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Monday, November 14, 2011

Tuesday, November 8, 2011 Fond Parisien/Gonaive--No Guardrails

Doug
Gonaive is a little village to the northwest of Port au Prince, a two and a half hour drive. I have not been here since my first trip to Haiti, October 2009, prior to the earthquake. Memories tug at me as we drive to the village of Saint Marc and drive on further up. I remember a poor village, where many children were malnourished . I remember being relieved when I saw Gonaive has a school. A school means schoolchildren get to eat. This village has not been visited by a mission team since our last time here.
We arrive. It is a forgotten village, a poor village, and I hope things are not too desperate here. Living in this village is like careening down a twisty mountain road, mere inches from going over the edge, and there is nothing to stop the fall, no guardrail.

Guesly
Erika returns with her assessment: The patient’s cervix is 7 to 8 cm dilated and almost completely thinned out. This is her third pregnancy. I look around me in this dark cinder block church with primitive wiring for electricity powered by a generator. The roof is corrugated aluminum sheet held with sparse wooden trusses The church is dim with light creeping in from a few well crafted fenestrated cinder blocks. The floor is a mixture of dirt and large sharp rocks which remind me where I am with every step. I think we might have to deliver her here. I make my way to an unfinished alcove behind the altar. It is the only area that is semi-private.. As I enter the room, I see a women in her late 20’s to early 30’s lying on a oversize trash bag which covers most of her trunk on the unforgiving rock. Her feet and sandals are darkened to the color of the dirt; her dress is pulled up over her belly. She moans with each contraction. It has been almost five years since I finished residency , I know delivering children is far beyond the scope of medicine I want to practice. Haiti does not care about my preferences and brings unexpected and inconvenient challenges with each mission trip. This is Erika’s second trip to Haiti and already she knows to expect the unexpected. But it is not so much the unexpected that is the problem. The problem is that there is no system equipped to handle the unexpected. If we, the intermittent and temporary mission teams, are the best response, then the system is broken. To change the high morality and morbidity of newborns and their mothers, the whole system must be fixed.

“Dokte, dokte- nou gen yon maman ke vini avek yon tibebe ke mouri nan vant li!”* I am sitting in the dining room playing a game called Qurko with my sister Sabine and Ouyse, a family resident from Kansas City, when I hear the call of one of the translators. I spring to my feet, and grab Cory Miller, an OB-gyn resident from Columbia Missouri. We rush downstairs to find a women in the operating room, lying on the surgical table. At first glance, I can tell something is not right, something beyond the moans with every contraction.. Her appearance is off. Her face was swollen like someone suffering an allergic reaction, but I know that is not the case. The swelling is also encompassing her arms and legs. She is lethargic and remains still until a contraction stirs her to thrash and moan again. I asked her name and age. In Creole, she tells me she is 19 years old and 8 months pregnant. She continues to answer questions in a soft, anguished voice as I translate for Cory who does not speak Creole. We both notice her husband is not present in the room but waits outside in the lobby area. She explains that she lives in the mountains past a place called Fond Varette. As she speaks, I start to understand how difficult her journey has been. Fond Varette is a mountain where we often hold mobile clinics. The terrain to the small village is very unforgiving and painful. It has no mercy for people or vehicles. The road is very dusty because it runs along a dry riverbed. It has ruts due to erosion from repeated heavy rainfall and haphazard road construction. The drive itself is a slow climb on a road built to handle one vehicle but often carries three to four lanes of traffic. When I ride on it, I always hope I am on the vehicle closest to the mountain, not the vehicle on the outside where the edge falls off to a several thousand foot drop. No guardrail will arrest the fall. Traveling that road in the middle of the night in the back of a tap-tap is terrifying to imagine, even for someone who is not eight months pregnant. As I think this, she tells us her story.
On Friday, the mother developed a fever and noticed ther baby was not moving. The next day, she developed sudden abdominal pain,causing her to double over, and she began bleeding from her vagina. Her husband urged her to go to the hospital. This is their first baby; they just married a year ago. They went to see a local midwife, but she refused to see the mother. They waited. By Monday, the pain and contractions are unbearable. They make the harrowing trip down the mountain.
After Cory and I both assess her it was clear there is no fetal heart beat. Her unborn child will not have a chance to fight for his or her life. Our minds turn to treating her current potentially fatal medical condition. She arrives with severely elevated blood pressure and swelling. She had a condition called preeclampsia, and if it is not treated she could rapidly develop eclampsia which could endanger her life. Preeclampsia is a hypertensive syndrome that occurs in pregnant women after 20 weeks gestation consisting of new onset, persistent elevated blood pressure. Eclampsia is the progression of the disease process with initiation of seizure. I defer to Cory’s expertise concerning the treatment and management of this condition. My concern is whether an emergency c-section will be needed to remove the dead baby in her belly. Cory and I decide to awaken the surgical crew and Dr. Higgins, the general surgeon who practices in Kansas City. Dr. Cory and Dr. Higgins perform the surgery. Once the baby is delivered, it is clear he has not been alive for some time. Around the placenta is old clotted blood. The placenta has separated prematurely from the uterus, a condition called placental abruption. This condition is rapidly lethal for the baby and very dangerous for the mother. Her condition is not uncommon, and if recognized and treated, the risk to mother and baby can be minimized. That requires good pre-natal care which the patient failed to get because of location she lives, the scarcity of physicians, the lack of education, and a health system that only provides care to those who could afford to pay. Since eighty percent of Haitians are poor, all those pieces rarely fall into place, and this outcome is all too common.

Doug
We name the baby Esau. It was clear from the moment he is handed to me his earthly journey was over before his mother ever came down from the mountain. He is tiny, less than 5 pounds. He is limp. He has lividity in his skin, the blood pooling due to gravity after death. I listen to his heart, and this formality confirms what I already know. I wonder if he could have been saved in the US. I don’t know. I certainly have seen babies stillborn at my hospital. But the survival rate of a child living until the age of two is fifty times worse in Haiti than the US. Mothers are 100 times more likely to die in childbirth.
We pray over Esau, welcoming him into this world, and wishing him well on his journey out of it. That night he is buried next to David.

Guesly
We cannot have the baby here. I think this as I look around the rural Haitian church. There are no sterile instruments, only dental floss to tie off the umbilical cord. My mind drifts back to only eight hours ago when we had to tell a 19 year old mother that not only was her baby dead, but we had to have an emergency operation. We cannot deliver here. Doug, our pediatrician, concurs with this. I realize the pain of delivery would be far from the only pain she would suffer with no comfortable place for her to lay, increased risk for infection, and the possibility of unforeseen complications which could even lead to death of her unborn baby. I think if we were closer, I would take her to Fond Parisian where we have trained staff and emergency equipment. Even in Haiti, we can have a situation where the likelihood of survival can be improved, but we are several hours from the hospital, None of us did think she would make it. I can imagine her delivering driving eighty miles per hour in a street packed with cars, motorbikes, bicycles, and pedestrians. Fortunately, we are told of a location five minutes drive away with a trained midwife. clinic. Without a second thought I tell Erica to get the mother, and she and Sabine drive her to that clinic.
Haiti must change in this modern age. It cannot continue to operate in a fashion that does not respect or treasure human life.

Doug
Gonaive is better than I had hoped. We have a long, but good day. There are two or three very ill people, and we do what we can for them. In general, these people are managing. As Guesly says, it is hard to appreciate that Haiti, as a governmental system, is living up to its role as protector of the people, to provide that safety for those weak, in danger, and at risk. It is indeed hard to see where there is enough value given to human life. For now, though, this forgotten village is continuing on its road, on the edge, without a guardrail.



*"We have a mother that came with a baby that died in the womb"

1 comment:

  1. "Haiti does not care about my preferences and brings unexpected and inconvenient challenges with each mission trip." Beautifully said Guesly.

    ReplyDelete