September 2013 Update

“I’ve unloaded a lot of my life here this week”- a quote from one of the members of our September 2013 mission team

The goals of the September IWISH mission trip were to inventory the items that have been shipped over the past two years to our colleagues in Haiti and, if possible, to render them functional before returning home. Equally important to the success of this trip was the training and equipping of our Haitian colleagues with colposcopic and LEEP equipment for the detection and prevention of cervical cancer.  In addition to our medical care providers, for this trip we brought with us Tom Parnin, a biomedical technician from Detroit, willing to work his butt off on all the equipment that had been shipped and brought into Haiti by IWISH.  We also asked him to evaluate the equipment piled up in the halls and storage units of the medical facilities (some of which has been sitting there for well over 20 years), for potential resurrection. The idea was to throw out any clutter that wasn’t deemed resurrectable.  Clutter is something that accumulates in Haiti, paralyzing the whole country, like someone with a hoarding mental illness.  We have a theory that the long standing abject poverty in Haiti has led to a sense that nothing should ever be discarded, even if the process of “piling something up” renders the asset useless.

Trips in which we are blessed by the presence of Jackie Horning begin with a “thought for the day”.  With our team united in Atlanta the night before our anticipated flight into Port Au Prince, Jackie shared the loss of her dear friend, Pete, who was the inspiration for these thoughts for our start.

We flew into Port Au Prince airport on Saturday afternoon.   The new airport facilities are impressive, actually looking like a bona fide international airport. Within an hour of arrival, Mr. Parnin and I joined Dr. Honore at the office he shares with Dr.Hosty, a friend who is a Urologist. The rest of the team went to the guesthouse to get settled in and organize the equipment we brought with us for the rest of the trip.

We reevaluated and performed maintenance on the equipment that he has acquired from me over the years. Those of you who have followed with us over the years will recall that Dr Honore was trapped for two days in the rubble of his collapsed office during the earthquake in 2010,  with the first donated portable ultrasound machine (Sonosite #1). Fortunately the Sonosite #1 and Dr Honore survived, but sadly that office and its surroundings are no longer in existence.   It was exciting to see that they actually continue to use Sonosite #1 in the office, where Dr. Hosty also uses it for prostate evaluation. A larger printer-capable ultrasound with vaginal and abdominal probes was also functional.

This first project took place in the evening.  Because electricity in Haiti is limited, isolated lights somewhat surreally illuminated everything here and there. Thus the quality of the images is suboptimal.  We had Dr Honore, Dr Hosty, Emanuel (our translator), Arisme (the Haitian biomedical technologist learning from Tom), Tom and I all squished into a small office shared by two physicians, their medical equipment and all the boxes that had been shipped to them over the past 18 months or so.  Tom’s first project was to service the two colposcopes in the office because IWISH Foundation had sent Dr Honore and Dr Hosty to colposcopy training last year in Maryland, so we wanted them each to be able to teach the medical students and residents the techniques they had learned. Next were the two fetal dopplers, one of which had been broken a bit in transit.  Once fixed, one of them was given to Dr.Anglade, the obstetrician who trained in Saginaw for three weeks after completion of her residency.

The video colposcope was a little more challenging for Tom to assemble, but was well worth the time spent!   Dr Hosty was imagining using the video scope to do prostatic biopsies.  I felt like I was watching two brothers getting their dream toy on Christmas, energized by the anticipation of playing with it together!

With the video colposcope functional, we moved onto the LEEP machine with smoke evacuator.  Again there were challenges for Tom but, with his work completed, he said he “thought it would work” but couldn’t test it without flesh to cut.  Being the only one in possession of a cervix, I considered volunteering for a split second, but then Arisme arrived with a hot dog!   Perfect!   It was great seeing Dr. Honore operating on the hot dog and then Dr. Hosty excited about the results of the smoke evacuator.

Arisme (the biomedical technician) and Tom did well together, despite the language barrier.  Tom learned “no”  “petit” and “Bon jou”, but he is really good at “no”. Emmanuel (the translator) actually learned a lot as well.  He is a mechanic; engaging, hard working and “a quick study”.   We later found out that Emanuel will be completing law school in May 2014.

When we finally got back to the guesthouse, everything was already quiet for the evening.  I noted that the guesthouse dog was sleeping under my cot when I arrived in my room.  By morning he was actually sleeping on one of the cots next to me and most of my team were peppered with fleabites.  The guest house care taker later shared with members of the team that the dogs shouldn’t be in the house because they are afflicted with fleas and ticks.    Yep!

We figured that out!

Sunday, after reviewing the breadth of work yet to be completed, instead of attending church, the whole team descended on Port Au Prince General Hospital, inventorying the equipment that actually made it from Covenant through customs, to the hospital, currently being used at the maternity unit. Babies in warmers and women in birthing beds, the new neonatal unit….. It was all amazing!

We then rounded the bend into the high-risk antenatal room where there were women afflicted with sepsis and preeclampsia.   Despite my concern about the women, I actually broke out into a bit of a laugh when I saw the second Sonosite machine (which had been rescued from the hospital during the quake by the then chief resident) chained to the wall with a Prison-size linked chain, the likes of which I haven’t seen except in the movies:)!!! It was crazy!!

Niki Krupp (our photographer) went to take a picture of a healthy, gorgeous newborn baby in the neonatal warmer donated by Covenant.  She then turned her camera to find two babies dead on the floor.   One was “five kilos” and “it’s dead” according to the OB resident that Niki stared down because of the atrocity she was witnessing.  I wasn’t with her at that time so she came to me in tears explaining the egregious situation she had witnessed. I spoke with Dr Batch (one of the amazing attending physicians on teaching staff at PAP General) regarding what was going on. He took Niki and Heidi Richards (our trauma nurse practitioner), with some sheets that we had donated, and let them swaddle the babies.  He translated for Niki as she showed the swaddled babies to the residents and said indignantly, “This is a human life, and it deserves to be treated like this, with dignity.  NEVER put a newborn baby on the floor.  Alive or dead.” And then he proceeded to use it as a teaching moment explaining emphatically what he learned while he was doing training in Virginia about grief preparation and support for mothers.

It was great being able to watch the Haitian physicians teach the Haitian residents what we perceived were subtle but important aspects of medical care.  Most importantly, it was important for my team to help these doctors-in-training to realize that although we realized that as Haitians they are constantly inundated with the darkness of death and dying; as physicians, they have the power to dignify lives despite death.  For some of my team, this was an introduction to the reality of life and death in Haiti.  It was harsh and in their face, but again… this is their reality and that is why we are there… to give them hope that we can change that reality.

The team witnessed the delivery of a woman on the floor in the lobby of the hospital.  She happened to be a prisoner who had been arrested for kidnapping and hadn’t been taken to the hospital until she was in advanced labor. Tom had just fixed one of the OB beds, so we grabbed some of the sheets and put the mother and her baby lovingly, non-judgmentally on the bed in front of physicians, nurses and patients.

After a long day at PAP General, we had a wonderful visit with Dr. Anglade and her family at the guesthouse. Monday we flew to the island of LaGonave where we spent three days seeing women in Ob and Gyn clinics, fitting in surgeries between office.

The first day we were there, I was leisurely walking to clinic when I was urgently diverted to the room usually used by the ob residents for clinic triage.  Just prior to my arrival at the clinic, a woman had been brought on a motorcycle by her family from the mountains,  with the history that she had given birth to a baby boy at 2 am, six hours earlier.  The umbilical cord, which was tied off with a ragged piece of cloth, was hanging between her legs. The lay midwife became concerned when the placenta hadn’t delivered after several hours.  Miss Vero, our head nurse, was with her and asked for my assistance with evaluation of what was going on.

Although we probably would have figured it out eventually, the ultrasound made the diagnosis quickly and easily.  There she was…. The second twin…. in perfect position, wondering what the heck had happened to her brother:). Instead of delivering the placenta, we transported the woman to the delivery area and brought the stubborn baby girl into the world kicking and screaming (thank God).  We sent the motorcyclist back up the mountain to get the first twin (a baby boy) and bring him back down to the mother. The fact that it was over 100 degrees out probably contributed to the fact that he arrived in relatively good health despite the bumpy two hour ride in the open air, without food or water for well over ten hours!!  Great genetic pool! Haitians truly are bred to survive the ultimate adversities, right from birth!

Gynecologically, this was a crazy trip because I had many women on LaGonave presenting to see me because they had “fibroids” diagnosed by ultrasound in Port Au Prince and they were worried, requesting hysterectomies. One patient had a beautiful uterus but had a huge dermoid cyst on her left ovary and a large multi cystic right ovary. She was in pain, so I was able to give her the good news that her uterus was normal, but had to tell her that she DID still need surgery for the ovarian pathology that we saw. Because she was in so much pain, we were going to take her to surgery either way, but because women with fibroids don’t usually present with acute pain, it was reassuring to know what we were getting ourselves into before we took her to surgery and we were able to prepare her more appropriately (with the help of our translators and Ms. Vero).

Another 38 year old woman had been bleeding for eleven months.  She seemed to have a uterus the size of a five month pregnancy but when I did the ultrasound I realized that the uterus itself was nice and small but she had a very large fibroid (which measured nine cm in smallest diameter) trying to deliver from the inside of the uterus out through the vagina, like a baby.   In fact when I did her pelvic exam it felt like a baby’s head getting ready to deliver.  Poor woman!!! Dr. Honore and I were able to “deliver” the fibroid through her vagina by cutting it up into pieces to the size of a small baby with the LEEP cautery equipment.   She ended up going home without the bulge in her belly or the bleeding…. And no incision on her belly!

Dr Honore had taken Tuesday and Wednesday off of his busy schedule to work with us on Lagonave.

Thursday morning we had our grand tour of the new hospital built by Haitians,  supported by Lemon-Aid, a philanthropic organization out of Scotland. It is magnificent, with beautiful wood carved doors and tile flooring all with an Eco-friendly design that makes air conditioning virtually unnecessary. The new courtyard is smack-dab in the location where we shoveled and wheel barreled out rocks at the base of the foundation at noon with the hot Haitian sun beating down on us during our last trip.  So much progress has been made in such a small amount of time!

Our birthing beds and isolette are ready to go after the grand opening whenever the rest of the hospital equipment gets through customs.  Bobby and the lab, having received the posters illustrating organisms that cause human morbidity and mortality, are ready for the transition as well.

After the early morning hospital tour, Thursday we flew back to have a colposcopy clinic for all the OBGYN residents at Port Au Prince General.  We went to Dr. Honore’s office to pick up the video colposcope and LEEP machines, which we carefully transported to PAP General. I used this opportunity to teach them transvaginal ultrasound evaluation of ovaries for infertility evaluation and treatment.

I just loved the fact that we could fit the colposcope, the LEEP machine with its smoke evacuator, five OBGYN residents, two attending physicians, the examination table, the patient and my Sonosite ultrasound machine in a four by six foot room!  Seeing their response to visualizing the dynamic process of ovulation by ultrasound was truly amazing! Seeing two cancer patients and LEEP-ing off the abnormal cells on a young woman with precancerous changes was a good experience for the residents but not as “amazing” as the ultrasound teaching/learning.

Thursday night, we dropped the video equipment at Dr. Honore’s office and talked about the trip to Jeremie.  We still didn’t know how we would get home from Jeremie, but we had covered our bases:  Either a six hour road tour starting at five am or by plane, the itinerary of which was uncertain, perhaps making us miss our plane out of PAP.

Friday we had a beautiful flight to Jeremie, one of the largest cities on the southwestern tip of Haiti’s mainland.  Papaya the size of a baby, were sold for five dollars.  Avocados the size of softballs were eaten like apples!

Jeremie is  like Hawaii without the commercialization We had originally been scheduled to teach the OB and Family Practice residents colposcopic techniques but there were mostly gynecology patients with routine problems. It was actually an awesome opportunity to just go over how to work up patients with various gynecologic complaints. One of the women was an overweight post-menopausal woman who came in with bleeding. I was worried about endometrial cancer because of her obesity, especially when I saw that the endometrial stripe was increased when we looked at it with the ultrasound.   What was awesome was the fact that when I put the color flow on,  there was no increased flow (which would be uncommon for someone with cancer)!!  So ….I had the residents practice visualizing the endometrium and putting the Doppler flow on to evaluate the thickened endometrium, then I asked the attending physician if it was alright to take some extra time for further evaluation.   Heidi just happened to walk in when I needed an extra set of hands and assisted me with a sonohysterogram.  Right there in the middle of no-where in Haiti, we could see a beautiful broad based polyp with color doppler, sonohysterography and were able to freeze the picture on the ultrasound so that the residents and attendings could see its significance!!  Awesome!

Instead of sending the patient around the country to PAP for cancer treatment, they signed her up for a little D and C in their own operating room!

In Jeremie, Tom worked for the whole day trying to fix the autoclave and instrument washers we had shipped earlier in the year from Covenant. The autoclave had been dropped a couple of times enroute from PAP to Jeremie but they were able to assess that it looked like it could work with the right resources!  Limited local energy support was available but now he knows what they need and vows to make it work with what they have:)

Saturday morning, we ended up flying to PAP airport to catch our flight home. So, in total during this trip, we visited four hospitals in 8 days with three separate training sessions for colposcopy and LEEP equipment as well as the various OB and GYN surgical equipment.  The process seems to be never ending, but at least we planted the seed, with the next trip planned for February/March