So here I am on the final day of the first week of class 10’s integration period. Last week the class finished their obstetric emergency practical skills exams. Those who were leaving for other sites said their goodbyes, hands were blessed and everybody realised that they didn’t have a piece of equipment that they couldn’t survive without. And so we began!
Integration is one of the most important periods for the students on our course. It is the time when they consolidate their knowledge and build the confidence that they will need to practice independently. It is the time when they truly come to understand what it is to be midwife in Haiti. They will work long hours under extreme pressure. They will be thirsty, hungry and tired and they will need to develop systems for cooking and washing as they work 3, 12 hour shifts back to back in the hospital. If they are in a birth centre they will be available to women at any hour, day and night with limited water and electricity.
After the first week there is good natured grumbling and complaint but there is also enthusiasm and pride in the path that they have chosen. Their love for the women is easy to recognise and walking in to L&D yesterday to find everybody dancing with a labouring woman (dubious music choice but who am I to judge!) I found space to be satisfied. This morning when I arrived, an excited student described how she had delivered a baby on all fours (flying against the culture of the hospital) another chimed in that she had done the same, triumphantly describing how her first time mother had finished with an intact perineum and a healthy baby!
Despite all the good news, this week has also reminded me of why Haiti is such a dangerous and difficult place to live. A wonderful volunteer who stayed with us for 3 weeks reminded me of an African saying: ‘ A pregnant woman always has one foot in the grave’ a painfully true warning for the women here.
This came to her as we were leaving the hospital after encountering a girl of 22 who had arrived unconscious with eclampsia at 24 weeks gestation. She was pregnant with her 3rd child and had never received pre-natal care. Her breathing was noisy and fast, extremely elevated blood pressure and a very fast heart rate. Her GCS was 4 with a slow pupil reflex. The hospital did not have oxygen but at this point she was saturating well. Instinctively we felt that she had had a cerebral haemorrhage but without a CT scan we could not be sure. She had been seen by a doctor who had started a misoprostel induction (not wanting to risk a section with such uncontrolled blood pressure) and we could feel waves of regular, strong contractions. We confirmed with ultrasound that her baby had died and we explained this to her family while gently trying to prepare them for all the possibilities. I have seen women arrive in this state many times and on many occasions I have seen them miraculously recover, even after I had lost all hope. This has taught me to be optimistic but I have also seen many women die and so when I received a frantic call about half an hour later, from a midwife at the hospital telling me that they desperately needed oxygen for her as she had started to desaturate, I asked for the heart rate.
One of our biggest expenses here is oxygen. We pay between $30-40 for every tank which can last for as little as 8 hours if the patient requires a high flow rate. Some of this we pay for with volunteer donations but more often than not the staff use their own money. Because of this we have learnt to be pragmatic about its use so when the midwife gave me a heart rate of 55 I made the decision to drink a cup of tea before leaving for the hospital again. When I arrived at the hospital 20 minutes later I was told that she had died shortly after they had called.
It occurred to me afterwards that I have made a fundamental shift in my approach to medicine and this realisation goes some way to explaining why western healthcare volunteers are often frustrated by the seeming lack of urgency or emotion expressed by many of the clinical staff here and in other low resource settings.
I clearly remember, not long after I arrived in Haiti, frantically trying to resuscitate a mother that I had cared for in ICU, tending to her for the whole day while she slipped into unconsciousness, unable to find the drugs, equipment and knowledge I knew could save her life in the UK. As I took over for another round of compression’s a doctor walked in, looked into my red, sweating face and said calmly ‘you do realise you are wasting your time here?’. I remember being absolutely flabbergasted. How could this man who calls himself a doctor, be giving up on this young woman before we had done everything in our power to save her? How could he just dismiss her life and abdicate his responsibility. I now realise that we probably had done everything in OUR power. We have never successfully extubated anybody in this hospital. We don’t have oxygen, we don’t have equipment. Medicine has limitations and you have to know where they lie. I remember as a nurse in the UK being frustrated with doctors who would keep performing invasive or painful treatments on patients that we all knew were going to die with or without dignity and that dignity was the only thing we actually had control over. Usually these patients were elderly, with multiple co-morbidities and no quality of life but I suppose the same principle applies?
This death happened last week and we talked at length with the students about the importance of pre-natal care and education for women on the signs and symptoms of pre-eclampsia. We talked about recognising the deteriorating patient and how to escalate their concerns. They entered their placements prepared and of course, completely unprepared!
Monday was hectic, L&D was packed with women in various stages of labour which was great for the students and stressful for everybody else. I received a call mid-morning to say that a lady had come in in respiratory distress and when I arrived she was pale, struggling to breath with a high pulse and panic in her eyes. She had 6 children, having delivered twins at home 8 days previously, and she had been steadily bleeding since, although she had now stopped and had only come to the hospital because she had been having trouble breathing for the last 2 days. She had HIV and syphilis and a cardio echo-gram revealed a cardiac anomaly. I drove to several places in town until I found a tank of oxygen and in the meantime she was transferred to ‘ICU’. Clinically we could see that she had severe anaemia and was in hypovolaemic shock but her haematocrit had come back at 33 so the doctors were reluctant to request a transfusion for her. This was frustrating but we have a very limited blood supply here and are regularly unable to do emergency surgery because we have nothing in the bank, so there is a justifiable anxiety around performing unnecessary transfusions. During the day her condition continued to be poor until, at about 10pm, I eventually convinced the doctors to let me go to the house of the red cross lady to beg her for help. On the way I passed the hospital director who was also looking for blood for a little girl who had undergone abdominal surgery and was also in ICU. In the end, after begging and blackmail she released the final unit of blood to me and a transfusion was started. During this time she kept pleading for us to help her. She was convinced that she was dying and I couldn’t bring myself to argue with her, instead promising that we would do everything we could to help her get better.
In the morning she seemed slightly better but could not hold her own without oxygen so we searched until we found more, in the end spending $120 in an attempt to keep her alive. Still with no blood, I tried to donate but was turned away because it was too soon since my last donation. Another volunteer kindly donated, however the red cross in Hinche is required to send donated blood to the capital to be tested before being returned and so, although we had the blood in our hands, we were not allowed to use it which was terribly frustrating. I visited her several times on Tuesday and although she was often asleep she seemed a little better, even getting up to use her bucket at the bedside and in the evening berating me for not visiting her enough!
The following evening I was working with a student as she helped a woman who had been labouring in the hospital since midday. She had been fully dilated for some time and the baby’s descent had been slow despite regularly changing position (she had an androidish pelvis so we were not surprised by a slowish but steady descent). The baby’s heart rate had remained good however there had been some thin meconium staining which was a concern, so when she finally delivered we were not completely startled to see that the baby needed a little help. We started resuscitation but after the initial 5 breaths she was not breathing independently and although her heart rate remained normal, after 10 minutes of ventilations she was still not breathing on her own. Eventually she began breathing independently but it took a long time for her blood oxygen level to begin to creep up to a nearly normal value and I left the hospital feeling unsettled and anxious. As I passed the door of ICU I considered checking in on my patient but it was late and I felt ragged so decided to return in the morning by which time, of course, she was dead.
The lady from the red cross phoned the following morning to say she had blood for my patient.
The baby from the night before spent the day seizing.
The little girl who needed the blood that I took for my patient had a respiratory arrest and was intubated. Her father and grandfather have slept on the concrete outside the door of ICU since she was admitted, they cry all the time, they have no money and now their hope is dwindling too. When I went to visit her, her small body was wracked with seizures and her eyes were open and dry.
Behind the problems of the hospital hangs a back-drop of political unrest. Violent clashes and protests in the streets have seen people maimed and killed. Inflation is out of control, fuel is scarce, people are hungry and dissatisfied so they make roadblocks, throw rocks and burn tyres. The police use tear gas and bullets to try to keep control.
After all this though, integration has begun. We will care for many women, deliver many babies and hopefully make things a little better, step by step.
Somebody has just called me to say that there is a woman in an outlying village who is labouring and cannot tolerate a motorbike ride to the hospital so will I bring the car to get her?
Obviously, as always, I’m looking for the keys!
Written by Perrine Stock