Petaluma doctor reports from Haiti

Dr. Julie Clark, an obstetrician/gynecologist based at the Petaluma Health Center, is on a two-week volunteer medical mission in Port-a-Prince, Haiti. The impoverished nation is still trying to recover from a devastating earthquake on Jan. 12. Clark will be sending reports during her two weeks in Haiti that will be posted on Petaluma360.com. Her updates will appear starting with the most recent post.

July 14

This will be my last entry from Port-au-Prince and it is bitter, bittersweet.

I went with Rischu to one of the refugee camps today. He's a med student who works with a German team of nurses, pharmacists and doctors. These are the healthworkers on the ground, literally, providing care to people in dire need from a makeshift tent. The dust is everywhere and it contaminates everything.

Treating diarrhea is not sexy. It is grueling but lifesaving work. Providing basic prenatal care isn't sexy either. You won't read about it in the NY Times. Problems like diarrhea, malnutrition, and lack of prenatal care require a basic infrastructure. Too often here, there is none. Tents and tarps were simply handed out. There is no consistent order in most of these refugee camps.

There is a government here; I'm told it has received millions in aid. But in my limited time here I can't find many concrete examples of anything the local government has

accomplished. As I have written before, the rubble makes many streets impassable. Earthquake-damaged buildings teter in mounds of debris, having become de facto graveyards.

Tents are a better option than crumbling concrete. But there's no regular sewage collection in most places and no one comes to empty the tent city latrines. The port-a-johns are foul and overflowing, a fertile breeding ground for every bad disease you can imagine.

Dust coats everything. So many people living in these tent cities have some kind of festering, infected wound. With such poor nutrition and dismal hygiene even the smallest cut can become a nightmare requiring debridement and rigorous treatment using combinations of neosporin, topical antibiotics, gentian violet, hydrogen peroxide, even calamine lotion.

My friend, Rischu, was in medical school when the earthquake struck. He's smart, funny and self-possessed. His med school was destroyed in the earthquake; many in his school perished. Rischu has certainly gained enormous first-hand experience in the past six months. He hopes to finish school and study cardiology. Haiti will be lucky to have him practice. His patients are lucky now.

It is my heartfelt conviction that Haiti should not exist.

But as I stand here on the hospital rooftop hoping to momentarily escape the heat between deliveries, I breathe in Haitian air. The cries of Haitian children fill this night air. A tap-tap truck toots his horn at the intersection. Haiti exists, all right. It is very real.

But have I told you that this Haiti I see is full of heroes?

The local doctors and nurses and teachers who refuse to give up. The nuns from the South Bronx who smuggled in money and built a house. The expats from Salinas who came back to teach and distribute food. The Italians who cuddle and sing to the orphans. The Germans who treat malaria and diarrhea out of dusty tents. The Kenyans who have begun to count and name people living in the refugee camps.

In the year 2010, just 90 minutes from Miami this Haiti is real.

This Haiti and these Haitians need our help. Take a moment and ask yourself: What can you do? What will you do?

I'm planning on going back. And I'm going to talk my friends into going. I'm also planning on organizing direct help for St Damiens Hospital and some of their programs. In a few days, I'll post a website for those of you who'd like to help.

Please allow me to thank the editors at the Argus Courier who graciously allowed me to post this blog, and Rick and Susan who first suggested it.

July 13

Yesterday. Today. Any day I've gone outside the hospital.

I see naked children sitting in dirt.

Little Annabelle is a success story. When an aidworker brought her to St Damiens, this 12 month old weighed less than 10 pounds. Her mother died in the earthquake and no one fed her afterwards. Doctors here didn't think she would make it. But now, after a few months and a lot of special attention, Annabelle is up, moving and responding. She has nearly doubled her weight. Little Annabelle is a survivor.

St Damien's malnutrition program sees about 400 children, most on a weekly outpatient basis. They measure growth, weight, and arm circumference. They dispense Plumpynut — it's a peanut butter substance fortified with extra vitamins.

There are so many other children still on the borderline here. You see their listless, disaffected faces. Many of these children have temporal wasting. It's what you see when the starvation is so bad that the body catabolizes normal tissue and the skull bones poke out. It's dreadful.

Mind you, this is not ALL of Haiti. There are nice sections with expensive restaurants, traffic lights and police checkpoints. But I wouldn't say the majority of people in Port-au-Prince live in the upscale sections. And no matter where you travel, there are refugee tents where people who lost everything in the earthquake live.

Most of the hospital workers live in such tents. They shower at work. Makes me think twice about complaining that there's no water again today and I haven't had a real shower in some time.

Too many people have asked me to adopt one of their children.

July 12, 2010

Today, there was no electricity because there was no gas delivery to power the generator. And again, no water. We are relying on AA batteries and handheld devices to monitor babies. If these run out, we'll use our stethescopes.

I'm living in a world of chronic shortages and intermittent outages. But Haitians have a make-do/can-do attitude that is inspiring.

One of the surgeons was telling me how he autotransfused a severely anemic patient. He put the blood she'd lost through a makeshift filter and gave it back to her in her IV line. It was her only hope as there wasn't any blood transfusion available. She did well.

I've realized how much I take for granted in the States. In the OR here in Haiti, for example, oxygen is severely limited to must-use situations. It certainly isn't protocol for patients undergoing spinal anesthesia and surgery. Even a new suture pack (about $7) isn't wantonly opened until absolutely necessary.

Nothing is wasted here. And I mean, nothing. Those scrub towels we so casually throw out in the States are carefully hand-laundered, then sterilized for reuse.

It makes me think /rethink so many things.

I'm particularly impressed by the Maternity plans. Set up just over 2 months ago, it is already becoming the respected referral center that Port-au-Prince needs.

Its mission is lofty; its goals concrete and doable. One goal: to reduce maternal mortality. Right now, the figure quoted is 630 maternal deaths per 100,000 births in Haiti. Compare this to 10 maternal deaths per 100,000 births in the US.

There is hard work to be done, to be sure. But I have met many Haitian doctors and nurses who have committed themselves to rebuilding their country.

I think they deserve our help.

July 11

The days are so hot here when the air doesn't move. Today the water is out but we're hopeful it will soon be fixed. The hospital has its own well, I'm told.

Big excitement today with the World Cup final. Everyone with a radio tuned in. About 5 of us huddled round to hear the game. Viva Espana! It's always interesting to hear different musical tastes. On the local radios here I seem to hear a lot of mournful Creole songs with just a hint of club beat. Celine Dion is also a big favorite, especially the Titanic theme. (Really, I'm not exaggerating.)

A special thank you to my niece who donated her manual breast pump. It is being put to very good use here. Breastfed infants have that much more reserve to protect them from the local viruses. Pediatricians tell me they don't see the severe malnutrition set in until after mothers stop breastfeeding.

The water did get fixed finally. Am glad for the hand moisturizers I've brought. Am doubly glad for the shower.

July 10

A clean wind blows today. I see now the geography I've read on maps. The city of Port-au-Prince is ringed by mountains. They look pretty and green.

Let me walk you through a recent obstetric case. I saw a young pregnant patient with a fever at Port Jeremie for her first prenatal visit. Nadeye is 18 and it turns out she broke her water days before but didn't really know what to make of it. I brought her back to St Damiens in the tap-tap truck. Nadeye can't read or write — she signed a mark that she understood and agreed with our efforts to treat her and her baby.

Due dates are mysterious here. I don't think I'd remember my last period if I'd lost my family and was living in a tent and bathing at the common outside faucet. By ultrasound, Nadeye was almost full term.

Overnight, antibiotics helped bring Nadeye's fever down and her baby looked ok. I didn't have a clean hospital gown for her (we save those for women to deliver upon), so Nadeye remained in her own clothes. At about 8am, I noticed a foul odor despite antibiotics and that the baby wasn't tolerating labor.

At 9am I called for anesthesia to come for a c-section. The baby had mostly recovered, but Nadeye hadn't made any progress and the odor worsened. I watched and waited and did all the noninvasive things I could do: hydration, oxygen, different positions.

I was able to start the c-section about 5 hours later. We wheeled the gurney down a wooden ramp to the operating room. The one elevator stopped working after the earthquake, so people built an uncovered outside ramp up the side of the building. I'm glad it wasn't raining but I will tell you the Haitian afternoon heat is overwhelming.

In the OR we used German gowns, Italian drapes and instruments, American anesthesia kits and tape. The OR tables here are small and thin; they're built for pediatric patients. The tables don't lock but we wedged it in place with wooden blocks. There was one lamp and today the air conditioner was working. Somehow a mosquito penetrated our best efforts.

After an uncomplicated surgery, a vigorous new Haitian boy made his way into the world. Nadeye and her little boy will stay here as inpatients getting antibiotics for 6 or 10 days. We put nets over the baby basinets because there aren't any screens here either.

Nadeye hasn't named her son. Most of the new Haitian mothers don't name their babies for at least 6 fmonths because the survival rate is so low.

July 9

The sun sets on a very hazy, hot Friday here in Port-au-Prince. Last week I heard drumming. Today there's only the truck horns, babies crying and women laboring. Kind of interesting to be in a hospital without an intercom system where you can hear open air cicadas. (I carry a walkie talkie to stay connected to Maternity)

Tried my first Milliton today. It's like a vegetable pear and is also found in Louisiana where they call it Merliton. It's delicious — a sweetish squash that tastes great in a spicy hot sauce. Have also learned to reappreciate the hot dog. It's a staple here, along with fried bread, potatoes and rice. A corn dish I like is a cross between porridge and polenta.

Drove through downtown again today — nothing has changed in a week. Women and children sell charcoal bits from roadside baskets. Men use wheelbarrows to move broken stone and concrete. Women shovel rubble from a riverbed. Tents everywhere. I do notice a few more fires dotting roadsides — turns out that much of the earthquake debris is flammable. The air quality is horrific. If only there were a breath of wind.

July 8

It has been a frustrating day. Trying to get simple lab results can take days. My orders don't get read. Or, they're read, but the tests don't get done. Or, the tests get done but we can't find the results. Or, the tests get done, and we have results, but they aren't the results needed and we have to start over. There is so much waiting here.

I am reminded by a relief worker that patience is a virtue. Also, that this is the best hospital in Port-au-Prince and it is the only one with a neonatal ICU.

At the government-run General Hospital across town the staff leaves at 5pm. They tell the patients to cross their fingers for luck. The local nurses, orderlies, OR staff, kitchen crew and clerks who keep a hospital functioning, and who themselves mostly sleep outside in tents, haven't been paid in 6 months.

A communications staffer who recently left the General told me this information. She also said that there are at least 10,000 nongovernmental organizations in Haiti right now. And still, we can't get the streets cleared — as the NY Times reported today. Makes you wonder where all the Earthquake $ has gone.

Here at St Damiens, the locals receive their salaries. The rest of us are volunteer doctors, nurses, midwives and physical therapists. Like a true hospital, St Damiens runs 24 hours. Pediatric surgeons utilize the ORs during the day. Orthopedic surgeons work through the nights, still revisiting and revising earthquake-related traumas. Of course, my obstetric patients don't fit into schedules, so we operate when as needed. I have done 3 c-sections and an emergency hysterectomy.

July 7

I've been in Haiti one week now. So much still shocks my senses. Paradoxically, some shocking things have already become de rigeur.

For example: I'm quite accustomed to the piercing honks and horns from the road outside the hospital compound. The sounds come from a major 4-way intersection where there isn't any traffic light or stop sign. Usually the bigger, louder horn prevails. Not infrequently, an unlucky driver ends up in the ditch and must await a tow.

Actually I haven't seen any traffic lanes, street lights or crosswalks here. Driving is pure chaos. Small pickups, buzzing mopeds and larger transport trucks crisscross corners and streets. The small pickups carry 15 passengers. They're called 'tap-taps' and are the equivalent of NYC gypsy cabs but with a uniquely Haitian feel. They're usually retrofitted with chicken cages, yellow-tinted plexiglass and painted designs. And yes, they carry everything, including the chickens. I travel in them to reach the outlying clinics.

But here's an example of something that shocks me. This hospital, like others in Port-au-Prince, sits inside a cement-walled compound guarded by armed security. Access to the free healthcare at St Damiens is literally restricted at gunpoint. Pregnant women, and mothers with their sick children may enter. My young patient actually brought her positive pregnancy test in her purse-- her fever of 102 wouldn't likely have gotten her past the guards.

I've been cautioned not to leave the hospital without escort. Last week there were two kidnappings in broad daylight of relief workers.

But what about the safety of the local folks? Most Haitians simply don't go out after dark. I can't get an anesthesiologist to come to the hospital after dusk for love nor money. No matter what.

I've been told by local Haitians as well as by UN soldiers that armed thugs and drug gangs rule the streets at night. People living in the tents keep candles lit all night to ward off robbers and the ever-present threat of sexual assault. Unfortunately this means St Damiens sees a lot of burn victims - flaming wax should never be within a child's reach.

The Italian UN forces, the Carabinieri, are encamped across the street from the hospital. They have watch towers and gun turrets. I'm told that crowd control is the principal UN mission here.

Frankly, it is a wonder that Haitians haven't revolted against the preposterous chaos in which they have lived for years. The earthquake just made the rest of us take notice.

But I think that the real threat to Haitians, and to Haiti itself, comes from the drug gangs. American drug addiction has made narcotics trafficking a very big business here in Haiti as elsewhere in Mexico and Latin America. This is not shocking. Drugs are a worldwide problem and we all know it. But the wide-reaching effects that play out on these small streets and in the individual lives of this destitute country 90 minutes from Miami should give us pause.

July 6

Port Jeremie is a ramshackle run of corrugated tin-tarp sheds lining a part of Port-au-Prince harbor. It's where the poorest of the poor live. A salty breeze stirs up the dust. And the stench. Pigs and children root through garbage and mudpuddles. Port Jeremie has been like this for years. The earthquake has only made it more isolated.

Got to hand it to the priests and sisters associated with the hospital. They started a school here 7 years ago for the children of Port Jeremie. Now 345 local children come daily for a free breakfast and lunch and learn to read and write. They sit on long hard benches facing metal 'chalkboards.' There's no light here except what the door lets in. But it's better than the immutable darkness that otherwise envelopes this place that the rest of the world has seemingly forgotten.

The clinic itself is a cinderblock building with two rooms and a bench in a hallway. There's an old exam table, a plastic writing table and two folding chairs in the room I use today. There's never been electricity here. And these women don't get any other prenatal care. There aren't any prenatal vitamins; there isn't much food. Everyone is so very thin. A young woman named Gerna helps translate for me. We check blood pressures, do sonos, encourage women to return for a follow up visit, and recommend a hospital delivery. But I wonder if many will manage it. Labor does have a way of surprising even those with cars and passable roads and money for gas.

In the other clinic room a nurse sees anyone else with a medical issue. She dispenses a lot of tylenol and some basic antibiotics (she doesn't have much else). It seems rather like putting a bandaid on a gaping, bleeding, pus-filled wound. It doesn't solve the root problem, but it is a start.

Right?

The future for Port Jeremie does have a more resilient tone. The Catholics from St. Damiens have also begun building housing here. Real buildings with windows and doors. I must say, there is a lot to be said for Liberation Theology and the kind of socially active dedication I see here among the clergy of St. Damiens parish. They have been building schools, orphanages, hospitals and clinics in Haiti for years. They are definitely in it for the long haul. And let's not forget, Haiti's only populist government was led by Jean Bertrand Aristide, a homegrown Catholic priest.

I can't speak regarding any of the other nongovernmental organizations here in Haiti. But I do think the New York Times provided uncomfortable insights this morning.

July 5

I traveled this morning to St. Luc's, an outside prenatal clinic. On average they see women 1-6 times during a pregnancy to give out prenatal vitamins and do basic screening. Compare this to American women who see their OB 10-15 times before they deliver.

Most Haitian women deliver at home. These home births are often attended only by a neighbor or a friend as there is a serious lack of trained health care workers here in Haiti. The hospital recently got a donation of WHO (World Health Organization) delivery kits; but we haven't identified who to give them to. The kits contain a clean towel for the baby, a sterile razor blade to cut the umbilical cord, and an umbilical cord clamp. Very basic but very effective in reducing neonatal mortality from cord infections.

Edna Jean, the receptionist here at the clinc, would love to study nursing. She is bright and articulate and caring. She is also the only person in her family with a job, so she supports her two younger sisters and a sick mother. Nursing school costs about $150 per month. The cost is daunting and there aren't any loan programs. I hope to arrange a volunteer position for her at St Damiens. I think it could expand her options.

Back at the hospital I had to cannabalize the soap dispenser (a beautiful lysol no-touch item) for its batteries. Much more import to power the oxygen saturation monitor than the soap dispenser. The monitor came with recharchable batteries, but no one knows where to find the battery charger. Besides, we can pour the soap into a different container to use manually.

Later I walked through the main pharmacy. This one made me cry. I always get sentimental in pharmacies — my father was a hospital pharmacist for years and they remind me of my childhood. So I'm probably also missing my father at this moment in time. But still. There are only 3 rows of dusty shelves, and they are mostly empty. I saw a smattering of antibiotics, antiepileptics, antihistamines and antiemetics. A very few anticancer drugs, one antiviral. The obstetric meds and OR medications are kept, of course, in their respective units. But still. I miss Dad's amazingly well-stocked and well-organized pharmacy. And its fastidious cleanliness.

July 4

While working here at St. Damiens, I've been sleeping in a tent. It's "camping deluxe." I share six bathrooms with 20 people staying in eight tents. We have cold running water and electricity from the hospital. By comparison, one of the "better" tent cities where many Haitians have been living since the January earthquake has 10 bathrooms for 150 tents. Entire families live in these tents. At five people per tent, a modest estimate reckons 75 people share each bathroom. And there is no running water or electricity.

Here are some other interesting numbers. The average working Haitian makes less than $300 per month. A unit (250cc) of blood costs $100. My patient needed two units after her surgery yesterday. There's no question in my mind: blood is more valuable than gold. But it also appears to be more expensive.

Another number: a six-inch nail used primarily in construction sells for $15 per piece. Difficult to believe, right? Price gouging like this example certainly stalls rebuilding. I saw a man balancing re-bar salvaged from the wreckage on his head. He might get a few pennies for it if he finds a functioning metal shop that doesn't already have mounds of salvaged metal rusting out front. Those pennies could buy him some water. Or some food. But likely not both.

July 3

Today, while looking for supplies, I stumbled into the room where the hospital stores the coffins. Every day at 11 a.m., a priest rings the bells for those who have died. He also calls out the names of those who have been lost in the last 24 hours. St. Damiens is primarily a pediatric hospital and I wish I didn't have to tell you that he calls out too many names each day. Childhood mortality rates are shocking here.

Yes, we know that the 5-year-old with bone cancer won't get the chemo she needs because it costs so much. That is a tragedy and shouldn't happen. But what about the horrible diarrheas that come from living in a place where everybody's sewage runs into drainage ditches lining what's left of streets?

It makes me think twice about those quaint old streets we tourists like to visit in Barcelona or Paris or Rome. Before governments created sewer systems, those streets were foul-smelling, and the cities, disease-ridden. But that's exactly the clencher here. Those medieval European streets of so much great literature are a horrible reality here in Haiti in 2010. They smell bad. And they're 're deadly.

On a different note, I do want to take a moment to thank my colleagues at Petaluma Valley Hospital who saved unused drapes and expired sutures and kits for me to bring. I'm grateful to have delivered babies on those clean drapes. The pediatric ER doctors have put those extra fine sutures to good use sewing up small lacerations on small bodies.

July 2

Window screens here are very rare. To keep a sterile field in this land of the ever-present, ever-rapacious mosquito is nearly impossible. But labor won't be stopped, and babies will be born. This newest little boy arrived screaming and healthy, weighing 7.5 pounds. That's on the heavy side by Haitian standards. Most of the 167 babies born here at St Damien's in the last two months have been smaller. Not surprising, given the recent tragedy and the horrible lack of basic services like food and water and hospitals.

The leading cause of maternal morbidity worldwide is postpartum hemorrhage. It's quite rare in the U.S., but is frighteningly common in places where there isn't any access to safe blood transfusions. There is one blood bank in all of Port-au-Prince and it is across town. If a patient needs to get blood now, her relatives must go across town to buy it. And that can take hours. Fortunately, there are good, inexpensive medications to help prevent such consequences. I made good use of them today and am grateful for them.

July 1

Gave out the sippy cups, diapers and toys today to the orphanage. Many thanks from the young patients at St. Damiens Hospital to all of you who gave so generously. There were so many smiling faces.

This morning I went with an Italian nurse to do outreach prenatal care. There's a building not too far from here by truck that hospital staff visits weekly. They send health educators and show prenatal TV programs. I did portable ultrasounds, diagnosing twins for a few surprised moms and checking due dates and fetal well-being for many more. October and November will be very busy months obstetrically speaking here in Haiti. Interesting that most women remember a last menses sometime in December, pre-earthquake. Makes sense medically, I suppose, since a common response to severe stress is amenorrhea (absence of menses).

What was unnerving today was my discussion with a young Haitian man. He told me that compared to the days after the earthquake, what we see now is a Haitian paradise. My young friend is shell-shocked, to be sure, but his perspective is echoed by others. Those first few days and months must have been so horrible. Today I see one common water faucet for this part of Port-au-Prince. Cows, people and goats share tattered tents propped up among cinderblocks. Electricity is rare. The hospital has its own generator, courtesy of the Italians as well as 24 car batteries. There aren't any ambulances, so people walk to the hospital. There's no state-sponsored schooling, so anyone who wants to learn must pay for it themselves. My young friend estimated a baseline literacy rate of less than 10 percent here in the capital city, but much less in the countryside.

This afternoon I joined some relief workers to distribute rice and water near a tent city. Our trucks stopped inside a former school and armed guards closed the gates to control traffic. We emptied two large trucks of rice one person at a time in less than 20 minutes. Pregnant women, amputees and older people were helped first. The need is so great here.

One of the first words I learned in Creole was "panye." It means 'basket' and whatever is in it is balanced on the head. It's how nearly everyone carries everything here. Yes, the 50 pound bags of rice, too.

June 30

Made it to the hospital in Port-au-Prince today through streets of rubble and squalor that make New York City's worst slums look luxurious. Tent cities in between rows of devastated structures. Taxi ride a little harrowing; dirt crumbled roads dodging UN trucks and chicken cage-like cars. So many people on the sides of the road, selling anything.

The obstetric wing here is two months old; there's one local obstetrician director and an Italian midwife who oversees local Haitian midwives. They have divided the unit into a low-risk delivery room and a high-risk/postoperative area. There's running cold water, but limited towels and soap. I'm glad I brought a bunch. From what I've seen there's little or no prenatal care. St. Damiens is trying to change that with mobile outreach clinics a few days a week. I hope to join them.

Oh, and did I mention that it's hot?