11 year girl who came in with seizures, right sided paralysis, and vaginal pain/itching. I got a history about her gynecological complaints and completed a very limited exam since she was viriginal. I walked the specimen to the lab to look at it under the microscope and diagnosed her with BV. It was very satisfying since this was a quick and easy thing I could perform to greatly impact this patient.

Next I met Dr. Coulanges. This was the second time we met, but he is very nice. He also speaks some English which is always a plus. He has been working at St. Damien for 1 year but has been out practicing for three years. I did a c-section with him for a woman at 37 weeks with twins breech/transverse. My new word of the day, marasa. TWINS. We discussed the differences between Haiti and the US at great length and even exchanged some comittee opinions. He is also very tall so I operated on my tippy toes.

On my way back up, Rene called me to show me an electronic fetal monittor that was donated to the maternity department. This was such an amazing gift and something they really need. This machine is like the ones we have at home. It has pulse oximeter, tocometer, EFM, and also does EKG. It can hook up an IUPC/FSE as well. The caveat is I have to do an in service with the maternity department and give progress reports to the donors. Happy to do it if it means they are able to better care for their patients. Afterwards, I brought the machine to the maternity department and screamed, “Madame Phillippo, Jwaye Nwel!!” That means, “Merry Christmas!!” She was so thrilled when I came holding the new Electronic Fetal Monitor. I began taking all the wires out and explaining everything. She nodded and smiled throughout, but when I got to the IUPC/FSE (intrauterine pressure catheter and fetal scalp electrode) she looked puzzled. These are internal monitors you can use to measure the strength of contractions (IUPC) and fetal heart rate (FSE). Madame Phillippo was amazed and had never seen this before. They currently dont have the means to begin using them but I hope they can in the future.

By the time I got back to archives, it was 3 pm and they closed an hour later. Hopefully next week I can really power through the charts.

In any case, IT’S THE WEEKEND. Excited to spend it exploring with Mom and Auntie Carine!

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Rene and I and the new electronic fetal monitoring system for the maternity ward~
Retard de croissance — April 12, 2018

Retard de croissance

Today I finally began to delve into my research, unfortunately, there was so much going on clinically, it was very late in the day, and the medical records department closed 1 hour later. I was only able to struggle getting through two charts, partially. I am going to need some help. My research, fetal growth restriction, also known as retard de croissance in Creole ( I titled this entry this because I keep forgetting the name in Creole !!!!) is a condition where the estimated fetal weight is less than the 10th percentile for the gestational age. It is very common here at St. Damien as this is a high risk population with a lot of medical comorbidities like hypertensive disorders and infections. Tomorrow, I am going to start my day in the archives department so I can ensure I am able to get as much done as humanly possible since this week was a trial. The archives department has been so incredibly helpful and flexible with my research. I write down the charts I need and they pull them one by one. I will be going through thousands of charts, I have to think of a good gift to give them.

My day started off with rounds as usual, Dr. Jean was on today as well as another very nice doctor whose name slips me. Dr. Jean speaks some English, so she was able to fill in the gaps a little on rounds and I could finally ask questions I have been wanting to ask but haven’t been able to translate all week. One of the patient’s has a fetal cardiac abnormality and since the Gift of Life (cardiac surgeons here for a week) team is here, I brought it upon myself a few days ago to “consult” them. Consulting teams here is not a page, it’s a face to face discussion with other team members and asking them to come assess your patient. In any case, I went to the PICU and asked the team if they could see her before the leave as this anomolay will require emergent surgery at time of delivery and I can speak English unlike the maternity team upstairs. The cardiac team said they would see her earlier that day, but got slammed and it was unable to be completed. So naturally at rounds this morning, everyone looked to me, the liason to the american cardiology team, for the update on this patient and I broke the news that it wasn’t able to be completed. I returned today to speak to them again. After a wild goose chase, I made it to one of the cardiologists and asked if he could perform the echo and some counselling. He ASSURED me it would be completed before the end of the day tomorrow. I am holding him to this!! I was also consulted today, by my friend in the pediatrics ED. There is a young girl with a gynecological issue so I offered my assistance and I was summoned.

I spent a lot of time in the abandonment room today. Speaking to the nurses, hearing the childrens stories, just holding them, dancing with them, and reading some stories. We even went on a walk with one of the wheelchair bound children so she could get some fresh air. This was my favorite part of the day. They were so upset when it was time to go, one of the children would just start crying each time you tried to put her down.

Next, I did two c-sections. First, the patient gets wheeled down to the first floor on a gerney to the salle de operation. You have to change your scrubs (even though they are sterile and you have been wearing your white coat) once you arrive to the OR. Haiti is very dusty so they try to best ensure a sterile environment. Next she is given spinal anesthesia and prepped with betadine and draped with sterile sheets. No marking pen, just cut. Nothing like the wasteful US! Resources are scarce, nothing is wasted. Every suture is used in it’s entirety. And, THERE IS NO BOVIE :O . You grab the bleeder with a hemostat and…pray?? Idk, crush injury causes hemostasis. Thankfully instrument names are universal, that made it easier. Otherwise, it was pretty standard. The instrument tables are also much more concise, there are no extra instruments, it is the bare essentials that you need to safely perform a cesarean section.

Lastly, MOMMY IS HERE!! She arrived this afternoon and I am so excited to share some of my time here with her. I can’t wait to show her the hospital and my friends! My friends at the house already love her, they have been asking all week when she was getting in, etc. She’s kinda the best. Can’t wait to explore Haiti with her this weekend (You too Auntie Carine)! She is also blown away by how well I speak creole. I guess that is what happens when there is no other option to communicate haha.

Bon soir !

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Transport wheeling patient down to the Salle De Operation for cesarean section
The “abandoned” room — April 11, 2018

The “abandoned” room

Today was a long day. Sorry for the late entry, I am just getting home. First things first, I was involved in 2 deliveries today which was very satisfying but also perplexing. It is very interesting delivering in Haiti and very different. I can’t quite put my finger on it yet but hopefully I can characterize it better as I do more deliveries but it is very simple. Literally 3 women lined up in a delivery room, naked, screaming in pain. There are no epidurals, these women are champs. They begin pushing at fully dilated, with intermittent dop tones. There is no doula or coaching, no family in the room. You push until you get the baby out. Occasionally the midwives would have the mom change positions during pushing depending on the fetal position (I.e OP), I paid close attention to this. After the birth, the nurse leaves mom to tend to the baby. This can take some time. There are no vitals for the baby, if the baby is rigorous it is thought to be healthy. Afterwards the placenta delivers and they are assessed for bleeding and repairs. The family is not allowed in at any point. The patient goes to the bathroom to shower before getting moved to postpartum.

I made some more friends (too many to count so I’ll just mention a few key who will recur) a few work on the board for St. Damien Hospital and NPH (the founding organization for St. Damien Hospital). We went to lunch and I was able to exchange ideas with them regarding the maternity department which was very exciting. I also spent the day with Renee, she’s a retired nurse from Seattle who is very involved with St. Damien and contributes money to the hospital. She spent the day at the maternity ward as well so we mutually gained from this partnership. I translated and helped incorporate her into the OB team while she showed me around and introduced me to a lot of influential people around the Hospital. One of the places she brought me was “The abandonment room” it’s a place where people drop off infants and children they don’t want or who have disabilities. This broke my heart. Literally dozens of the cutest little kids who have no one to love them. I found myself frequently walking past this room throughout the day wanting to hold one particular baby in a crib in the back. Maybe tomorrow I’ll muster up the strength to go in and hold him. I want to love on them. The realities of poverty are hard everywhere, but in Haiti they are almost inexplicable.

There is also a group here who comes three times a year to St. Damien to perform cardiac surgeries. They do 2 a day for a week which is incredible, if only they could do more or stay longer. #wishful-thinking. Since they’re here there is a blood shortage so through the Red Cross I donated blood at the hospital. During a tour with Rene, I met a pediatric resident in the peds ED of Haitian descent as well. Sasha. She’s here for a month and is a third year pediatrics resident, hope I can get to know her more.

All in all, today was a good day.

Me and my friend Sasha, a pediatrics resident for Virigina
To the left is Rene, she is my friend from Seattle and to the right is Michoutas, she is head of the midwifery department and a godsend. She calls me her daughter (there is total resemblance)
Donating blood during a blood shortage in the hospital
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