A labour of love

The Hopital Generale is still on strike. I managed to visit the hospital to look around, in the brief interval between the closure for a broken anaesthetic machine, which lasted a week, and the beginning of this strike. Rumour has it that it’s the anaesthetic residents who haven’t been paid in seven months, and that everyone else isn’t working as a show of solidarity. I think we’re on about day ten, but, to be honest, I’ve lost track.

The Hopital Generale is the publically owned university hospital in downtown Port-au-Prince, a few blocks from the presidential palace. It is a large, relatively spacious campus taking up a few city blocks. There is one department per building, all matching two-storey whitewashed blocks with green trim. Maternity is right next to Pediatrics.

Pediatrics is the only referral centre for neonates in the country. The chef de service told me that they only have three functional incubators (and four non-functional ones). Ten neonatal intensive beds in total. They are always full.

Last week we tried to transfer a couple of our babies there, but they came back to us. Pediatrics has also been affected by the strike.

And the catholic mission hospital that can sometimes accept transfers, like the probably congenital cardiac newborn we wanted to send last week. They are inundated with babies that have come from the non-functional general hospital.

Flooding is definitely the order of the day. The waters have gone down in Gonaives, I hear, but we are inundated with pregnant patients. So are the other public maternity hospitals.

I have never been a morning person, but right now it’s 7am on Sunday morning, and I’m alert and awake. And feeling articulate enough to write. This is very unusual for me.

This week, I’ve been getting up early because we’ve started la grande tournee de salle (grand rounds) at Jude-Anne. Rounds start at 7am, with shift change, so I get up before six with the first rays of dawn to get there in time. We are eight doctors discussing all the antenatal patients admitted to the first floor: two night docs, four day docs, chief gynecologist, and me. The night doctor who was responsible for that floor presents the case, and we discuss management. (This is the format despite that fact that this doctor has likely been in the operating room all night. For example, on Friday morning, he reported having done six or seven Caesarians – he’d lost track of the exact number – and two curettages.)

It was the idea of the chief gynecologist after I posed to him the problem that patients on the first floor were often lying around for days before definitive management (usually delivery). I thought this was not good quality of care, and not good for freeing up beds to admit new people, either. We had even found a couple of cases of patients being discharged with pre-eclampsia and still pregnant: really not a good idea.

Grand rounds has proven to be really great, even after only one week. We have the opportunity to discuss things academically. It has helped me understand some of the thought processes that are different than what I have seen at home, and target my literature searches for research that might change their practice. It helps a lot that we share a medical culture, so that even if we don’t agree, we have a framework for discussing it. This was not the case when I worked in Democratic Republic of Congo, where there was no concept of evidence-based medicine.

Patients are no longer lingering too long antenatally, for the most part. Beds are more available for new patients so we don’t have to transfer seriously ill patients out because of lack of space. We have the opportunity to suggest and teach new techniques, such as manual vacuum aspiration instead of curettage for specific cases. We have a better sense of how well the initial evaluation and documentation is done. And we know who has a tendency to turn up late. It has turned out to produce more benefits than we’d anticipated.

It’s definitely worth the early-morning effort.

DIC=disseminated intravascular coagulopathy, difficult to treat even at home, even when fresh frozen plasma and clotting factors and cryoprecipitate are available. Bleeding bleeding bleeding. In medical school, they told us – yes, facetiously – that all bleeding stops eventually.

This is a slightly-edited excerpt from my diary. Note that’s it’s pretty technical for the lay person, but my medical friends will understand.

…the early mornings are followed by fairly late afternoons. The patient with pulmonary edema died. The next day, we had a patient who was trying hard: delivered stillbirth with abruptio placenta at 9am, laceration of the cervix and 3rd degree laceration at the perineum. Bled lots, apparently slowed down, then the bleeding picked up again.

When I saw her, she was in the small procedures room, Canadian nurse and British midwife and Haitian midwife supervisor around her, patient in a puddle of blood, reciting psalms in Creole. Apparently had already lost a couple of litres of blood, and from the puddle, I believed it. Blood in the urinary catheter. Some discussion about DIC vs local trauma, 3rd vs 4th deg tear. From somewhere we got some fresh blood, useful for both its red cells and its clotting factors, added more ergometrine, vitamin K to encourage clotting and contracting. Planned to transfer her to OR for exam under anaesth, proper repair of laceration.

Half an hour later, the surgeon called me to the operating room to show me what they?d found. Laceration was 3rd deg, and he was re-repairing it. The bucket between his knees – patient of course in lithotomy position – had about 2L of blood in it. He said when they’d undone the cervical stitch, it had cascaded out, and was still bleeding. Patient was being transfused red cells, were trying to find some more. Decision was made to do a hysterectomy to control the bleeding, so I stayed for the surgery. They didn?t need to me to scrub since the surgeon responsible for the OR was already assisting, but I figured I should stick around. Tried to facilitate more blood.

Two surgeons and a scrub nurse and a messy hysterectomy because she was bleeding and bleeding. Anaesthetist had her on dopamine, despite which, for about a half hour, she had no appreciable blood pressure (but did have a carotid pulse and the oximeter was picking up). The bleeding was welling up mostly from the inferior segment of the uterus. More blood came from the Red Cross. I thought, she’s bleeding faster than we can transfuse her. I thought she would die on the table.

I left the hospital right when they finished closing. She did start making urine at the end of the surgery, that’s good. Before I left, I found her husband having an anxiety attack in VCT* office. He’d been trying to give blood, poor thing. Drenched in sweat, hyperventilating, complaining of muscle cramps. We gave him something to drink and some diazepam. Coached him on slowing his breathing. He started feeling a bit better, and asked me how his wife was. I said, she?s sort-of OK at the moment, just finishing the surgery, but she is very sick, and I can’t promise anything. He asked me if I was Canadian, because I spoke English and French. We found the social worker to talk with him.

The next morning, I asked the nurses if she was still alive. She was alive, awake, making urine, talking to me, had a blood pressure. All good things. Today (day 2), she’s in the big room. Her only complaint was that she’d missed breakfast. The nurse told me that she’d walked unassisted from the intensive care bed to her current bed. Her husband was out getting her food.

I think it’s a miracle.

*VCT=voluntary counselling and testing. These nurses are specialised in HIV counselling; at Jude-Anne they are instrumental to our blood bank as well as the HIV program.

I’ve been working on the mortality review for September’s medical report. Usually our mortality rate is pretty low, two or three women, but last month was significantly higher at ten. I haven’t been able to identify a reason why; it seems to have been mostly an unlucky month for us.

One case sticks out for me, though, because she didn’t die. She had severe pre-eclampsia, had had surgery, and remained in a coma for several days. Another patient with a very similar story had already passed away a few days previously. I was sure that this one would quickly follow suit. In the bed next to her was another woman who was very jaundiced, with HELLP syndrome, who, when I first saw her, was awake and alert but definitely yellow.

Two days later, I arrived to find the anaesthetists working on the patient with jaundice, who had had a cardiac arrest, from which she never recovered. But the one in a coma? She woke up. And the next day, she was sitting up and feeding herself. She was groggy but not complaining of any discomfort.

We don’t have a way to prove intracranial pathology here, but with severe pre-eclampsia, she was at very high risk for cerebral hemorrhage, which generally has a bad outcome (like death). I assume from the fact that she woke up that she had not had a cerebral hemorrhage, but ‘just’ some swelling, which had resolved with the steroids she’d been prescribed, and time, and delivery of the pregnancy (which is the cure for pre-eclampsia).

HELLP syndrome is on the severe end of the spectrum of diseases related to pre-eclampsia. I think it’s one of the best-named illnesses in medicine, for being doubly-descriptive. HELLP stands for Hemolysis, Elevated Liver enzymes, and Low Platelets. It is a serious illness that requires attending to with some urgency. Patients with HELLP definitely need help.

There are protocols for everything. The newest one is the protocol for births that take place outside of the hospital. It outlines the responsibilities of the guards who mind the gates, and the brancardiers (stretcher-bearers/orderlies), and the doctors. The Haitian gynecologist-supervisor wrote it, in collaboration with the Canadian logistician*.

One day at the hospital (inside the hospital, not out), our logistician and one of the brancardiers happened upon a baby and a placenta. Strangely, the mother was nowhere to be seen. So they each put on a pair of gloves, and Log said, “Brancardier, you take the placenta, and I’ll take the baby.”

* logistician (n) = person who takes care of all things non-medical, such as buildings, water, electricity, supply and storage, cars, computers, sanitation and waste management, security, administration, finance, etc. Highly practical individual.

Every day at Jude Ann, we’re full to the rafters with patients. Three floors full. Any empty bed is usually filled as soon as it’s cleaned and a new sheet put on. The courtyard is full of patients waiting to be seen in triage, or labouring and being followed by the delivery room staff. Today we arrived to the sight of a woman delivering in the courtyard, on the ground — fortunately being attended to by one of the midwives, but still, this is obviously far from ideal. And yet it is not so unusual an occurrence. As I said, empty beds are turned over pretty fast. I’d guess that most complicated cases stay about two or three days. Uncomplicated deliveries leave in six hours.

And we can’t deliver all the people who arrive at Jude-Ann. There are just too many. So we try to transfer the less complex, less urgent to other institutions. Transferring patients involves loading the LandCruiser with eight or ten pregnant and possibly labouring women, one midwife — armed with a delivery kit and some gloves, one administrative person, and the driver. The doctor on call for triage calls ahead to the receiving hospital, and then off they go. Busload of bellies.

Often, though, the receiving hospitals won’t receive. Right now, one of the biggest hospitals isn’t open because the operating rooms are closed. Problem with getting the anaesthetic machine fixed. Another hospital is often lacking surgical kits. Others only have an obstetrician during daytime hours. Another is often without an anaesthetist. I seem to be calling the same departmental heads almost every day to find out how their hospitals are doing, or what they’re missing in order to function. Sometimes we can help with that, sometimes not.