FYI -- this is totally out of order. I wrote this today, 1/21/12. I have several days to catch up on. I have been non-stop busy with births, patient care, and studying. I will outline past days in a future post….

It’s Saturday, 5 pm. Saturday evening festivities in Milot are gearing up -- I hear more activity than usual from the street; more motorbikes and more music and more people chattering and laughing. My small room at the hospital compound is not too far from the main road and I have my window and door open to enjoy the cooler air in this latter part of the day. I am under my mosquito netting, still in a pair of scrubs I wore to the hospital this morning. My roommates have gone back to the States and I have a quiet little space to myself. It’s so intensely social here between patients, other medical staff, and the volunteers, and communicating in Creole requires some effort, so I appreciate these few moments of solitude to rest, gather my thoughts, and write.

Geoff and I have just returned from a long, wonderful walk along a less beaten path. Usually we walk through the main part of town and then off into little sub-towns -- the various neighborhoods that blend one into the next. Today we went left out of the compound gates and found ourselves seemingly in the middle of a jungle neighborhood, walking along a path that is actually quite a well-travelled path to the neighboring town, but no blans were there -- it’s not the tourist path.

Large stretches of our walk were quiet except for birds. We chatted and marveled at the amazing array (and size!) of the plants and trees. Large birds were chatting above us, we passed locals whose stoic faces break into ear to ear smiles as they reply to our greeting of “Bon Swa.” We agree that if we were women in labor, it would not be appealing to make the long walk all the way to the hospital, and we might also choose to stay at home with our mother, sister, or neighbor to give birth as so many of the women here do. After all, most of the births happen easily and naturally, so what’s the big deal? Except for the small percentage of time that it is…

Along the way we recognized cacao, grapefruit, and banana trees, an aloe of some sort, and found an orange tree with a fruit low enough that Geoff could jump and reach one, which we split. At some point one forgets about all the hands we’ve shaken along the way -- the kids are always reaching out to touch our hands and the adults love to high five and shake hands, too -- and then you just eat. One can only remember Purell so many times in a day. It was a delicious orange -- clearly edible and normal -- but we did joke about diarrhea and Pepto-Bismol. It’s hard not to. Diarrhea is prevalent here and we walk through the cholera tent to check on patient hydration status every couple of days.

Our workday began at 8:30 this morning. It’s a perfect morning. The temperature is in the 70s, there’s minimal humidity, and the sun is shining. There are few vendors on the street so our few hundred meter walk to the hospital is brisk, rather than slightly encumbered as usual by the men and women who call out: ‘Aviva, Dr Geoff, you remember to buy from me before you leave.’ We now know many of their names: Charlie, Henri.

We begin the day with a stop by the NICU. We are bringing the cardio-thoracic team by to help evaluate a 3-week old baby with a possible congenital lung problem. We need an echocardiogram and an assessment and they can do it. A wonderful surgeon named Andres, a handsome man built like Arnold Schwarzenegger, and with a German accent, carries the baby’s heavy oxygen machine while I carry the baby to another building  of the hospital to do the evaluation. I am moved by this giant man tenderly talking to this tiny baby, the baby’s hand in the giant man’s hand, through the procedure. No major heart defects. We’re still not sure what the problem is, imaging is limited, and even if we know, what can we do about it?

We walk up the steps to maternité, passing the usual array of patients and family members of women who have delivered, are here to be assessed, or are waiting for some other purpose, and past the security guard, and enter the maternity ward.

By ten o’clock I had first-assisted a cesarean that resulted in a neonatal death. The woman had initially been laboring at home for a long time with a matwan, the local midwife, usually a completely untrained older woman in the community (more on that another time), then she went to a clinic, and after 24 hours of ineffective labor with prolonged pushing, she came to us, as our hospital here is more like a tertiary care center. She was quickly evaluated and found to be completely dilated, with the baby’s head too high in the pelvis for how long she’d been in labor, and a lot of swelling of the baby’s head. Her abdomen did not appear to have the normal shape, suggesting a possible malposition of the head. She’d received Pitocin at the previous clinic, and the surgeon I’ve been working with daily, Dr. Romeus, made the reasonable call to go straight to cesarean. The baby was born without a heartbeat. As the baby was coming out I quietly said to Geoff, who was in the OR and in-waiting for possible neonatal resuscitation, that this one was gonna need some help. The baby was limp, lifeless, and had just emerged from a uterus filled with pea-soup meconium. I handed the baby to Geoff who adeptly whisked the baby out of the OR and across another room where resuscitation occurs. It was not a seamless transition -- nothing really seems to be here. There are too few hands, needed equipment is just not within reach -- sometimes it’s not even available.

In another minute I broke scrub from the section to join him in the area for “reanimation de neonate” -- a room we’ve tried to stock with adequate neonatal resuscitation equipment beyond the two broken baby warmers and various supplies that were haphazardly stuffed under the warmers. Neonatal resuscitation requires two people to be done properly. There was only Geoff and a nurse with no neonatal resus skills with that baby. Sure enough the extra pair of hands was needed.

The baby still had no heartbeat or respirations. We proceeded to work in unison for the next 7 minutes to jump-start that baby into the world of the living. Other than a slightly misshapen head, he looked perfect and was full term. He was still warm and initially, mostly pink. We were both teary-eyed as it became evident that this little beautiful baby was not going to take a breath – ever-- and I think we were both thinking if we just wish hard enough and just keep resuscitating he’d open his eyes and gasp and have a beating heart in that tiny chest we were taking turns compressing. But did this not happen and we were now part of the infant mortality statistics of Haiti. We examined the baby’s body. We wrapped him. We watched as his skin became more bluish.

We talked with the OB after the birth. We asked if he was sad. He was sad for the baby, and while he was non-judgmental of the mother, he wished she’d have come in sooner rather than as it was, too late. Geoff and I took a little bit of time to deconstruct the situation. We realized there was nothing we could have done differently, but that there are big cracks in the system that could lead to a problem because valuable time is lost going from one room to another, or reaching/finding supplies, initiating resuscitation. We talked about how to fix the cracks -- which always leads to a larger discussion about how to be culturally appropriate and also realistic about what is possible. We talked about the futility in saving babies in a social environment where there is no support for children with developmental delays, nor for their families. This is a well-accepted reality by the physicians and families here and is in stark contrast to the US where we save every baby we can regardless of the long-term consequences. We talked about the social consequences of this in the US and also about the fact that had there been a neonatal death in a US hospital, the National Guard and CIA would practically be called to investigate, not to mention the lawyers who would be following not far behind. Here it was just a matter of fact, no different than had she birthed normally. It wasn’t ignored; it just wasn’t newsworthy. We talked about that, too, and whether as a culture Haitians are just very accepting of the natural flow of life and death, or whether as a culture, Haitians are just so accustomed to a high infant mortality rate that they just accept it as normal.

Early in our visit, we observed practices that, to us, seemed outmoded. Routine episiotomy is the most glaring example. Our overwhelming conclusion has been that the reason for the routine episiotomies is that the nurses who do the deliveries just don’t know how to do any other type of repair, so they do a long, lateral epis, which to our horror, they close with one continuous running stich, including an external running stich of the perineum which ends up looking the seam of a baseball when the repair is completed. We have struggled with the possibility that there are reasons for some of the practices here. We’ve tried to change things by example, demonstrating birth “pas epis” and practicing delayed cord cutting with skin-to-skin contact between mom and baby.  But we don’t just want to be blans (= gringos) coming from the US imposing our views and opinions.

Respectfully trying to communicate our observations to the Medical Director, and our willingness to do some teaching to help contemporize practices, Geoff diplomatically said (I am paraphrasing something he said more eloquently), “There are some things that we do that are different. It’s not that what is being done is wrong, it’s just that what we do is based on more recent evidence.”

Weeeelllllll….today we had a change of heart. Some things are just done wrong. They are done because of lack of resources including training, knowledge, proper equipment. We are not just blans trying to bring in western technology. We are blans coming into an environment where western technology is already being used -- sometimes just ineffectively. We are blans coming in and recognizing that the neonatal mortality rate should not be 15%.

We barely had time to integrate the baby’s death when another woman was ready to birth. I had examined this woman yesterday afternoon. She was a first-time mom who came in because she though her water had broken that morning. She was not even examined when she was given 20 mg of Pitocin in an IV. When I checked her she was barely dilated and a sterile speculum exam revealed no signs of her membranes being ruptured. But it was late and she was tired, and she’d been given Pitocin, so she spent the night at the hospital. Of note, when I was checking her for ROM I asked the OB if he had nitrazine paper, which is a standard in every US clinic and costs pennies. This very competent young Haitian doctor replied honestly, “I’ve read about nitrazine paper in books but I’ve never seen it.” Fascinating…

12:24 AM: The tree frogs have their regular evening chorus going. Just back from the hospital. Well, that’s not exactly true. I got back about and hour and a half ago. The time since has been spent variously between deep, serious, and sincere conversation about medicine in a 3rd world country (I can’t quite call Haiti a developing nation. It’s not quite there. But there are many here who are trying) and outright hysterical laughter over the sheer preposterousness of some of the situations. You see, Geoff and I were leaving L&D after a long and satisfying talk with Dr Romeus, who to our delight, had no idea that routine episiotomies were occurring on L&D and who agreed that this needed to stop immediately, when we were asked by a young Haitian intern to check on a patient who needed an IV but didn’t have venous access. Basically when you’re a family doc down here you can get stopped to care for anyone with anything from a baby being born to placing an IV or catheter to treating someone presumably in congestive heart failure like we ended up doing for this man. But it’s hard to treat without access to necessary lab tests and medications, and there are ethical issues of whether to start treatments that the patient will have no way to access or afford down the road. It’s not funny but at some point it becomes comical; or perhaps comic relief becomes necessary to cope with the actual devastating realities here.

Oh, tasted rum and coke for the first time tonight. It was Haitian pineapple rum and real Coke like we have in the US. Delicious. I just had a sip but if there’s more tomorrow night I might have to make it a cup…

Thanks for listening, amis!

~ Aviva from Milot, Haiti