Voluntary Counseling and Testing (VCT)

April 1st, 2009 by wendyl

We posted a recruitment notice last week for a VCT nurse.

VCT stands for “voluntary counselling and testing,” as in counselling and testing for HIV. We treat women during labour and babies after they are born to prevent vertical (i.e. mother-to-child) transmission. Our VCT nurses do the testing, do the prophylactic treatment, and refer patients for follow-up because we do not do HIV care outside of the delivery period. Patients need full-service HIV clinics for that.

We’re recruiting for some daily workers, rather than a full-time VCT nurse. Our full-time positions are filled, but we need a pool of trained staff to fill vacations and sick leave.

My name and telephone number are at the bottom of the notice.

I’ve been getting a lot of calls, from nurses and auxiliaries, all looking for more information. Many haven’t yet passed their state exam and so are not licensed, which means they are not eligible. Some don’t speak much French, also a requirement to work with us. Some have no idea what VCT is and are looking for general nursing work.

Yesterday, my phone rang at four-thirty in the morning. OK, strictly speaking, it was 0442h. The woman on the line had a very soft voice. I had a lot of trouble understanding her, but she was calling to enquire about the job. Her soft voice was all the more inaudible because she was standing next to a rooster who was crowing loudly and repeatedly.

Or perhaps it was the rooster who was calling me, and he happened to be standing next to a nurse with a soft voice?

I’m not sure. It was four-thirty in the morning.

Remember?

March 28th, 2009 by wendyl

Last weekend, I was sitting in a restaurant in Petionville, having a late dinner. We were too lazy to cook, and hadn’t been grocery shopping recently anyway. There is a place that makes really excellent
fresh Italian pasta (the owner is from Rome).

We had finished eating when the guy tending the bar approached our table. He was smiling broadly. He showed me a studio photograph of a plump, healthy infant. He said, do you remember this baby?

I said, I’m sorry, she is lovely, but I have no idea who this is.

He said, don’t you remember October 31st?

I apologized again. I really didn’t remember. I felt badly because he was standing there, still smiling expectantly. And clearly a proud father.

But come on. We deliver a thousand babies a month, on average. In October, it was about 1600. I can’t remember them all!

Then he said, she was born in the intersection. You pulled her out of the car, and I walked with you to the hospital.

Dans le carrefour. Yes, I do remember this child! Of course! From a car in the middle of the intersection, after wading through traffic. The car broke down, he said. Her mother delivered in the back seat.

It is so satisfying to see a Jude Anne baby later, doing well. In October, we were in full assembly line mode because it was so busy. Sometimes we forget that they grow and develop and have futures,
because we aren’t there to follow it. But of course, they do. And the parents don’t forget.

It seems that some things never change

March 7th, 2009 by wendyl

Despite the fact that, while we were moving, patients were not arriving on our doorstep and the other maternities in the city were able to absorb the increased patient numbers which included transfers
from us… despite that, we are again in a situation of being alone in our ability to function.

The general hospital doesn/t have surgical linen packs (sterile field, surgical gowns). They used them all today and they haven?t circulated out of sterilization yet. The maternity at Issaie Jeanty has multiple problems, including lack of gauze, lack of gasoline, etc., that led them to close their doors (‘fermer la garde’). Choscal, in Cité Soleil, doesn’t have a gynecologist; maybe one will come at 7 or 8pm. Hopital de la Paix has no water.

We have just rewritten our admission criteria. The idea is to really focus ourselves on the sickest, most critical patients. We want to save lives! But what is the point of new admission criteria if we
cannot apply them? It seems for many women, the choice is for us to keep them or for them to labour at home.

It is extremely frustrating. In particular, it?s frustrating because it’s a chronic problem. Also because it seems there?s little we can do about it, except discuss and object and advocate.

I need a new index. (Floor delivery index these days is usually zero. One on Thursday) Maybe NFI Non-Functionality Index. Number of days a month that a hospital cannot take transfers. Also cNFI: continuous Non-Functionality Index, for number of consecutive days.

Most days…

March 3rd, 2009 by wendyl

Most days I love my job but today was not exactly a highlight.

Rounded this morning on antenatal ward, as usual. The first patient took us a long time to discuss: she has severe pre-eclampsia, and intra-uterine growth restriction, and appeared to have some ascites and some dyspnea. She was apparently well in the morning, had breakfast, and had just received her dose of magnesium sulphate. We saw her somnolent and floppy, complaining of being hot.

Unfortunately, it is not common practice here to check and follow patellar reflexes in our re-eclampsia patients. There is a reflex hammer (even this is optional; I am often in the habit of doing it with my stethoscope), so I asked for it. Her patellar reflexes were absent. (Brachial and biceps about 1/4)

Several of my Haitian colleagues did not like my technique for testing patellar reflexes in a supine patient. I said, there are several possible techniques. They said my technique was wrong. I said again,
there are several possibilities. They said, that is not one of them. I said, I suppose the neurologists I studied with at home were wrong?

They said, yes, it seems.

It is not a good way to start the day, being insulted. Actually, there is no time of day when I feel good about being told I am a bad doctor.

Later in the morning, someone came to tell me that there was a cardiac arrest in the delivery room. I arrived to find a resuscitation underway: patient already intubated, gynecologist performing chest
compressions. Shortly thereafter, efforts were discontinued.

The patient had apparently been in labour but well. Her blood pressure was normal. She did not fall into our admission criteria, which have been tightened in order to accept only the sickest patients. (Other patients certainly need care, but can be cared for in other centres). As she was getting into the car to be transferred, she felt the urge to push, and so was brought to the delivery room. There, she had a seizure. Then pushed out a stillborn baby, and a placenta that clearly had abrupted. Then she had a cardiac arrest from which she never awoke.

It is a strange case. My theory – not having yet examined the chart – is normotensive eclampsia, abruptio placenta. The cause of the cardiac arrest: possibly hemorrhage from the abruption, possibly amniotic fluid embolus, possibly something else.

It was so sudden. The staff was shaken. The family, of course, was devastated. The walls shook with their grief. Their screams went on for a long time. I was thankful that the psychosocial team was so near at hand.

And immediately after, one of the gynecologists came to find me. He looked extremely upset. What should we do? he said. There was a patient about to be operated, with severe pre-eclampsia and two
previous caesarians. She is already anemic, with a hemoglobin of 5.4g/dL. They were about to start a transfusion, but, it turns out, she’s a Jehovah’s Witness and so refused the blood transfusion.

I discussed with the anesthetist and the gynecologist. The patient understands the risk of death without the transfusion. She accepts the surgery. We agreed that it would be good to discuss again with patient and with her family, to know if they all agree, or at least have understood the wishes of the patient. We decided to document the refusal of transfusion separately from the consent for surgery. The doctors asked for the psychosocial team to help with the counselling.

The Brazilian psychologist told me later: everything was arranged. The family agrees: no transfusion. Members of the church came also. The patient would have her operation.

This evening, as I left, I found the anaesthetist, and the surgeon. I asked how the patient was doing. Poorly, they said: she has a systolic blood pressure of 60. They were bringing the husband upstairs to see her.

Rainy season

February 26th, 2009 by wendyl

Rainy season started three days ago. Or perhaps over the weekend, while I was in the mountains resting and relaxing.

At any rate, the dominant element is water. It’s been raining heavily for two hours. It’s deafening. I can’t hear the music on my computer as I type.

Today at the hospital, logistics told me we had a problem. A fairly big, serious problem, which took precedence over the meeting we were supposed to have about the logistics priorities for Solidarité in the weeks to come. Today’s problem was the priority; the other priorities will have to wait.

The problem is: water. More specifically, the hospital plumbing and the hospital septic tank. Water backing up from the drains. Septic tank full every four days. Pipes exploding, because too much pressure, or not properly assembled. Apparently we might have to pump gray water into the yard on Monday because of the urgency of the matter. I don’t quite understand it all. I hope it’s just gray water, and nothing more toxic than that.

I do understand that we can’t run the hospital without proper water available. Also required: a proper way to dispose of it, especially if contaminated with biological waste. Logistics told me that triage and the delivery room might not have running water while they try to get things worked out. Unfortunately, that is an indeterminate period of time, so we are trying to think of other ways to get water in, at least temporarily. I asked for more Purell from the warehouse.

And now, after two hours of downpour — the new hospital is on a plain — the logistician is going back to Solidarité. (As if 12 hours of work wasn’t enough!) Flooding, he says.

I have commented before about Haitian culture being very church-oriented. Shops have religious names. Vehicles do, too. So do some people.

Our Haitian water and sanitation guy is called Dieupuissant (God Almighty). But I must stop making jokes about floods.

Furcy, Haiti

February 21st, 2009 by wendyl

Here in the mountains, it is cool and quiet. All the ambient noise stress of Port-au-Prince is absent. No generators, no traffic. You can hear voices from below in the valley. The wind rustles the pine trees. It’s lovely and peaceful. A good place for restoration and re-grounding.

Re-grounding is necessary. Friday was a busy day. I had intended to get to some of the meat of reports that are overdue and plans that are urgent. Instead, after doing rounds and one circuit of the hospital to see what was going on, I then had a list of things. Six requests for logistics. Three big issues to discuss with the project coordinator. Two subjects, probably for new protocols, for the chief gynecologist. It seemed that every time I sat down at my desk to start something, I had to get up immediately to urgently attend to something else.

The public hospitals are again not functioning. One is on strike. The other is having intermittent electricity problems and a more chronic oxygen problem. The others are full. Again, then, we have problems transferring patients out and focusing on the most critically complicated pregnancies.

Still to do: the monthly medical report, which is very, very late because of the move; create a global plan to address the shortage in our blood bank; revise the job profile for the expat gynecologist who is arriving soon (and who will eventually take over my job); start formally evaluating the local doctors that I supervise; improve our HIV program…

Goals

February 18th, 2009 by wendyl

We — as in the gynecologists and midwife-supervisors — had mortality rounds this morning, late because all of our regular reports and meetings were delayed for the move. Four deaths in January, an average number for us. The discussion was pretty good, although the deaths were inevitable.

At the same meeting, we discussed our admission criteria for the new hospital. Our annual plan says we should be focussing more specifically on really critical cases. We do too many normal deliveries, over fifty percent of our total, when there are other structures here who are capable of managing them. There are also other structures who can manage some complicated cases, so, as I am fond of saying, there are a lot of patients who need care because of their complicated or high-risk pregnancy, but do they need to be cared for by us? It is a difficult ethical distinction to make, but it must be made, or we would be rapidly overwhelmed.

As part of this discussion, we also debated whether to continue the donation kits that we currently give to each patient we transfer. There is a free obstetrical care program here, funded by the World Health Organisation (WHO). It is supposed to cover all the costs of delivery and follow-up. So we have been thinking of stopping the donation kits.

The meeting today, then, was actually a wonderful experience: with 15 or so local staff, we had an excellent discussion. About MSF and our current goals. About worrying for the well-being of patients. About why patients are at risk, whose responsibility it is, whether our donation kits help or not. About the ability of public hospitals to function and what their barriers are. The gynecologists did most of the talking. The most satisfying part is that they, like me, do this work for a reason. They have chosen it. They understand and believe in our role here. They acknowledge our limitations. They understand — I’m sure better than I do — the political, structural, social context here. I am impressed by their perception and analysis.

Other observations:
We’ve been officially open for five days. By 5PM today, we had admitted a total of 125 patients in the last five days.

Logistics is recruiting a technical logistician, so there is a job notice posted on the gate of the hospital. (I am also recruiting a gynecologist, for which the notice is posted right beside the logistics one.) They are receiving a massive quantity of applications, so much that it is better measured by altitude rather than number. I do not exaggerate here: they are over-flowing from a box. Maybe 30cm high? Or 40cm? And the deadline is next week, so there will be many more.

Where did all the patients go?

February 16th, 2009 by wendyl

We were trying to understand where all the patients went, when we were closed for moving. It seemed unnaturally easy to empty out the hospital, given how often we are overflowing with patients and delivering most of the city.

It’s still an important question. What happened to people while we were closed? Was there an important impact on morbidity and mortality?

But, as quickly as they evaporated, they’re back. Not the same ones, of course. This morning, I arrived to news that the hospital had admitted 42 patients on Sunday, of whom 20 were normal vaginal deliveries, 5 surgeries (including a hysterectomy and a curettage). Solidarité is filling quickly, even as we are still unpacking boxes and repainting furniture.

Pediatrics had admitted seven babies already. In addition to the 700g premie from the other day, now there is one who is 600g, delivered vaginally after abruptio placenta.

And as I walked into the lab to check the blood bank, I watched the lab tech give to a midwife the last bag of O positive blood. I looked at the hemoglobin result to be sure the patient really needed it: she did, with a hemoglobin measured at 2.3 g/dL.

So now I have two questions. Where did patients go when we were closed? And where are they coming from now that we’ve reopened?

Day 8

February 14th, 2009 by wendyl

Ladies and gentlemen, I think we’ve made a hospital.

The last night at Jude Anne was quiet, by all accounts. By the time I arrived at Solidarité this morning, staff were in the process of retrieving the last things from Jude Anne. Patients are coming, registering, waiting in the waiting room. Normal hospital things are happening almost as if they have always happened here.

Our inpatient ward was nearly full. I asked them to start sending the post-partum and post-operative patients upstairs, since it had not happened last night. We started organizing to get Pediatrics upstairs to their designated corner also. I figure the settling in, shifting, arranging, will continue for quite some time, some of it planned, some of it organically. There are still boxes to unpack. Some furniture is… not quite lost, but not quite locatable, either. It’s all the more confusing because we have used some pieces temporarily in other services, so now we have to trade and rearrange back so that each service has more or less what used to belong to them.

I returned to Jude Anne late morning, to pack the tiny administrative office we had there. I’d been putting it off: the office is dusty and full of miscellaneous crap. One of the Haitian logisticians was also at Jude Anne, disconnecting all the batteries and inverters, and loading leftover everything into cars to take to Solidarité.

Jude Anne is really and truly empty. It is stunning to finally see this, given that it was so recently full to bursting, with perhaps 100 patients, 50 staff, 30 visitors, and all the furniture and equipment that we were using. Empty, it is clear what a small building it really is. It had been a 35-bed hospital at the beginning, and it really is only big enough for a 35-bed hospital. Empty, Jude Anne is a marked contrast to what it is when packed full. It is also vastly different than Solidarité, which is cavernous and tranquil by comparison.

Yesterday, I was sitting under the mango tree outside of the office at Solidarité, thinking. I think I was thinking about medical supply, stocking, and security: a difficult subject. People kept coming to ask me questions – I am nothing but everything, or perhaps just the central repository of hospital information. The shade of the mango tree is cool and peaceful. And then, a mango fell. It was small but perfectly shaped, and ripe. It is good for labour to have a fruit.

Day 7

February 13th, 2009 by wendyl

It’s our last day of running two hospitals. Activity at Solidarité has now surpassed activity at Jude Anne. We rounded on eleven inpatients at Solidarité this morning. There were three babies in Pediatrics. Jude Anne held only two patients, of which one was to be discharged after normal delivery, and the other, I decided to transfer to Solidarité. (She was the one operated for ruptured ectopic pregnancy the other day.) The registers said, 11 consultations yesterday at Jude Anne, and 25 at Solidarité.

It’s a bit of a miracle to me that our planned “cross-taper” of activity has worked.

And, the biggest improvement, now that rounds are at Solidarité: it’s quiet. Our discussion doesn’t have to compete with trucks in the intersection, or the generator of the bank next door.

They unpacked and installed the second OR today. Niveau 2, normally our post-op and post-partum (of complicated pregnancies) service, started settling in this afternoon. The idea is to separate our mixed inpatient service back into its component parts, i.e. antenatal, post-op, post-partum. Triage and accouchement will similarly be again distinct services. The lab moved the rest of the stock from the blood bank over to Solidarité, too.

Logistics moved the main generator today. It requires a crane. Electrical wires are in the way. Traffic continues on a busy road beneath. I wasn’t there for that – and I’m sort of glad – but I apparently did manage to call the logistician at a particularly awkward moment. I needed waterproof mattress covers for the foam mattress pieces, so that post-partum could accept patients. He was looking at the generator suspended mid-air, while a demonstration swarmed past, and the midwives were attending to a patient who had delivered in the back of a tap-tap (modified pick-up truck turned commuter bus). Jude Anne has always been an exciting place, even to the last moment.

Now the sign has been painted over. A banner says in Creole that we’ve moved. There are staff there tonight (one triage bed, three inpatient beds, no operating theatre, a lab that can measure hemoglobin – had I known that they were taking the triage beds, I would have asked to leave at least two!). As of tomorrow morning, there will only be a guard.

The work is not done, of course. The remaining furniture and equipment will be moved tomorrow, perhaps into next week. We need to organize and open all the departments properly. Then we start work on what the Czech logistician calls “The List of 1000.” It is a list of all the things, small and large, that will still need to be done to make the hospital function better. The essential has been done (water, electricity, medications). Now we worry about having enough chairs, shelves in appropriate locations, curtains to control radiant heat, etc. The List of 1000 will keep us busy for months.