A labour of love

The patient who had a ruptured ectopic pregnancy is doing fine. We rounded on her this morning at Jude Anne. She is having some pain, and is still a bit tachycardic, but stable.

On our arrival this morning, though, a UN ambulance had pulled up to the gate. A medic in full battle gear was leading a pregnant woman out. I caught up to him just as they approached, and said, in French, “This hospital is closed. The new one is in Cité Solidarité.” The medic looked at me, shrugged, pushed the patient towards the gate. “No,” I said, “we’re closed. Aqui, cerrado.” The UN unit in this part of town is Brazilian, but I don’t speak Portugese. I was hoping my Spanish was more comprehensible to him than my French. (Didn’t even try English.)

It must have been quite comical, really. He was trying to nudge the patient into the gate. I was trying to stop him. I was trying to speak to him, he was not understanding any language I know. Finally, after several tries of, “non, aqui, cerrado!” comprehension dawned across his face. He smiled, nodded, and whisked the patient away.

We had four patients in Jude Anne. I lectured the staff in small groups about the surgical transfer team. The OT team started packing the second OR. We distributed boxes to everyone: back to boxes and tape and packing lists.

And, we had four patients in Solidarité, plus one baby. Today, we accomplished our second and third surgeries. More patients are coming through the door: at least to check out the facilities, even if they have no physical complaints besides pregnancy.

We did our first surgery today, at about 2pm, right around when we were wondering if we should just go ahead with moving the second OR without having test-driven the first. The case was a transverse presentation, in labour, uterus fibromatous. The baby was small and had some mild respiratory distress. Hopefully transient. Apparently the fibroma made things a little tricky, but the surgeon tells me that blood loss was minimal. Logistically, all we needed were new batteries for the oximeter. (The new rechargeable set are still at Jude Anne.)

This evening, though, Jude Anne called me with news. They had received a patient with a ruptured ectopic pregnancy, tachycardic and not exactly stable. Definitely someone to rush to surgery. Except that, they had no scrubs. The gynecologist on call had the right instinct and was preparing to transfer her urgently to Solidarité. I told him to send the anaesthetist with her, and two brancardiers also, so that they can go straight up to the OR. He had already called ahead to prepare them on the other side.

Then I called logistics. The laundry moved yesterday, and while it is functional and clothes are clean, there is a problem of drying. The weather has turned, the wind picked up two days ago, and so there is dust everywhere. We have to rely on the electric dryer.

He passed the cell phone to the anaesthetist at Solidarité. She knew the case was coming. She said, we have no sterile sets for spinal anaesthesia. We’ve had none since the afternoon. Can you send some from Jude Anne?

This astounds me, since we’ve only done one surgery at Solidarité. How is it that all the spinal kits are at Jude Anne? But this question I will try to sort out tomorrow. The ectopic pregnancy would be done under general anaesthesia anyway. I called Jude Anne back. They said they would bring some.

In the meantime, logistics managed to find some scrubs that were ready and was sending them to Jude Anne in the car. Right now. So I called Jude Anne again, to say, since scrubs are coming, better to operate on the patient there. It’s better for her. I really would like to minimize having to transport patients who aren’t exactly stable.

Then, logistics called back. We thought they were sending the spinal kits, but the driver received nothing in return for the scrubs. Argh! Another phone call to Jude Anne, the receptionist brought the phone up to the OR where the surgeon had just scrubbed. The anaesthetist assured me she had given the kits to the guard, who was to give them to the driver. And yes, when I called back to logistics, he had heard on the radio that the driver had arrived with them.

I said, let me make absolutely sure that they arrive to their destination. I called Solidarité, and that receptionist went up to the OR to find the anaesthetist there. I told her that the patient would be operated on at Jude Anne. She said, yes, the driver has just come upstairs with the spinal sets.

Tomorrow, though, we will be packing and moving the second OR, so we will have to transfer surgical patients to Solidarité, so the system (anaesthetist, brancardiers, car, call ahead) must be efficient. I worry about this.

Today, I decided to start my day at Solidarité and then move on to Jude Anne, as opposed to the opposite as I’ve been doing for the last few weeks. Last night, after all, was the first night of Solidarity being open to patients. I thought they’d have a night of nothing at all: but lo, four patients had been evaluated, three transferred, and one delivered. Solidarité has had its first baby.

Now, in having the first baby, apparently there were also some items that they realized they needed but still didn’t have. It necessitated an extra trip to Jude Anne to pick up a few things.  This is natural, I suppose, but I am worried that despite the teams assuring me that they have everything necessary to do surgery, there might still be a few small items missing.

As a result, we’ve decided that the first surgery at Solidarité should be a simple, stable Caesarian, to ensure that we can do it.  I spent much of the day looking for a good surgical case to inaugurate the OT, but didn’t quite find it.

At Jude Anne, we had the same two patients today as yesterday. This afternoon, we transferred one of them to Solidarité (this morning, her blood pressure was still too high, but by afternoon, was under control). The other, we decided not to transfer until we know that the OT works. She has placenta previa, and is stable for now. But if she starts bleeding, she could destabilize extremely quickly and would be a difficult first case for the OT.

In the meantime, I ended up involved in the resuscitation of a woman who I think had a post-partum pulmonary embolism. She had delivered at Jude Anne one month previously, and was carried in today awake but hysterical. She was hypotensive, hypoxic, tachycardic (BP 70/palp, SaO2 84% on room air, HR 170), with distended jugular veins and hepatomegaly. Hgb measured at 9 g/dL. She looked terrible.

I have to say that things were not particularly organized, though the essentials were accomplished. A fluid top-up, the first dose of low-molecular weight heparin, a dopamine infusion. She looked a little better once her blood pressure became more respectable, even though her heart rate remained unchanged, and she was saturating at 94% on 7L oxygen. We agreed that we could not look after her at Jude Anne — it’s a maternity hospital, after all, and she needed an intensive care unit. So I sent the Haitian anaesthetist and two stretcher-bearers to accompany her to the general hospital, with a small donation of medications (including more LMWH) and materials (gloves, angiocaths). Also, I gave her family the change needed to pay for starting a chart (25 haitian gourdes, or 62.5 cents US). Her mother was sitting in the courtyard, hands to her face, crying. One of the ambulance drivers was gently explaining things to her; I appreciated enormously his presence and attitude.

Several hours later, I saw the anaesthetist as she returned from the transfer. The expression on her face spoke volumes. It had taken her two hours, because the receiving emergency department was crowded and disorganized, and they could not properly receive even a critically ill patient. They said they had no bed for her. They said there was no oxygen. She was thoroughly disgusted. She despaired for the patient — we all did, even as we were organizing her transfer.

Day Zero is defined as the first day that we look after patients in Maternité Solidarité.  Or, as it turns out, the first day that we’re in place and ready to look after patients, should they materialize.  Our first official day of opening is Friday (13 February).

Yesterday, the technician came by to make sure our hematology machine was properly installed. Decontamination (of used surgical instruments, etc) was also set up, on freshly-laid tile counters.  Mostly, though, we tried to have a quiet Sunday.

This morning, I discovered one good thing about being up for breakfast at 6am.  The full moon was just setting over the bay, huge salmon pink orb. It was the only moment of peace for the whole day.

There are two patients in Jude Anne, so all there is well.  Transfers to public hospitals continue to go smoothly.  Our staff are under-occupied.

At Solidarité, the construction workers were taking out the wood supports for the concrete roof of our septic tank, the one for OR runoff.  We briefly lost, then found, the keys for the medication cupboards.  Anaesthesia told me they were missing a number of the medications they needed: some were in a cupboard they hadn’t discovered yet, some hadn’t been delivered because they require cold chain… and the cold chain order had been delayed, or forgotten.  And of the things they had received, it seemed that there were inaccuracies in the count. It’s clear that we have a lot to do to secure our medications, with keys, and counting, and orders. We had a medical supply meeting that lasted three hours in the afternoon.

But before that, in deciding whether or not to open to any potential advance patients, I resisted.  I said, we cannot have a maternity without oxytocin (part of the cold chain order).  Or misoprostol (in rupture in the warehouse, but available in the pharmacy at Jude Anne).  I was waiting for those medications to arrive and be delivered to the departments before saying that they could let patients in.

One patient straggled in before I gave the go-ahead: staff re-directed her elsewhere.  Finally, everything was in place by 3pm.  After that, no one.  Now we have two hospitals where staff are under-occupied.

As I left at around 6pm, I ran into the Haitian logistics supervisor.  I asked him why he was still at work.  He was arranging the switch of the generators, training the guards, refilling the diesel.  Ok, I said, as he ran off. And five minutes later, he was back.  He asked me to talk to the medical staff.

And this was the inanity of the day. The medical staff, with no patients, were sitting chatting on the first floor.  It was hot.  They wanted the water cooler from Jude Anne to be moved over as soon as possible.

I said, this is not high on our list of priorities right now.  We are struggling to have the basics that this hospital needs, like running water and stable electric current.  And essential medications like oxytocin.  For the moment, you are going to have to drink water at room temperature.

Yesterday was a bit of a blur for me, largely because I woke up already exhausted. The neighbour’s generator had been on all night. It’s not so much that I hear it, more that I am aware of its presence. Evenings here are a chorus of generators from all sides, including our backyard. And, another neighbour has the generator that coughs and chugs like a old diesel one-tonne truck; it is more or less situated in my bed.

Jude Anne continues to manage fine, with ever-dwindling quantities of patients arriving at triage. They had done one big case in the night, of a woman who had a severe abruptio placentae and DIC (disseminated intravascular coagulation). She required three units of blood. Fortunately, the surgeon managed to save her uterus (i.e. avoid a hysterectomy), but the fetus was dead from the outset. By morning, when we rounded on her, she looked pretty good. Well, hmmm. By ‘good’, I guess I mean stable. She had just come out of the recovery room.

At Solidarité, since I am the everything-but-nothing person, I needed to arrange for people to get the things they needed in order to get on with setting up. I don’t seem to have anything much to set up myself personally. The medication cupboards had been finally finished the night before, so each department needed to receive their order and properly manage the stock count. The operating room needed their machines back to plug them in and test them. Fridges, furniture, the right supervisors with some extra staff to help, key expats in key places. (There were nurses and midwives around, but mostly under-occupied. The brancardiers and cleaners were somewhat busier.)

Sterilization sterilized their first batch of instruments without untoward incident. This is the first medical function successfully accomplished in the building. Also no small feat since it involves propane, water, significant heat production, as well as cleanliness and technical personnel and specific material (autoclave tape, sterilization paper, surgical instruments).

So after fixing the rotation schedules that were mine (midwife supervisors, transfer team) to reflect the delay of opening day, I switched from being medical over to logistics. I spent the afternoon caulking. It’s slow but sort of meditational. And I was too tired to do anything else, like read the papers on blood transfusion policy that the lab tech gave me.

In a way, though, I think the best sign of progress, is that compared to the day before, my phone rang significantly less yesterday. There was medical work to be done, but the team had what they needed to do it. They were hard at it and didn’t need to call me with problems.

The new nomenclature, because we are delaying Day 0 (defined as the first day we care for patients in the new hospital), means that tomorrow is day x1, followed by x2 and x3. The new day 0 will be Monday.

Today, I took the supervisors of each service to Solidarité, on a tour of the hospital (“My name is Wendy, I’ll be your tour guide for today, and our first stop is reception and triage…”). It was a good opportunity to explain what has been done, how we plan for the hospital to work, and what is yet unfinished. This led to a natural segue to the delay of opening day.

Much of the electrical wiring in key places was finished today. And someone explained to me the fridge plan. It’s complex. We were expecting to receive some units of blood from the Haitian Red Cross this afternoon, as buffer stock while running two hospitals. The fridge in the lab has been malfunctioning for the last month, so despite having been moved into the new lab, and rested appropriately after having moved (apparently the coolant has to settle), it is really not reliable. The other non-reliable thing at the moment is the electricity supply: we do not have power 24h a day, so a standard fridge is not likely to remain cold. Some fridges can maintain a constant temperature without power, though. There is one in the pharmacy, and one in the office; but the office one, despite being brand new, has needed the technician to come to make it work. The pharmacy also has a standard fridge which can be moved to the lab as a replacement to the defective one.

So, the blood will be received in the pharmacy, since we do not need to access it until there are patients in the building on Monday. The temperature will be stable there without 24h electricity. On Saturday, we’ll move the upright fridge to the lab, plug it in on Sunday (needs to rest after moving). By Sunday night, we will have reliable, constant electric service, so the fridge will get, and stay, cold, and the blood can go into the lab fridge on Monday morning.

Then there was the plan for the medicine cabinets, to stock and secure medications. I understand it but I can’t describe it. It’s even more complicated than the refrigerators.

We met with the VIP from Europe, which was an interesting experience. We waited and waited, then suddenly received a call that he was en route. Shortly thereafter, the police escort with sirens wailing pulled up, three SUV’s sandwiched between. First to emerge were security guys in suits with earpieces, and an entourage of poorly identified functionaries. The VIP wanted only the briefest summary. They stayed about ten minutes, asked four questions, and left. For them, a ten-minute experience; for us, two hours out of our day.

My whole timetable for tomorrow has to change, since it was supposed to be Day 0. The re-framing will be my first task of the day, after rounds. I am too tired to do it now.

We rounded on three patients this morning, no babies except the one being discharged with its mother who was also being discharged from the fourth occupied bed.

Today was a big day for the operating room team: preparing and unpacking the first theatre in Solidarite, as well as completing packing and moving sterilization. The theatre was ready, except they were still installing the air conditioning into the recovery room, and there is still no faucet on the scrub sink. We’ve not yet given them back their machines (anaesthetic machine, suction, cautery, lights) for fear of injury by dust and dirt, but tomorrow morning looks promising.

The sterilization is interesting because of the monstruous autoclave: it is heavy – though less heavy than the operating table – and needs a propane hookup. Also there is a window-mounted exhaust fan as a bonus. But actually, the sterilization moved without a hitch. In a way, this is not surprising: we’ve moved it three times in the last nine months within Jude Anne, so the logistics guys are well-versed in this particular process.

Another several truckloads of furniture and boxes came over today. We brought a bunch of brancardiers (stretcher-bearers) and cleaners from the hospital, too. Jude Anne is so quiet right now that they are much more needed at Solidarite, for some industrial-strength lifting and cleaning, respectively.

In fact, it’s amazing how some things completely change one’s perspective. Much of the metal furniture is being repainted white, to cover rust and stains and make for easier cleaning. The hospital got a thorough cleaning, removing the piles of sawdust and broken tile and dirt and grime, and tidying of various cabinetry under construction and pieces of plywood lying around. Now it looks plausibly like a hospital about to open.

However, today should not actually be called day -2, because we concluded that we cannot open in two days. There is too much left to be done. I pointed out today that even if all the construction was finished now, that only gives the medical team one day to prepare to open the hospital. We cannot realistically do that. So we have delayed day 0 to February 9th.

I’m not sure what to call the days from now until then.

In the meantime, we still aim to open officially on February 14th. The second week of our move will have to be compressed. Perhaps it’s not a bad thing: it reduces the length of time that we are running two hospitals simultaneously.

Miscellaneous observations:

• Our technical logistician, who is elbow-deep in decommissioning and moving Jude Anne, starts his day with a clean MSF t-shirt. I see him in the morning at the breakfast table at 6am. In the course of the day, he gets dirtier and dirtier by visible increments, worse at noon than at 10am, worse again at 3pm, and really filthy by 5:30pm. It is impressive.

• My job, the everything-but-nothing job, is apparently quite energy-consuming. Today, after rounding, I collected some miscellaneous furniture that needed to go ahead to Solidarité so we can duplicate some services. So I told the staff who were using the desks involved, then cleared them off, labeled, and carried them to the courtyard so they wouldn’t be forgotten when loading the moving truck. Then, I went to Solidarité to see how the OR team were doing with their disinfection and unpacking, and settled some language and communication problems they were having. Got logistics to get us the chlorine tanks they needed, and in doing so, ended up unloading a Land Cruiser. Spent some time in the office printing papers and asking when I would receive various other orders I’ve made for the new hospital. Etc. But it’s apparently energy-consuming because I’m always hungry at 9:30 and starving by 10:30am, despite my regular oatmeal and ground flax breakfast.

• High-level donor visit tomorrow, which requires me to look nice. This is hard. I will borrow clothes from a team member. Mental note: next mission, bring at least one better shirt.

• Tonight, required to stay in for security reasons… not that we had plans to go anywhere. If the security measures remain in place tomorrow, I’m not sure if that makes us more or less likely to regain some strength.

We moved furniture in today. Most impressively, the OR table – which takes ten men to lift. It had to come down the stairs at Jude Anne, into the moving truck, then out of the moving truck, and up the stairs at Solidarité. Mostly, I’m thankful that no one was hurt in the process. That table is a beast.

That went into the second truckload of things. It was preceded by a quantity of boxes, beds, tables, shelves, etc.

In the meantime, major cleaning went on in the new operating room. It’s not yet totally disinfected, but all the collected crud from construction has now been expunged, even as they were putting the last touches of paint on the door frames. Tomorrow the OR team will settle in and set up. That’s for the first theatre only, and a small recovery room.

Jude Anne continued packing: post-partum ward finished packing and was transported, sterilization started packing to prepare for their move tomorrow, small procedures room also getting ready. The big autoclave in sterilization will also be a beast.

Also today: several fridges. Apparently fridges have to sit for 24h after being moved, before you can plug them in. The electrical plug in the lab isn’t ready to receive the fridge yet, anyway. Unfortunately, the lab isn’t ready to receive much. There are still tiles to lay around the sinks. The walls need paint. The air conditioner has not yet been installed. The lights aren’t finished. And the room needs a deep cleaning.

As opposed to logistics, who are these days doing everything all the time, my job is an everything-and-nothing job. I try to make sure things are going according to plan, or that the modified plan still makes medical sense. I spend a lot of time explaining and communicating what’s supposed to happen, and when. I’ve packed about two boxes, and lifted about two objects. I write protocols. I distribute call schedules special for the move. I’m trying to prevent the medical team from having a nervous breakdown, also to avoid having one myself. I need to make sure important details aren’t forgotten.

Then there is what logistics calls ‘The List of 1000′. Those are all the things we will ask for once the move has finished, after Day +7. I’m sure that list will keep them occupied for at least the next six months. Right now, what we’re doing is triage of tasks: is it essential and must be done now’ Or can we add that to the List of 1000′

Patient census today: four patients, no babies.

We rounded on eight patients today, and two babies. The whole hospital rounds took about an hour. We are still transferring patients out, and we’ve kept a few, including an eclamptic patient this morning, and a ruptured ectopic pregnancy this afternoon.

Supervisor meeting this morning resulted in a great big discussion about packing lists. It’s remarkably complicated, especially for personnel who do not usually pack things. So, boxes labelled with name of service and a number. One list per box, detail of all items inside. One copy of the list goes in the box, the other kept by the medical supervisor of the service. Then another master list of the number of boxes.

The hospital set about packing. They spent most of the day at it.

In the meantime, we had another big move meeting. Update on what’s done and what’s not. There is still painting and doors and air conditioners. A tap for the scrub sink, yet to be purchased. Water hookups. Counters in decontamination that don’t exist yet.

Tomorrow, we have to move the equipment in for one of the operating rooms, so we can set up and make sure it works. Also, a fridge for the lab. Three days to ensure that we have a functional hospital. It’s a little scary.

This afternoon, a big puddle in the operating block demonstrates that the wall tiles are not sealed with the floor tiles. And this evening, malfunction of one of the big suction machines in the operating room. Retrieved the other one, that is supposed to go into the new hospital. Several hours later, the fridge holding the blood bank is reported to be 17 degrees Celcius. We’ve been awaiting a new one for months.

It’s Sunday, and today’s task was to move the hematology machine. This item had been moved up to accommodate the schedule of the external technician. We wanted to make sure the machine was properly secured and properly installed, in his presence.

The machine was packed up, and transported, but once he arrived in the new lab to assess the situation, he took one look at it and said, you can’t install it now. There is too much construction work left to be done. The dust isn’t good for the machine.

As we feared. Fortunately, his schedule isn’t as restrictive as originally thought. We’ll store the machine in a safe, undusty place, and he’ll come back this week to install it, once the lab is properly finished. It has to be functional by day 0.

Jude Anne remained quiet. Patient count: 8. They operated on someone this morning. All of the inpatients, including pediatrics, are now concentrated on Niveau 1 (what used to be antenatal). Niveau 2 will finish packing up tomorrow.

As one member of the team commented yesterday, our biggest challenge is not what might not be finished in time in the new hospital (though there are lots of little things that add up to big worries), but really, making sure we are communicating well within the team. We are all preoccupied and exhausted. It’s hard to remember to handle our words as carefully as we’re handling the equipment.