A labour of love

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.

The hospital remains calm. The number of patients who arrive at the doors dwindles steadily day by day. Today, the total number of patients in the building this morning (inpatients plus those awaiting assessment) was nine.

The patient who was short of breath yesterday looked better today. Yesterday, we rounded on her — it was a ward round of one patient — and concluded that she had an infected hematoma at the site of the operative wound, as well as a lot of risk factors for pulmonary embolism. So, opened some of the skin stitches (they dehisc’d on their own), continued antibiotic coverage, encouraged mobilization. During yesterday’s discussion, the team had a good chuckle, because the
patient’s sister told us that she is half the size she used to be… and she is still morbidly obese.

Problems arose simultaneously today: I stopped by the operating block to see what there was, and noticed that the recovery room looked as well stocked as usual. This is not a good sign, because half of it was supposed to be packed yesterday, so that once in the new hospital, we can open one operating room, and one recovery room bed. The nurses said they had not received any instructions on the recovery room. And no one seemed really sure that what had been put in boxes yesterday
was sufficient material to open one functional OR. Unfortunately also, it is unclear if there are any packing lists for those boxes, which makes it all difficult to verify.

OK: I have learned my lesson about packing lists and packing instructions. It is easy but not necessarily obvious, especially for medical personnel who do not usually pack things. The next services to pack will get more specific instructions.

At the same time as this became evident, we also got news of a major medication recall. Part of the team went to the pharmacy to see what we had in stock that might be affected. As it turns out, it is a significant number of essential drugs that we use. Some of them, we have been able to borrow from another source. But I have also made some difficult decisions about withdrawing some from our formulary entirely, but leaving others still available because they are life-saving when needed. They will be replaced as soon as other stock is procured, but we cannot be entirely without them.

I suppose it could be considered a good time, since we have so few patients that our consumption is extremely low. It’s just that we’re a little busy with this move.

And, will the hospital be ready on time’ The electricity part of the logistics team was finishing installing extra fluorescent tubes in the OR today. The outlets are functional, and the wall tiles pretty much done. We’re still working on the scrub sink — it got tiled today — and the double-hinged swinging doors are also in progress.

I’m also worried about the lab because we have to move the hematology machine tomorrow. It’s the only day that the technician is available to help move it and service it. But there is still more logistical work to be done there: finish tiling, finish painting, finish electrical circuits, install the air conditioner. We are trying to protect the machine as much as possible; it will involve a lot of plastic sheeting.

This afternoon, then, I asked the medical team to meet. The overall plan is continually evolving, something ahead of schedule, some behind, and I wanted to be sure that we didn’t overlook any crucial elements when advancing some activities while others were delayed. The chief of gynecology is eager to collate our patients into one mixed inpatient service. The team agreed that this is feasible, and that we still have enough extra capacity if our patient numbers creep up. We’ll see if we can move pediatrics down to our mixed service also. This would entirely liberate the second floor.

The last meeting of the day was in the car on the way home. We are having a daily meeting of both logisticians, the project coordinator, and me (medical team leader), to discuss problems and progress. It ended at the dining table at home, interrupted by learning when we arrived home that the generator would not turn on. (Logistics jump-started it from the car battery.)

The most difficult moment of the day was mid-morning. After hearing that the packing of the OR might not have been as smooth as I’d originally thought, and that we had this major drug recall to deal with, I received a message from headquarters commemorating the one-year anniversary of the deaths in Kismayo, Somalia. Three MSF field workers were killed by a roadside bomb. One, Damien LeHalle, was a friend from the ‘primary departure’ course we took before our first mission. In the middle of stress and frustration, I needed to grieve.

There were six inpatients in the hospital today when I left.

Today, the plan was to pack up one of the operating rooms. Tomorrow, it is supposed to be moved.

So, at 8am, the operating team was asking for boxes. They received them at about 0915h. At 10am, they had finished packing Salle-A. By 11am, even the cleaning was done.

Really, the whole hospital has packing fever, even services that are not due to pack and move for another week. I find myself having to restrain them from getting too far ahead of the plan. I think the staff are very enthusiastic to leave this building.

The problem with the operating room is that the day they move has been delayed. The new hospital isn’t ready yet: workers are still tiling and painting and wiring the surgical block, and there is dust everywhere. Putting equipment in now would not be good for it.

We have built some buffer time into the schedule, so it’s OK, more or less, that the OR can’t go in until Monday or Tuesday. Only, it means that if anything else poses a problem for that service, we might be in trouble for the opening of the new hospital.

So, since the OR can’t go into the rental truck tomorrow, logistics plans to move beds from the post-partum ward. They weren’t scheduled to go until Day -2, but they have been ready since yesterday.

Today is the day before what we call day -7, which itself signifies the beginning of the moving process. The hospital remains calm. I don’t actually think there will be a storm; it’s just that there will be a flurry of activity. We’re trying to plan ahead so as to minimize confusion, but of course there will be some unforeseen chaos.

The hospital staff are relatively un-busy. Logistics, on the other hand, are running around madly. I am, too. Today was a day of meetings, running to meetings, or running around between meetings.

We started with a meeting in the car at 0645h, as a now-daily check-in between logistics (technical log and supply/admin log), medical team leader (that’s me), and project coordinator. The car was actually quite productive, although we continued about another 15 min after arriving at the hospital. I missed ward rounds, though; not serious, since we had only a handful of antenatal patients, and the chief of gynecology rounded with the team.

Then I met with the chief of gynecology, to discuss the last details of our restricted admission criteria during the move, and to discuss more details on how and what we will consider donating to other hospitals, as support while we are closed.

I had to see also one of the guards that we will train to help with coordinating transfers. He’s been on vacation for the last month, so hasn’t heard much about the plans. Thankfully, he’s willing to help in whatever way asked of him, and he learns fast. I explained the overall plan, and what was his role in it.

Then, with the chief of anaesthesia, about what had been decided about how to arrange the furniture in the operating block, and also about (again) the anaesthetic medications to be donated to other hospitals.

After that, I caught a car to the new hospital. Logistics wanted me to verify the order I put in last week for surgical instruments. We’re making extra sets for Caesareans. I looked at the backup light for the operating rooms, since we can’t get real operating lamps in time. (The backup light is a construction lamp with a compact fluorescent bulb in it.)

Then, back to Jude Anne. I had to find my lunch, and while waiting, listened to an entrepreneur from the new neighbourhood make a sales pitch to the staff in the lunch room. He wants to take orders for their lunch when we move. He’ll deliver. Most remarkably, I understood almost all of what he said in Creole.

Next meeting: with logistics and the OR nurse about the last items needed for the OR to move. We didn’t want to duplicate any previous orders that went in, but of course we don’t want to forget anything either.

Mid-afternoon, the big move meeting, which included most of coordination, all of the logstical expats, and me. Where we’re at, what needs doing, and, most importantly, what are the Plan B’s for major problems like the hospital being full when we try to move it, or the other hospitals going on strike, or the new Maternite Solidarite not being ready.

That meeting, then, melded into a meeting about my job and my successor.

I went on from that to making photocopies, and then, my last jaunt around the hospital before hopping in a car to get back to the house for the expat team meeting.

Step 1: Empty the hospital

My first principle for moving the hospital was to try to empty it as much as possible. It’s easier to move furniture, rather than furniture containing patients that you’re trying to care for while displacing them.

So we have a multi-pronged plan for emptying: publicity campaign, rapid triage, lots of resources for transferring, restricted entrance criteria. That part is supposed to start on Friday.

Yesterday, we started with a slightly reduced entrance criteria: no normal deliveries unless the baby is crowning (‘tete a la vulve‘). Otherwise, we continue to admit pre-eclampsia, third-trimester bleeds, and incomplete or septic abortions.

And the hospital is empty. Nearly, anyway. Empty compared to the overflowing that happened in October and November. Today when I left: a total of five patients (capacity 18 beds) in antenatal, and 18 empty beds on post-partum (capacity 35, up to 40).

But the strange thing is that I don’t think that it’s much to do with our change in focus. Perhaps the publicity campaign is particularly effective. Women just aren’t coming, aren’t coming to be assessed in triage, and so aren’t being admitted either. The rough statistics posted in reception indicated 49 women this morning (total patients in the building, admitted, discharged, waiting to be evaluated — we’ve had up to 140 during the peak).

It’s weird, but we’ll take it.

Postscript:
Not everything is smooth. Came home this evening after a long day — mostly meetings to ensure that staff know what will happen and how the hospital will work — and had dinner while listening to other team members discuss consumption and pharmacy orders. (Thankfully didn’t have to contribute meaningfully to that discussion.) Had a good discussion with one of the logisticians about what needs to be done to get this move accomplished.

And then: learned that the cold chain has failed. Four fridges plugged into same power bar; power bar failed. Thus, the clever technique of splitting the stock so if one fridge failed, we wouldn’t lose all of any one item, was indeed clever. But four out of five fridges on the same extension cord, less so.

This led to a rapid logistical and medical assessment of our losses. Which items can stand to be warm for a while? (Let’s say, 12h at 20 deg celcius.) What do we have extra of, in the fifth fridge? What is essential to the medical functioning of this project?

So, at 2130h, we have learned: that the blood typing reagents can be warm for a while, the vaccines are probably ruined but are not essential to the project (we get our patient vaccines from the Ministry of Health), the biochemistry reagents are no big deal because our machine hasn’t worked in months, and the HIV, HepC, and syphilis tests are also OK. Thankfully, oxytocin and methylergometrine can also be at room temperature for several weeks. The biggest issue is the control substance for our hematology machine, which is toast, and has been difficult to obtain.

Disruption of the cold chain is extremely unfortunate and quite expensive. Not to mention a major headache and very time-consuming. But the project will be able to run.

There is a worldwide shortage of injectable hydralazine. This is a major problem because this medication is crucial for rapid, controlled reduction of elevated blood pressure in pregnancy. Pre-eclampsia and eclampsia are by far the most frequent complications we see at Jude Anne, comprising 20-30% or so of our caseload. They are much, much more frequent here than at home, and much more severe. We admit women regularly with systolic BPs over 200, or convulsing (this is eclampsia). The principles of treatment, then, are magnesium sulphate to prevent seizures, something (often hydralazine) to stabilize the blood pressure, and delivery as soon as feasible. Delivery is the definitive cure, although the patient remains at risk for several weeks post-partum (and we see seizures post-partum fairly regularly, too). Hydralazine is not the only medication you can use to stabilize a patient’s blood pressure, but is usually one of the first-line choices, and certainly the one our staff are most used to. We go through 1000 ampoules a week. If we ran out of injectable hydralazine, it would be catastrophic. There is only one manufacturer of injectable hydralazine in the world, apparently. My understanding is that one recently-made batch didn’t satisfy their quality control, and so didn’t enter the market. So supplies are scarce, and the going rate from at least one source has increased from 3 euros per ampoule to 17 euros per ampoule. Logistics has promised me that we will not run out. Meanwhile, last week our Haitian Chief Gynecologist and I wrote a new protocol for anti-hypertensives in order to conserve hydralazine. It involves immediate-release nifedipine capsules as an alternative (we have them in stock). (Labetolol is reserved for resistant hypertension because of quantity in stock and lack of local comfort with it.) Word has it that the worldwide shortage will resolve in January or February, when the next batch will be ready.