A labour of love

At long last, and after several teams-worth of trying, we’ve found a new building for Jude Anne. Really, we’ve long outgrown our space. It is at once a big relief and an enormous task ahead. Our patients, and our mostly-uncomplaining staff, deserve a hospital where one can actually walk around 3 sides of the bed. Right now, we have barely 3 inches between. It would decrease everyone’s stress level. We would be better able to focus on quality of care. But to get there will take Herculean effort. We have a building, with nothing inside, not even walls. We need to create a hospital. The floor plan was a process that involved the builder, our Australian/multi-national hybrid Logistics Coordinator, me, and the whole medical team. It has taken multiple iterations; the most recent change was made last Thursday when the builder was chalking the floor for where the walls will go. Designing a hospital was not on the curriculum in medical school, by the way. However, I am very pleased for the design we’ve made, for work space and patient flow, within the logistical constraints of the building. And now, the LogCo has a ‘To Do’ list, with timeline, of all the other things that need to be accomplished. Item 7: ‘Move Hospital’ I don’t yet know how to this, move a busy, actively-running hospital. (Hm. But I worked in Campbellford Emerg the weekend that Peterborough moved their ER. Does anybody have the plans for that’) Here are the principles of moving, as I see them: 1) have as few inpatients as possible; 2) have as many ambulances available as possible; 3) move the most stable patients first. The specifics, we’ll have to work on.

The Hopital Generale is still on strike. I managed to visit the hospital to look around, in the brief interval between the closure for a broken anaesthetic machine, which lasted a week, and the beginning of this strike. Rumour has it that it’s the anaesthetic residents who haven’t been paid in seven months, and that everyone else isn’t working as a show of solidarity. I think we’re on about day ten, but, to be honest, I’ve lost track.

The Hopital Generale is the publically owned university hospital in downtown Port-au-Prince, a few blocks from the presidential palace. It is a large, relatively spacious campus taking up a few city blocks. There is one department per building, all matching two-storey whitewashed blocks with green trim. Maternity is right next to Pediatrics.

Pediatrics is the only referral centre for neonates in the country. The chef de service told me that they only have three functional incubators (and four non-functional ones). Ten neonatal intensive beds in total. They are always full.

Last week we tried to transfer a couple of our babies there, but they came back to us. Pediatrics has also been affected by the strike.

And the catholic mission hospital that can sometimes accept transfers, like the probably congenital cardiac newborn we wanted to send last week. They are inundated with babies that have come from the non-functional general hospital.

Flooding is definitely the order of the day. The waters have gone down in Gonaives, I hear, but we are inundated with pregnant patients. So are the other public maternity hospitals.

I have never been a morning person, but right now it’s 7am on Sunday morning, and I’m alert and awake. And feeling articulate enough to write. This is very unusual for me.

This week, I’ve been getting up early because we’ve started la grande tournee de salle (grand rounds) at Jude-Anne. Rounds start at 7am, with shift change, so I get up before six with the first rays of dawn to get there in time. We are eight doctors discussing all the antenatal patients admitted to the first floor: two night docs, four day docs, chief gynecologist, and me. The night doctor who was responsible for that floor presents the case, and we discuss management. (This is the format despite that fact that this doctor has likely been in the operating room all night. For example, on Friday morning, he reported having done six or seven Caesarians – he’d lost track of the exact number – and two curettages.)

It was the idea of the chief gynecologist after I posed to him the problem that patients on the first floor were often lying around for days before definitive management (usually delivery). I thought this was not good quality of care, and not good for freeing up beds to admit new people, either. We had even found a couple of cases of patients being discharged with pre-eclampsia and still pregnant: really not a good idea.

Grand rounds has proven to be really great, even after only one week. We have the opportunity to discuss things academically. It has helped me understand some of the thought processes that are different than what I have seen at home, and target my literature searches for research that might change their practice. It helps a lot that we share a medical culture, so that even if we don’t agree, we have a framework for discussing it. This was not the case when I worked in Democratic Republic of Congo, where there was no concept of evidence-based medicine.

Patients are no longer lingering too long antenatally, for the most part. Beds are more available for new patients so we don’t have to transfer seriously ill patients out because of lack of space. We have the opportunity to suggest and teach new techniques, such as manual vacuum aspiration instead of curettage for specific cases. We have a better sense of how well the initial evaluation and documentation is done. And we know who has a tendency to turn up late. It has turned out to produce more benefits than we’d anticipated.

It’s definitely worth the early-morning effort.

Dr. Wendy Lai is starting her 2nd mission with MSF in Port-au-Prince, Haiti, with a focus on emergency obstetrics.

She has worked with MSF in the field, previously in a primary health care project in Shabunda, the Democratic Republic of Congo (DRC).