A labour of love

22 nov 08

We’ve developed the floor delivery index as a measure of how relatively busy it is at the hospital on any given day.

It’s always busy, of course. But some days are more busy than others.

I’ve run out of superlative adjectives to describe what is happening at Jude Anne, even to the staff that work there. I couldn’t verbalize what I thought about the third public maternity closing, when I heard the news. The doctor who informed me told me that he felt terrible about it, as a Haitian, that when they told him, he felt like he was having a heart attack.

I’ve called it ridiculous, unacceptable, unbelievable. I ask lots of rhetorical questions, like, where are women supposed to go to deliver’ How are we going to manage even more patients coming to Jude Anne’ Where are we going to put them’

But I feel like I am overusing these words and phrases. They become to mean so little.

So, the floor delivery index. It is what it sounds like: how many women deliver on the floor on any given day. It’s a function of how busy the staff are, how occupied the triage and delivery beds are, and how we sometimes can’t attend to women waiting to be seen until something spectacular happens.

That said, though, I will add that our midwives are very professional. Floor deliveries are not usually uncontrolled or unattended. Usually the midwives spread out a little absorbent pad for the patient, and are right down with her delivering the baby with clamps and scissors in hand.

For example, on Tuesday, I was trying to take a day of rest, to replace the Sunday that I had worked. I wasn’t in the hospital. I sent a text message to our British midwife to see how things were going. It was crazy-busy: floor delivery index 6.

Today, we had a visit from some American journalists. I think they were appropriately impressed by the activities in the hospital. We told them, today is a relatively calm day: floor delivery index 1.

16 nov 08

We’re delivering all of Port-au-Prince these days.

I exaggerate only slightly. The Hopital Generale is still on strike–we’re at about five weeks now – and so is Hopital de la Paix. The remaining major hospital has closed since Friday afternoon for decontamination. Apparently they have been having problems of wound infections there. They plan to re-open Monday morning.*

So, besides us, there are two small hospitals at opposite ends of the city, each with small maternity wards, that remain functional. But they usually don’t have anaesthesia available after hours. And sometimes they don’t have an obstetrician present. There is supposed to be a midwife there 24hrs a day.

When I arrived at Jude Anne Hospital, two months ago, it was a 65-bed hospital. Despite already being cramped and always full, we have managed to become a 79-bed hospital. This doesn’t count the triage and delivery beds, which we have also increased to nine and six, respectively.

It also doesn’t count the pediatric ward, which is really a neonatal unit. We have a lot of premature babies because of the medical complications that women are admitted with. One day last week, we had 21 babies admitted, so many that they were sleeping on the desk and on the scales. Fortunately they’re small.

We should be medically triaging patients and keeping only the most urgent and serious cases. But with no other maternity to transfer patients to, we’re keeping everyone.

And people come not only from Port-au-Prince, but from further afield also, to deliver here. From a town 120km away, for instance. Our staff tell me that there is no reliable health care in that area.

Since March, there has been a national program for free obstetrical care (Soins Obstetricaux Gratuits). It’s funded by CIDA through the WHO. I won’t comment on it.

*as of 22 nov, they are still closed.

Logistics includes everything that is non-medical and non-policy-related about a project. At Jude-Anne, a 70-bed hospital, this is a big, big job. Walls and beds, water and electricity, laundry and sterilization, cleaning–and maternity is messy business–and waste disposal. The guards, the orderlies, the cooks, the drivers: all logistics. (Then there’s the logistical stuff related to the office: finance, procurement, communications…)

Last weekend, we had a generator problem. I noticed on Thursday, when I tried to wash my hands. No water in the tap. Found one of our Haitian logs, and said, there’s no water in the lab.

He said, I know, there’s no water anywhere. We’re trying to fix the generator.

I replied, Please do! I can’t have a hospital with no running water.

The water problem resolved within minutes. But two days later, our generator showed worse problems.

I know nothing about generators. (That’s why they don’t let doctors do logistics!) I can’t tell you the diagnosis of our generator. Sick, is all. Gravely so.

We have a back-up generator, which is very small. Just barely enough to run the lab and the OR, temporarily. I’ve been told that generators need to be switched off regularly, or they overheat.

The logistics guys were madly rewiring the circuits to the hospital. I ran around madly turning off lights and fans and unplugging cell phone chargers. And explained and apologized to the staff: it’s a bit dark, and it’s very hot, but we have to prioritize the lab and the OR. God help us if we lose a fridgeful of blood for transfusion. Or the lights in the OR.

The hospital staff continue to amaze me. No one really complained. Lately, we’re doing double the usual number of deliveries, way beyond normal capacity for this hospital, and a subject for another blog entry. That night, they were delivering by the light of emergency lamps, the kind used on construction sites. It was baking hot. The midwives shrugged and kept working. Babies wait for no one.

Logistics rented another generator, not quite big enough, but it was what was available late on a Friday afternoon. It came on a truck with a crane. I had no idea they were so big.

But not quite big enough, as I said. Two Haitian logisticians split the weekend, because everything needed switching over every four hours. One did the days, the other did the nights. We agreed that ironing the gowns and sterile fields for the OR was unnecessary luxury. As long as they are clean, dry, and sterile, who cares if they have wrinkles’ Apparently the iron takes a sizeable electrical load. The dryer was more important.

We made it through the weekend, though the delivery room spent some minutes in absolute darkness. Now we have a new, even bigger, generator, that also came on a truck with a crane.

Yes, logistics. Amazing.

On Friday morning, one of the guards came to find me. He said, someone has delivered at the intersection (?dans le carrefour?). You need to come.

Look, I?ll admit: I like to be needed. It?s one of the reasons I went into medicine. So when he said, you are needed, I went. But I wasn?t really sure why I was needed, or what I was going to do.

I stopped into triage to get some materials (gloves, delivery kit, absorbent pads). The doctor and midwives there had heard that something had happened outside, but they had their hands full with patients who were already inside.

Out the gate, down to the corner, with the brancardiers (orderlies) at my side. I asked them to bring the stretcher, just in case. We waded through the usual throngs at the gate and on the sidewalk. A tall man in dreads and a beret was leading us, beckoning onwards.

Waded through traffic on Delmas, which was not nearly as scary an experience as I would have thought, probably because perhaps a lot of people were waiting for us, probably also because we stood out, me in my MSF shirt, the brancardiers in their sky-blue scrubs. At the time I wasn?t thinking that much about it, but I generally have a policy to cross roads with locals rather than on my own. Locals know how local traffic works.

Wow, when they said, ?dans le carrefour,? they were not exaggerating. Literally in the middle of the intersection, a beat-up station wagon had stopped dead, oblivious to traffic. (And it is a very busy intersection which contributes significantly to the noise in Jude-Anne.) Inside, a woman in the back seat, her head on her companion?s lap, and a baby between her knees.

Fortunately, the baby looked great. Pink and dry, cord no longer pulsating. Not even crying. She looked pretty comfortable on the back seat.

Someone suggested that the car pull up to the corner, about 5 meters ahead. This seemed like a good idea. We walked with it. Once there, I clamped and cut the cord. Bundled the baby in the green pads. I asked the brancardiers if they wanted to get this woman out of the car. A smiling man at my elbow told me he was the father. And that he and I could go together with the baby back to the hospital. The car would bring the mother.

So we waded back through traffic, me following the dad, baby in my arms. The car completed the left turn and pulled up to our ambulance bay at the same time. The orderlies helped her out of the car and I delivered the placenta in the usual fashion, on a triage bed.

The question is, why did they stop so abruptly in the intersection? They were clearly trying to turn left to get to Jude-Anne. The baby stopped everything.