A labour of love

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.

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…

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.

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.

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.

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.