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      On Friday we closed clinic just a little bit early then we all piled into the land cruiser- Jay's family, Roseline, Chancela, Amberly, Lacey and her almost 2 year old little girl- Nyanna, and I and we headed down to Port-au-Prince. Luggage tied down on top. I thought our rig fit in very nicely with the other assorted loads we passed on the road. All except for the land cruiser with multiple goats on the top... we were no competition for that! Chancela and Roseline were going to be with their families for the weekend. Lacey was flying home for a few weeks to see her family. Jay's, Amberly and I went to Tin Street Friday afternoon then Jay had booked several nights at a Bed and Breakfast there in Port. We were planning to go to the beach on Saturday,  then I flew home on Sunday and Brianna had an appointment on Monday to get her second COVID vaccine. The bed and breakfast was a very nice place- air conditioned bedrooms, swimming pool, etc... Jay ordered some pizza to be delivered and we all got in the pool. 

     Saturday morning we went to a public beach that is close to the Wahoo Bay resort. From there we got on a small boat and headed out to an island. We have hired this same guy to take us there in the past and the boat ride normally takes an hour. Not today... we didn't realize how windy it was until we headed to the island. Amberly and I and the older girls all were sitting in the front of the boat, this lasted about the first 10 minutes. Then the driver, Fransisco,  wanted us to come inside under the shelter. The waves were good size and splashing into the boat on a regular basis. The plan was to go back a ways keeping close to shore then go out towards the islands and let the current help us get there. I'm going to guess we had been on the water about 15 minutes and there was definitely water in the bottom of the boat. It was hard to tell how deep it was because we weren't holding still. Probably somewhere between 1-3 inches, depending where you were in the boat. Fransisco guided the boat closer to shore, into some "shallow water" so he could turn on the pump to get the water out. I guess it worked the first time, at least partly, but it wouldn't empty completely. So we started off again. After a while the water was re-accumulating so Fransisco rummaged around down by the pump and found a container. It probably was supposed to hold a gallon, but the top had been cut off. He hands it to Jay and asks him to "bail water" out of the boat. So Jay fills it with water then hands it to Fransisco to dump over the side. They had a routine going- my guess is getting 1-2 quarts of water out each time. This went on until we nearly got tangled in a lobster net. While trying to avoid that Fransisco lost hold of the container they were using to bail. We turned around and tried to get it but it was too deep already, we couldn't reach it. We headed back toward the island again, but now Fransisco hands Jay a quart size container- the bottom has been cut out AND it is missing the lid, and wants Jay to continue to bail... I am guessing that now each time he is dumping 1-2 cups of water because it is a small container, plus he has to hold it just right so his hand can cover the place where the lid is supposed to be. By this time I wasn't sure the island and another attempt at snorkeling was worth it. Actually, I had already wondered if this trip was worth it several times. It was definitely the most eventful boat ride I have ever taken. I also was wondering exactly how much gas this guy had, I have been on a boat ride in Haiti before where we ran out of gas. But we kept on.  Slowly but surely the island was getting closer and the shoreline was fading from view. The place where we go snorkeling was on the side of the island that shouldn't have high waves with the direction the wind was blowing so we were still hopeful about that. When we arrived, the water was beautiful. No big waves at all. Amberly and I went snorkeling first while Jay's took the girls to the other side of the island where there was a sandy, shallow place for the girls to play in the water. It took me a long time to be able to breathe with the snorkel but I did it! I wore a life jacket and didn't go out as far as the rest did but I saw some pretty fish, coral, and a couple other creatures I couldn't identify. Also some H.U.G.E. sea urchins! My guess is their spikes were 6-8 inches long. After a while Amberly and I went  and played in the water with the younger girls while Jay, Brianna, and Lydia went snorkeling. Lydia caught on to the whole breathing through the snorkel technique and really enjoyed it this time! The boat ride back to the public beach was totally peaceful, no big waves at all. It is amazing how much difference a little bit of wind makes! The beach wasn't crowded at all so we stayed there a while longer. A man who was there on the beach beside us went out in the water just a little ways and was bringing in starfish. He had 18-20 live starfish in a very short amount of time. They were beautiful! He put them on the rocks there on the beach and we watched them a while. After a while they started slowly moving back towards the water. They are almost creepy looking when they move, using all of their many, many suction cups to inch their way back into the ocean. When we left the guy said he was going to sell them. We ordered Chinese food for supper on the way back to the bed and breakfast.

     Sunday morning we went to church in Blanchard then went to Vol for a quick lunch before I needed to be at the airport. I was looking forward to Haitian rice and beans one more time before I came home but was sadly disappointed.  They had rice and beans, but it was the rice that is fermented. So far I am unable to enjoy rice cooked that way. I got my COVID test done there at the airport and left at 4 pm. I had a layover in Miami then got in to RDU at 10:35 pm. Some of my friends picked me up and I got to my house a little after 12:30. 

     Now the question is... should I go back to help out at the clinic for a few more weeks? Currently there is no one there to take my place. There is a girl who can hopefully go in January but until then- the clinic will have to limit the number of patients they see some days. Jay will probably be able to fill in some days but he won't be able to be there every day. I need to work a few shifts, talk to my boss, etc... to see if I can get something worked out- unless there is another volunteer...

Sunday afternoon surgery... and a sixth sense.

      I was on call this past weekend.  Sunday morning a lady came, in labor with her first child. Everything seemed to be normal except she had an elevated blood pressure. I don't know if it was only because she was in pain or if she really needs a controller blood pressure medication so I just gave her a one time dose of Nifedipine. She was dilated to a six and the baby's heart rate was 136 so I sent her back home with some prenatal vitamins and Tylenol for pain. 

     In the afternoon a 17 year old boy came to the gate with a "blese" (cut) - on his left hand. The fourth finger was totally cut off right at the base of his nail and the fifth finger was almost totally cut off between the knuckles. It was attached by a very small amount of tissue and some skin. The bone was completely cut through. We took him to the clinic to clean it and see if it was something we could fix or if he needed to go down to the hospital. Initially there wasn't a family member with him, just some neighbors. We needed someone to make the decision whether they would take him down to a hospital to find a surgeon to re-attach the finger or what they wanted us to do. The boy's dad was at church but he came to the clinic to meet us. We wanted to explain what options were available. The first option was that we would just put a bandage on his hand and they would take him to the hospital in hopes of getting the little finger re-attached. The second option was we would do what we could here- but that would mean partial amputation of his little finger also- we would not be able to re-attach it. The initial decison was to just do what we could here, and cut off that "piece" of his little finger but that decision was made by the neighbor and the boy's dad over the phone. We wanted to give them a little time to think it over so we used some lidocaine to numb his fingers and cleaned them really well then Jay went to talk with his Dad again. After some discussion, it was determined they would take him down to the hospital in hopes of re-attaching his finger so I worked on putting a bandage on his hand while Jay started to call hospitals to try and find one who would accept him as a patient. The first place he tried was a hospital that uses "Doctors without Borders" but they only accept major trauma and two fingers was not considered a major trauma so they would not accept him. The second hospital he called wouldn't accept him because they do not have a surgeon currently. Whether that meant they truly don't have a surgeon on staff or if they didn't have a surgeon because it was the weekend I don't know. So, plans change again. We do not have an accepting hospital and now Dad is saying "God will heal" his son, they don't have to go down. So we determine to do what we can here. We do have a small tool that is used to cut bone... I can't remember what it is called though. Over the course of the next couple of hours, we trim the bone and close the fourth digit at the knuckle- missing only about one inch of finger and the fifth digit at the knuckle also, but this one is missing over half of his finger, he only has about one inch left. He also gets a dose of IV Ancef, Zofran, and Tramadol. We send him home with 2 different antibiotics and motrin for pain. He came back this morning for his first dressing change. It looks pretty good so far but we are going to try to keep a close eye on it and have asked him to come back every morning for us to look at it and change the dressing.

     This afternoon after the clinic was closed for the day, a lady came to the house in labor. First baby, dilated to 8. Everything seems normal except the Mom's blood pressure is elevated. I was doing a house call when this lady arrived so Roseline and Chancela had checked her. Since it was her first baby it might be several hours yet but I think a sixth sense kicked in here. They decided to have her walk a while then they would check her again. When they checked her the second time, she was ready to push. After she had pushed a short time, I broke her water and soon a little girl was born. She was gasping around and had taken a few breaths and we were using the bulb syringe to help clear her airway. After we cut the cord, they took the baby inside the house and Roseline and I stayed on the porch to deliver the placenta. It only took a few minutes to deliver then Roseline went to get a clean pad for the mom to sit on... and she didn't come back so after a few minutes I went inside too. The baby was not breathing, she had taken a few gasping breaths but was totally limp and very pale and her heart rate was maybe 20 when Jay listened to her with the stethoscope. We were trying everything we could think of to try and help this baby breath. We had gotten a lot of mucous from her nose and mouth with the bulb syringe but she still was not coming around. We had held her by her feet and slapped her on the back, etc... S.L.O.W.L.Y... she was coming around. Her heart rate was maybe in the 60's and we were still getting mucous out periodically with the bulb syringe. But she was starting to pink up a little. We decided we really needed to get her to the clinic, now! At the clinic we have a suction machine, oxygen, and a bag valve mask. We did not have these options at the house. So, I take the baby- still wrapped only in two towels, grab the bulb syringe and head for the vehicle.  Jay runs inside to get the keys. Of course the gate is closed and locked and I head toward it but Brianna is already on her way with the keys in her hand so I turn around and get in the machin. The baby is doing better but still not breathing normally. She is trying to cry though. And, guess what... the machine will not start! The battery is dead. This lady came on a moto and it is right outside the gate. The driver is here somewhere. It is decided that the driver will take the baby and I to the clinic because his moto is right here and Jay will bring another moto. May I add here that it has been raining every day for over a week and the road is very muddy, and slick... Thank the Lord this moto driver seemed to know what he was doing. He drove safely but as fast as he could. I was very thankful because I was holding the baby in one arm and could not hold on with my other hand the whole time. I definitely was holding on with my legs though!😅 Monday is market day in Oriani and to get to the clinic we need to go right through the market. The driver laid on his horn and honked the whole way through market. When we got to the clinic I gave the moto driver my keys to unlock the gate then hurried inside with the baby. The "delivery" cart is kept in the pharmacy so I went to get it first thing and hauled it and the baby into my exam room. I plugged in the suction machine and had part of the tubing to perform deep suction but was missing one piece. By now I am not as worried about the baby, she is crying but still has a lot of secretions. Jay gets there then and gets the suction set up and we deep suction her several times, still getting a lot of mucous out. I checked her heart rate after suctioning her. It is 160. Much better! She is pink now too. Jay had brought the mother on his moto so we get her in the room now also. She had been waiting outside. We monitor them both for a short time and try to get the baby to breastfeed. She doesn't do too well with that yet. We sent them home probably 20-30 minutes later- after discussing that in the U.S. the events of the last hour would surely warrant at least an overnight NICU stay. I firmly believe if we had sent that lady home to have her baby the baby would not be alive... Thank-you Jesus!

     

SVT

      Yesterday it looked like we would finish seeing patients at about noon. It was a little before 12:00 and we only had a few patients left. One of my patients was a little baby, about 1 month old. I took her temperature, then put the pulse ox probe on her foot to check her heart rate and oxygen saturation. Her oxygen was good but her heart rate was elevated. The monitor said her heart rate was 266 so I listened with the stethoscope to verify. Yes, her heart rate was greater than 260. We have an old monitor so I verified again, yes, the baby was in SVT. So, how do I treat this here? The first thing we try at home when a baby comes in with SVT is to apply ice to the face. It looks scary because you literally put a bag of ice over the baby's mouth and nose and hold it there for 15- 30 seconds. It is supposed to make them do the vagal maneuver which often makes their heart rate go back to normal. I wasn't sure if we even had ice at the clinic. We do have a small refrigerator/ freezer unit where we keep the vaccines and yes, there was some ice. Someone had filled an empty Tylenol bottle with water and frozen it so there was some ice available, I just had to figure out a way to crush it. Throwing the bottle down on the cement floor only broke the lid, it didn't crush the ice so I went on the hunt for some kind of a tool I could use. I found a wrench out in the depot that I thought would work. It did! It worked very well. The tylenol bottle was made from thick enough plastic that it didn't shatter when I hit it but it did crush the ice. I put the crushed ice in a bag then explained to the family what I was doing to try to help their baby. The first time I applied it to her face I only put it over her mouth and nose and obviously didn't hold it there long enough because nothing happened. So I tried it again, this time covering her whole face and holding it in place a little longer. This time it partially worked. Her heart rate came down to 190- 200. Still high but not as high. She was fussy and I didn't know how much her heart rate was elevated because of that so I gave her to her mom and told her to breastfeed her to see if that would calm her down. She breastfed but it wasn't even 5 minutes later and she was puking it all up. By now her heart rate was back up to 250- 270. I had been in contact with Jay and he wasn't at the clinic yet but was coming. While I was attempting the ice to the face maneuver he had been researching to see if there were other options of things we could try. I tried the ice twice more, keeping it in place 20 seconds each time (by the way, 20 seconds seems like a very long time when you are occluding a baby's airway!) Each time her heart rate would come down when the ice was on her face but as soon as I removed it she jumped right back up to 250. Jay suggested using a rectal thermometer to try to stimulate the baby to bear down. This also is supposed to stimulate the vagal maneuver.  We did not have a rectal thermometer but I  used a q-tip with some lubricating jelly on it. It worked the same way, when I removed the q-tip her heart rate went right back up to 250. By this time Jay had gotten to the clinic and we concluded there wasn't anything else we could do at the clinic for the baby. She needed to go to the hospital for more testing and medications.  We told the family that they needed to take the baby down that evening.  They could not wait until the next day. I think they understood the urgency but said they needed to go home and get some clothes first. So that was the first patient I sent down yesterday.

     The second patient I will write about was on a moto that pulled up to the clinic shortly before the baby and her family left. It was a lady in labor. This was her 8th pregnancy so we thought it should be fairly straight forward. That's what we get for thinking... I checked this lady and it seemed like she was ready to have that baby, whenever she wanted to push. She was having pretty regular contractions but said she did not have to push yet. We waited around a while, I restocked the pharmacy, etc... she still said she did not have to push. Suddenly she was hungry... I thought surely after some food she would have "strength" and be ready to get this over with. No, she still did not have to push. We got her up to walk but that idea turned out to be fairly short lived. We tried to convince her that the baby was right there, couldn't she just push? Yes, she agreed, but did absolutely no pushing, at all. Finally, we decided to put in an IV and start some Pitocin. That takes a while though because it has to be titrated up slowly. It seemed she was having contractions but was trying her hardest not to push, rather she was putting all her efforts into doing some kind of maneuvers with her mouth during each contraction. She definitely was not acting like she had ever done anything like this  before. We kept trying to encourage her, her family kept trying to encourage her, but we were not getting anywhere. I was beginning to wonder if there was a reason she did not want to have this baby. Finally Jay told the family members that were there at the bedside to go get the dad, he was apparently outside. Shortly after he came in the room either the mom decided it was time to push or else she could no longer fight against the contractions. In a few minutes a little boy was born. He was a very cute little guy, weighing in at 2.75 kg. I got him dressed and gave him to a family member while we waited for the placenta to be delivered. Nothing happened...nothing at all. We tried pulling gently but the placenta was very firmly attached and not letting loose. It had been thirty minutes and still no progress. Finally we decided one of us would have to try and manually help with the removal. I gloved up and followed the cord up to... I don't know what. It felt like her cervix was totally closed. I was getting no where and was causing the lady a lot of pain so I stopped. We tried to research what might be causing this problem.  She was continuing to bleed some off and on. Finally we decided that she would need to go down to the hospital also. She needed more care than we were able to provide at the clinic. The patient still had her IV in so we gave her some IVF's and a dose of medication that is supposed to reduce bleeding. Meanwhile Jay was calling hospitals to see if they would accept her and also calling the ambulance driver and getting him and the ambulance on the way to the clinic. He found a hospital that accepted her so when the ambulance arrived we loaded her onto the stretcher and sent them down. Jay got the dad's phone number so he could call and see how everything worked out but so far we haven't heard back from them. So, I put in a long day and sent two patients down to the hospital. We got home a little after 7 in the evening. 

     We start each day at the clinic with a prayer. This is a good time to look over the crowd to see if there is anyone who looks particularly ill and might need to be at the front of the line of patients to be seen. This morning I noticed an older man who was shaking off and on, almost like as if he had chills. He was very thin and looked sickly but not deathly ill and he was in the front row so I didn't call him in early. He came into my exam room about 45 minutes after we started. His blood pressure was okay, no fever, but his oxygen sats were 62% on room air and his heart rate was 130. Practically no lung sounds. I asked Jay to come help me decide how to treat this patient. His complaint was that he had a "fever" and he hadn't been able to eat for about 2 weeks. I did the rapid tests we have for HIV and syphilis and Jay did a rapid COVID test then we put him on 5 liters of oxygen. That only brought his oxygen sats up to the mid to upper 80's. His rapid HIV test was positive and so was his rapid COVID.  Now what? We decided to send him to the "ti kay" for a couple hours while we tried to figure out the best plan for him and while we saw the rest of the patients who were waiting. We finished seeing the clinic patients by lunch time. The sick man in "ti kay" had oxygen sats of 87% on 5 liters. His family had went home to get clothes so they would be ready to go when we found a hospital to accept him as a patient. It was rather odd, the first phone call Jay made they accepted him. Didn't care about his age, etc... just said to bring him. So Jay loaded him up in the ambulance and headed down the mountain. He is still in Port, he has been waiting for hours to get diesel. The are supposed to start pumping soon but who knows? He is first in line though... so to leave now probably wouldn't be the smartest move.