February 5, 2012: Day 24 of 30 Days in Haiti

This continues to be an incredible journey. Each day is so packed with rich interactions, experiences, thoughts and feelings that it is hard to know where to start writing, and I know I can never do justice to the constant backdrop of color, music, cacophony of smells of charcoal and burning rubbish, people, sewage, animals, and cooking foods, the sounds of roosters crowing throughout the day, chickens and goats and dogs walking through the town, hospital grounds, and even into my room (just a chicken…). Initially I was able to keep up with writing, but the deeper into the community and culture I’ve gotten, the more time consuming my days and evenings have become. And the more the experiences – both inner and external accumulate – the harder it is to sort out which to write about. Then I am like a teenager with a room that is so messy I don’t know what to pick up first.

Last week I wrote the basis of an essay, after a particularly tragic couple of days, but I didn’t send it because my husband said it was too sad to send. After this I became internally blocked in my writing because I didn’t want to make readers sad. But every day here one witnesses some tragedy, or many. I have thought about this and realize I am eyes and ears and heart for others to know how it is for women who have no food and no prenatal care and who suffer the consequences of this. I bear witness, hold space, and honor their truth and reality through my writing, and hopefully in some small way, this will be inspiration for others to find ways to contribute and make change. In part by my writing, I remember and preserve those who deserve to be remembered. I apologize if what I write in the few remaining Haiti blogs to come, as I catch you up on the adventure, seems sad. You are under no obligation to read these stories. I do feel obligated to write them. And there are a few things left to say.

There is, under the sometimes seemingly indomitable spirit of these people of Milot, population 35,000 and surrounding areas, population 200,000, the ever-present tragedy of poverty, starvation, and frustration. The absolute beauty and grace of so many Haitians in spite of this, has caused me to well up with a strange mixture of sadness, humility, gratitude for my own relative wealth, and admiration more than once, and does even now as I write. Part of me finds it very hard to get ready to leave the warmth of these people in the next few days, because I recognize that in spite of intense material poverty here, compared to so many in the US (aren’t almost 50% of Americans on an antidepressant?), there is an incredible spiritual wealth here. There is community, people smile often, life is social, people are connected to the land they are a part of, and to the rhythms of natural light and darkness. The beauty of the people of this northern region of Haiti is even more evident in face of the glaring contrast of the daily reality of most Haitian’s lives. Here, middle class literally means having a roof over your head. There are many partially built homes here, mostly cinderblock, built block by block as the owner can afford to purchase the next few blocks. This takes many people years to accomplish. People often eat, at most, one meal a day, and the diet is horribly devoid of nutrition. There are so many neonatal deaths. So many eclamptic women. So many kids that die before age 5. So to not share the naked truth of it would be to dishonor these people or paint a rosy picture, and I cannot do this, especially to the women of this nation, who manage to wake up and wash and cook and breastfeed and clean and carry loads with too little food and too little security or comfort in life.

Here is the email I wrote that my husband said was too sad. I need to send it. It is the truth and yes, it is sad. But to be a person of hope, is to use the sad, hard, painful as a motivating force for change…

Last week started out rough. By Sunday midday we’d had 4 babies die, 3 within several hours of each other so that I barely left the NICU, one overnight that same night, and then on Monday, another. At some point I just went numb emotionally and into automatic pilot, resuscitating babies and just sort of wishing my life force into them along with Lisa, the nurse who was working with me, a dedicated 22-year old woman from Minnesota who has been to Haiti many times and is now living here for a year.

It started out early Sunday morning with me arriving at the hospital to find a postpartum mother in the maternity triage area. Sunday is somewhat of a quiet day in Milot; people go to church, people don’t work. But of course, births never stop and Sunday seems to always be one of our most hectic days on maternity.

The woman in triage was lying on an exam table, her feet in stirrups, her thin dress wet and pulled up to the waist, below which she was naked. She had mud on her feet and lower legs, and the trickles of blood that had run down her inner thighs and on her feet were now dried. Mud on the feet and legs of the women that come in to maternity has become a tip-off that I have to come recognize, suggesting that a woman is on the exceptionally poor spectrum of poor, has had to walk far to the hospital, and that she is likely going to be more malnourished than even the average woman here. Her belly was about the size of a 4-month pregnancy, so in quickly surmising the situation – the blood on her legs and the size of her abdomen, I thought perhaps she was having an early second trimester miscarriage.

Within about 10 seconds I was informed by the nurses that she had just been brought in minutes ago by a team of UN police (so that’s why there were UN police outside of the hospital on my way in…) who had found her by the side of the road where she’d recently given birth to twins. I was the only physician available on maternity at that moment to examine her. I assessed her for bleeding, vaginal laceration, any signs of medical problems before concerning myself about the babies. There is a saying in Haiti that states “Better water spilled on the ground than a broken gourd” which means that it is more important to save the mother at the expense of the babies than the other way around. (Doesn’t it say something about maternal and infant mortality when a country even has a saying like that?)

Ok, deep breath, mom’s fine, so I leave her to the capable nurses to get her cleaned up and comfortable. I ran out the door, past the security guard, down the stairs, and across the courtyard to the NICU, a relatively poorly equipped but best attempt at providing intensive services to the babies having trouble at or soon after birth. There I found the two tinier-than-I’d-expected twins. They’d been cleaned and put in a bassinette with a small floor lamp placed near one of them as a heat source, but they were not receiving any obvious medical attention. One appeared dusky and was having some breathing difficulty, but with a little blow by oxygen and stimulation, pinked up – temporarily. The other baby was so tiny that she could barely open her eyelids – a marker of significant prematurity, but she looked surprisingly sturdy. I examined and weighed the babies; the boy weighed 1.3 kg, his tinier sister just 1 kg, and she appeared the stronger of the two. Being generous on Ballard scoring, I estimated a gestational age of at most 26 weeks. More likely they were slightly less. Twenty-four weeks is considered a viable baby in the best of circumstances in the States.

Over the ensuring hours the babies in turn, then simultaneously, began to struggle. Resuscitation attempts were initially successful but were increasingly becoming only temporizing measures, and eventually it became evident that that were not going to survive despite our watchfulness, stimulation, warming, IV fluids, neonatal resuscitation including repeated rounds of compressions and bag/mask, and each of our silent prayers and wishes. The little girl died first, then about 12 hours later, so did her brother.

In the interim, another NICU loss unfolded. I left for about 30 minutes to check in on L&D, and when I returned, I found Pierre, a 6-week old sweetie baby with a lung problem that we could not fully diagnose or treat with the services available here (I kid you not when I say limited resources – we had 3 days where we could not get an x-ray in the hospital because the hospital was out of x-ray film!), being improperly resuscitated. In spite of training, most health providers, I discovered here, even some American nurses and American doctors, have not actually done a resuscitation and have no idea how to get a good seal on the mask, get a chest rise, or do effective cardiac compressions. If you are planning to do maternity care in a developing nation, you will likely need to do neonatal resuscitation. Don’t just rely on the fact that you are certified in it; get someone to show you how to do it before you travel. In fact, I have decided during this trip, that I will be offering an intensive weekend course on critical skills for midwives traveling abroad. There are things midwives don’t do and see at home that important to know how to respond to in a setting like this – it was my family medicine training that prepared me for this level of skills, though my midwifery training that prepared me to support women through labor and achieve a level of human connection and communication that many doctors never learn.

Anyway, I took over the CPR, while instructing a long-term nurse volunteer in the proper techniques, and also showing the local nurses. A visiting anesthesiologist was quickly called from the OR across the courtyard and he intubated Pierre. I manually ventilated him for quite awhile but eventually withdrew, with agreement from the group that had now gathered, because, in reality, his death was inevitable and there was no value in causing him prolonged discomfort. I explained the situation to his mother who had come to breastfeed him many times each day, and with whom I shared a smile and a simple bit of encouragement each day for being such a dedicated mother. The mothers and fathers here do not, customarily, hold their dying or dead children, at least not in the hospital, so I held Pierre while he died as just an hour before I’d done for one of the twins.

Then, as it this wasn’t all sad enough, the smaller of the twins we’d delivered the Sunday prior, went into what looked like probable DIC that morning and died, also in my arms, about another hour later.

As I was getting ready to finally leave the NICU and get some fresh air – it was deadly hot in there and resuscitations take a lot of physical and emotional energy, as if that wasn’t enough, the mother of a baby that was born 2 days prior when I wasn’t at the hospital, gestured me over to look at her baby’s back. I walked to the isolette and lifted the baby’s dress (a little pink dress on a baby boy – no clothing or color distinctions for newborns here in Haiti!) and found a large meningomyelocele, a severe spinal defect which we rarely ever see in the US anymore because of our policy of fortification of food with folate which largely prevents it. There is no neurosurgery in this region. The mother would have to bring the baby to Port-au-Prince, a 4-hour drive away, for treatment, if at all possible. Spina bifida is not uncommon. A 14-year old girl with spina bifida had been brought to the hospital for treatment just a few days prior. Sister Ann, a remarkable nun who lives here, discovered her in the mountains. She lives with her family. She never received treatment as a baby or child. She never learned to walk. She pulls her body along with her hands. And she is incontinent. US policies in Haiti led to a transition from rice grown domestically to complete dependence on rice from the US. It would be easy to make sure that this rice, which is the primary dietary staple here, is fortified. And that all women of childbearing age receive folate supplementation.

The last neonatal death for that week was the baby of a woman who came in with eclampsia seizures. Treatment for eclampsia here is standard fare and the nurses are far too accustomed to starting IV’s with the required 4 mg bolus of magnesium sulfate and seeing to the hourly appropriate subsequent doses. The family reported that the mother had several seizures at home, and she was brought in seizing. I can barely convey how disturbing it is to see this, and to see the fear and worry in the faces of the family – usually a brother or father of the baby – who has carried the woman into the hospital. The baby was born severely hypotonic and appears to have had severe ischemic encephalopathy and is likely (and you know what I mean when I say maybe – even hopefully) not going to survive the neonatal period if even the first week of life.

I have tried not to cry in the midst of the families who are experiencing their own tragedies. I was told it does not help the families who have their own ways of handling grief. So I did my best to keep a poker face while I held Pierre as he was dying, his mother next to me waiting for word from me that he’d taken his last breath after about 10 minutes of agonal breaths, as the dying breaths are called. I quietly held my hand on her shoulder while she wept, and simply said “Mwen regrette.” I kept it together and kept on moving through. Until a couple of days later. I woke up one morning with vertigo and couldn’t get out of bed. I was unable to work for the whole day. I literally just lay there on my back trying to keep my own small world from spinning. At some point an employee at the compound had a radio on while she was folding laundry in the small courtyard outside of my room. At some point the music reached my awareness. There was an incredible Haitian gospel rendition of Amazing Grace and I thought back to the woman who sang this song in labor with her 7th pregnancy. It was just one of those versions that only women of African descent can pull off – no offense to anyone, but I’ve never heard white women that can sing like that. It was deeply soulful and grounding. Then a song came on – I don’t know what it was – but it was a children’s choir. Somehow the sound of those kids singing, in my half awake, dizzy state, just got me. I lay there sobbing, deeply sobbing. I find myself dazed at how some of us can have so much material security, and how so many have little… or none.