Saturday, November 12, 2010--Choices--David's Story--Our Story

(Doug)
What happens in Haiti, stays....
Our lives are full of choices, some momentous, some minuscule.  Haiti has a way of holding up a mirror and forcing us to examine the choices we make.  The realities here are harsh, The contrasts between those who have and those who have not are stark. There is a great temptation to write Haiti off, to think that the choices that we make, good or bad will make no difference in the life of this country or our lives in the real world.
Yesterday, we took a mobile clinic to Thoman, up in the mountains.  It was gorgeous there.    The weather was cool.  We saw 125 patients in a little more than 4 hours.  It is a really good day.  We feel like we make a difference in a few lives, and the people are very appreciative.  It's our last day of work, and it feels like a good way to end it.
I haven't discussed the work of the surgical team very much this week, mainly because I've been pigeonholed on the medical side, but Dr. Ted Higgins and his crew have been slogging through a demanding schedule.  I'll try to get someone from that team to post on their work.
When we finish with our clinic and in the OR, we all take a while to relax and unwind and celebrate the week, the joy and the sorrow.  In a lot of ways, it's been more relaxed than previous trips for me.  I haven't been called upon to see the volume of patients that I have before.  It has also brought some struggles with our very ill patients.  For the first time in a very long time this week, a patient under my care has died, and 2 in one week is something I have not experienced.
I've spent a lot of time questioning the choices I've made with those patients in particular, but with all my patients as well.  Did I make good decisions? how could I have done things a little better?  Did I do too much, not enough?  People talk about second-guessing like it's a bad thing.  To me, it's just an acknowledgement that I am not fully formed yet, that the clay from which I am molded has not yet hardened.  I am still learning and trying to become better every day.  Meritsky taught me much about malaria.  You can bet that I read all I could about it after he died.
In Thoman, I see a 2 year-old girl who had fever about every other day for two weeks, had lost weight and  would go between shaking chills and sweating.  Given my experience, it's not hard to suspect malaria, and I make a special effort to adapt our adult chloroquine to a form that a 2 year old could take.
Friday night shows  us that Haiti and her medical problems were not finished with us.  While the rest of us relaxed, Sabine was busy with a 27 year old, Eric, who'd been laying in the hospital for 2 days with typhoid and now had some respiratory distress.  There is also a woman who is pregnant, maybe 25 weeks along, who had ruptured  her amniotic fluid, the bag of waters, and  about to deliver.  When I hear that, my ears perk up.  After all, that's what  I do....but I am quickly reminded that  I have no ventilator, no round-the-clock ICU nurses, no surfactant, the medicine that helps premature lungs stay open.  In the US, at a properly equipped hospital, that's a better than even bet for survival.  Then I dismiss that thought.  I can't do a 25 weeker here.  I decide to put it out of my mind.
Sabine is busy.  I come to keep her company, and we discuss Eric.  I make some suggestions.  Technically, he's out of my age range, but he could have been my patient when I started practice. The premature baby has been delivered and not resuscitated.  Another woman, this one at term has come in laboring, her second baby. I try to hang with Sabine for a while, Chantel comes down as well, but I am beat.  I go to bed.
She wakes me up sometime later.  I am sleeping hard, so I am confused and it takes a minute or two for things to start to make sense.
Chantel and Sabine are watching Eric, who is uncomfortable most of the night, but relatively stable, when they hear a splash and a baby cry from the shower.  They scramble in there and the baby is delivering.  The umbilical cord is wrapped around the neck, but they manage to extricate the baby safely and he is fine and healthy.  In the aftermath, the Haitian midwife makes a horrifying discovery--the premature baby, alone now for four hours, is breathing on its own. He's cold and looks terrible, but he's still alive.  Sabine rushes to wake me up.
As I wake into what is in some ways my worst nightmare, my mind is reeling.  I get there, and what I see,confirms my fears.  He is still alive, but he won't be for long.  His fingers and toes are starting to turn black, a sign that bad things have been happening with his oxygen.  I weigh my options.  After examining him, I feel confident that he is about 32 weeks gestation, much older than we had thought.  The possibilities flash through my mind.  I want to do everything.  I want to bring this child back from the edge.  If I was in my home hospital, this wouldn't be a question.  Here, I have to think about the oxygen tank that is being used for the 27 year old, the ventilator that I don't have.  The labs that I can't draw to track electrolytes, the Neonatal Intensive Care Unit where I can't send him.  He is dying.  He will die.  I feel certain that I can delay it, but I can't turn the tide in our favor.  I shake my head.

I can feel the pulse in my temples.  My face is flushed.  My answers become clipped, tight.  My voice is quiet and measured.  Sabine and Chantel know what this means.  I am not the type to scream and throw tantrums.  I'm not exactly sure where my fury is directed the most.  Myself, for not making sure I was there at the delivery, just in case--or for not doing everything I could, or for being so helpless...the delivery team, for setting aside the baby without resuscitation, without calling me to examine him...Haiti, for being so poor and lacking in heath care resources and so difficult to deliver adequate care...at God maybe...how can he allow so much sorrow to be visited on one place?  I feel nauseated.  I have to leave.  I sit on the steps outside the mission building for a long time.

Inside, the parents don't hold the baby.  It's not something I understand, but here, when children die, the parents don't hold them.  He is bathed, Sabine names him David.  Chantel holds him until he takes his last breath.
Our decisions stay with us.  Being a 32 week premature infant is a survivable condition, even in Haiti.  It's not guaranteed, it's not even easy, but it can happen.  This one is on us.  I can't blame God or Haiti.  Just as we can't expect to save everyone here, we also can't use that as an excuse to not try when we can.  There has to be the same standard of care as at home.  The level of care, we can't match here, not yet, maybe not ever, but out decision making cannot be so clouded by despair that we fail to try.  I can't tell you what may have happened had I started with David 4 hours earlier, maybe nothing different, maybe a slightly longer but  more painful life, maybe a life of disability, maybe a healthy life.  I can't tell you what would have happened, but I can tell you I should have been there, and I should have tried.  I owed David that.
I know that this week I have presented three stories of sorrow tempered only by Sabine's story of joy, but I don't want to give anyone the impression that this has not also been a joyful trip. The team members have been fantastic.  as I sit here typing on the roof of the mission, I can hear the children playing soccer in the courtyard, laughing.  The view from here of the lake and the mountains beyond is fantastic.  the people I see, as I have said before, smile when they see us.  They do not hang their heads.  They do not dwell on the sorrow.  Haiti is Sorrow and Joy, Joy and Sorrow..  If I could take away one thing from this week to apply to my life, it would be Chache lajwa.  Look for the joy.
Why are we here?  Because the need is enormous.  Are we able to  address the need right now?   No, but here in Haiti, you build a house brick by brick.  One brick doesn't make the house appreciably bigger or stronger, but little by little, the house gets built.  This week, we've added another brick.  At home, you can add a brick by contributing whatever it is you can...service, money, kind words, prayers...we can use them all.  This week has been as I had both hoped and feared.  Last time was so overwhelming, and I was so bolted down, that I did my job and did not allow myself to live the sorrow and joy.  This time I have.

What happens in Haiti...stays with us.

Chache lajwa.

Doug