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.

We were trying to understand where all the patients went, when we were closed for moving. It seemed unnaturally easy to empty out the hospital, given how often we are overflowing with patients and delivering most of the city.

It’s still an important question. What happened to people while we were closed? Was there an important impact on morbidity and mortality?

But, as quickly as they evaporated, they’re back. Not the same ones, of course. This morning, I arrived to news that the hospital had admitted 42 patients on Sunday, of whom 20 were normal vaginal deliveries, 5 surgeries (including a hysterectomy and a curettage). Solidarité is filling quickly, even as we are still unpacking boxes and repainting furniture.

Pediatrics had admitted seven babies already. In addition to the 700g premie from the other day, now there is one who is 600g, delivered vaginally after abruptio placenta.

And as I walked into the lab to check the blood bank, I watched the lab tech give to a midwife the last bag of O positive blood. I looked at the hemoglobin result to be sure the patient really needed it: she did, with a hemoglobin measured at 2.3 g/dL.

So now I have two questions. Where did patients go when we were closed? And where are they coming from now that we’ve reopened?

Ladies and gentlemen, I think we’ve made a hospital.

The last night at Jude Anne was quiet, by all accounts. By the time I arrived at Solidarité this morning, staff were in the process of retrieving the last things from Jude Anne. Patients are coming, registering, waiting in the waiting room. Normal hospital things are happening almost as if they have always happened here.

Our inpatient ward was nearly full. I asked them to start sending the post-partum and post-operative patients upstairs, since it had not happened last night. We started organizing to get Pediatrics upstairs to their designated corner also. I figure the settling in, shifting, arranging, will continue for quite some time, some of it planned, some of it organically. There are still boxes to unpack. Some furniture is… not quite lost, but not quite locatable, either. It’s all the more confusing because we have used some pieces temporarily in other services, so now we have to trade and rearrange back so that each service has more or less what used to belong to them.

I returned to Jude Anne late morning, to pack the tiny administrative office we had there. I’d been putting it off: the office is dusty and full of miscellaneous crap. One of the Haitian logisticians was also at Jude Anne, disconnecting all the batteries and inverters, and loading leftover everything into cars to take to Solidarité.

Jude Anne is really and truly empty. It is stunning to finally see this, given that it was so recently full to bursting, with perhaps 100 patients, 50 staff, 30 visitors, and all the furniture and equipment that we were using. Empty, it is clear what a small building it really is. It had been a 35-bed hospital at the beginning, and it really is only big enough for a 35-bed hospital. Empty, Jude Anne is a marked contrast to what it is when packed full. It is also vastly different than Solidarité, which is cavernous and tranquil by comparison.

Yesterday, I was sitting under the mango tree outside of the office at Solidarité, thinking. I think I was thinking about medical supply, stocking, and security: a difficult subject. People kept coming to ask me questions – I am nothing but everything, or perhaps just the central repository of hospital information. The shade of the mango tree is cool and peaceful. And then, a mango fell. It was small but perfectly shaped, and ripe. It is good for labour to have a fruit.

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.

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.