Labor Repose

Labor Repose
LaborPayne during her 6th homebirth (9th baby) at age 44

Sunday, November 14, 2010

Lactation Consultants


I made the recent decision to become a lactation consultant. In 2012 the required criteria will change to become more stringent. I decided now was my chance to do it. I had most of the requirements already, save one. I need 500 hours of clinical time with a lactation consultant, following her, learning her trade. I need to complete those 500 hours in six months, the deadline for the lactation consultant exam. That's 80 hours a month, 20 hours a week, to eek out of my already packed schedule. I'm up for the challenge. I had my first full day last week with Charlene Burnett, a long time friend and lactation consultant. In one eight hour day, I followed Charlene as she taught two breastfeeding classes, one to inpatients, and one to outpatients. She was called to the pediatric clinic twice to do on the spot consultations with moms having breastfeeding troubles. She did morning and afternoon rounds on all the breastfeeding inpatients, consulted constantly with the staff nurses on their patients' status, and conferred with the quality improvement nurse on gathering breastfeeding statistics to document all her efforts. She also oriented me to the unit, processes, procedures, and culture of the floor. I've know Charlene for many years, but I've never seen her in her element. She was like poetry in motion, zipping from one place to the next, swooping in to save the day (or sore nipples as the case may be) her white coat standing in as her superhero cape. It was all so impressive seeing an expert, high functioning lactation consultant at work. I was actually brought to near tears, as I watched her work with an African-American young mother back in the Pediatric clinic with her week old infant. The young woman's mother hovered near by taking in every word, with a look of concern for both her daughter and infant grandson. Charlene asked the young woman questions to gauge her concerns, then asked to see her breastfeed her son. Charlene watched the woman nurse for a minute or so and asked more questions. The entire time in a low soothing tone, she also spoke to the infant, giving information about breastfeeding basics (of course this information was intended for the mother and grandmother, though she was addressing the infant- very cute). After asking permission to touch the woman's breast (as she was careful to do all day with every patient), she showed the woman how to more effectively position both her breast and her baby to prevent sore nipples. She had immediate positive results and you could see the relief on both the mom and grandmother's faces. She ended the visit with a few positive encouraging words. The entire visit was no more than 10 or 15 minutes, and yet this young mother had turned a corner. I had no doubt that that short visit would reap benefits in keeping this mother nursing her baby for a longer duration. She was more confident and empowered than the worried, anxious mother we had met when we entered the room. Charlene had even convinced the skeptical grandmother that her daughter could give her grandson adequate nutrition. Leaving the room with mother and baby happily nursing, we stopped at the desk for Charlene to give her report to the pediatrician. She explained in a few words what the problem had been and the tools she gave the mother to manage the situation. The pediatrician looked at her with gratitude and relief, and thanked her. She garnered respect from all her peers, it was clear that everyone saw the value in the service she offered. We quickly moved on to the next task at hand. During the outpatient class, three new moms sat around a table nursing their babies of varying ages and chatting excitedly about how their breastfeeding had evolved from the previous week. After each mom had shared, Charlene asked about their difficulties and then worked with each mom individually on her particular nursing issue while I chatted with the others about their baby's progress and development. She ended the class by giving each mom a gift before sending them on their way. (She had written a grant and used the money to purchase breast pumps, nursing pillows, fancy burp blankets, etc.) Later that same day, I watched as Charlene gave instructions to a Latina patient in Spanish (!) on getting her newborn on the breast. I loved getting an up close personal view on the impact an LC can have on the families she serves and her work environment.

Though I have no plans to work in the hospital setting, I'm looking forward to being able to provide this level of guidance and assistance to those who need it. My plans for my LC credential include educating staff nurses on breastfeeding basics, and breastfeeding supportive behaviors, and creating research to measure educational effectiveness for nurses. My research and experience has shown me that staff nurses in labor and deliver, nursery, or mother/baby are often the weakest link in the breastfeeding support chain. I'd like to dedicate my efforts to strengthening that link.

Tuesday, November 9, 2010

IPV

- A sweet young couple are laboring nicely for hours, until the husband leaves the room to go to the bathroom, whereupon, the woman clutches my hand, and pleads with me in a desperate whisper, "Please help me, he's threatening to take my baby from me."
-A refugee woman is slapped and pulled from the bed by her hair by her husband, just hours after giving birth.
-A young woman labors all night with premature labor, induced by a kick to the abdomen she received from her boyfriend. Though the baby is rushed to a high level neonatal intensive care nursery, he dies early the next morning.

These are just a few of the cases of Intimate Partner Violence I saw personally during my stint as a labor and delivery nurse. One of the things I found most shocking about my job, was how often I would interface with violence. It was not something I expected to encounter as a labor nurse. I quickly learned that if I was going to work with women, I was going to encounter occurrences of violence.

Intimate partner violence is defined as: violence that occurs between a victim and perpetrator who are current or former spouses or partners. The Center for Disease Control (CDC) recognizes four types of intimate partner violence:
  1. physical violence-the intentional use of force involving hitting, punching, kicking, etc.
  2. sexual violence-the actual or threatened use of force to compel a person to submit to sexual acts against their will, attempted or completed sex acts with a person unable to avoid participation, communicate unwillingness, or understand the nature of the act, and finally, abusive sexual contact
  3. threats of physical or sexual violence
  4. emotional abuse-use of humiliation, name calling, deliberate embarrassment, controlling their activities, isolating from family and friends, controlling or withholding resources including financial
  5. coercive control and intimidation- acts perceived as threatening or violent
The CDC website declares that "all women are at risk'' of intimate partner violence no matter their socieconomic status, education level, age, religion, ethnic or racial group, etc. In other words folks, you can't tell by looking. My experience taught me that. My biases had me keeping an eye on the refugee women with their submissive social structures and missing completely the educated middle class couple with the controlling husband. To become better at detecting IVP and intervening with needed resources, I had to learn that no one is 'risked out' and that every woman in my care should be screened for domestic abuse.

For maternal and fetal health, the consequences of undetected IVP can be grave:
-miscarriage (less than 20 weeks gestation)
-infant injury or death from maternal trauma (more than 20 weeks gestation)
-maternal stress and depression
-self medicating with smoking, drug use, alcohol (all linked to poor infant outcomes)
-decreased or delayed prenatal care (also linked to poor outcomes)
-maternal injury and death
-child abuse or children witnessing abuse

Unfortunately the cost of intimate partner violence doesn't stop there. The Women's, Infants, and Children's Health Committee that I co-chair recently published a report on the literal costs of domestic violence in our city. A 'point in time' survey was sent out to law enforcement, healthcare agencies, shelters, the courts and other agencies to determine the services and fees provided related to domestic violence in a 24 hour period. The total estimated costs of domestic violence for one day in our city was $61,000, or an estimated 2 million dollars a year! About 94% of the funding was provided in services to victims, the other 6% in perpetrator expenses. Of those receiving services for violence, about 6% were pregnant. This cost of IPV snapshot was quite eyeopening.

When I attended the obstetrical complications workshop last week, Ms. Otemba reviewed the following information important for nurses who are on the front lines of assessing for IVP.

Cues to IVP
- delayed prenatal care
-noncompliance to therapeutic regimens
-frequent ER visits
-controlling partner
-somatic complaints (headaches, pain, fatigue, stress)
-fearful, evasive affect
-characteristic injury pattern (head and neck, torso, different stages of healing)

Assessment
Appropriate assessment means universal screening for every patient. Let the patient know that you ask every patient these questions and they should be asked in private without any family members presents.
"Within the year, have you been hit, slapped, kicked or otherwise physically hurt by someone? Since you've become pregnant? Has anyone forced you to have sexual activities?"

While these questions are appropriate to ask every patient, to get patient disclosure we have to create an environment where it is safe to disclose. Privacy, brevity (the abuser may be lurking near by), trustworthiness, nonjudgmental attitude, acceptance are all a part of what we have to offer patients in order to facilitate disclosure. Most healthcare providers may have discomfort asking these questions, or may not know what to do if the answer is yes. It is important to have a plan.

Supportive Intervention

You ask your patient with suspicious injuries if she has been beaten, and she answers, 'yes'. Now what?

-Emergency management: It's imperative to know your community resources. Here in my city, we have the Bridge SPAN (Safe Patient Advocacy Network) program. Our local shelters work closely with the hospitals so that through Bridge, with just a phone call from the nurse (or any staff member) a shelter counselor will be dispatched to the hospital 24/7 to offer shelter, police protection, orders of protection, counseling, case management, and child protection and other needed emergency services.
-Validation: "You do not deserve to be afraid, controlled, threatened, or hurt." The patient may need repetitive validation to understand that it was not her/his fault and that they do not deserve such treatment.
-Evaluate the severity: There are many tools available. In our area, agencies are encouraged to use the Lethality Assessment Program to determine the level of danger a patient might be in. This will help to determine the appropriate interventions.
-Education: often control has been establish by lies and deceit. Patients need to know the facts about their situation and what their rights really are.
-Referrals to ongoing community care and support such as legal services and support groups.

Recently, I met with a woman who has left an abusive relationship after many years. Her abuse was revealed to me during care provided for one of her pregnancies. When she felt it was safe to do so, she planned an escape that was two years in the making. When the opportunity came to flee safely, she took her children and left, with a well executed plan in place. They have remained safe from their abuser for a number of years. Talking with her about her situation reminded me, that there is hope for a life beyond the violence, if we are all willing to do our part.


Center for Disease Control: Intimate Partner Violence in Pregnancy. Retrieved 11/8/10. http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/sld001.htm#10

Otemba, J. (2010). Complicated Pregnancies; implications and management. PESI healthcare. Workshop presented on 11/5/10 in Lenexa KS.

Kansas City Health Commission. Estimating the costs of domestic violence in the Kansas City area: a report on the 2009 domestic violence, point in time survey for the greater Kansas City area. Women's, Infant's, and Children's Health Committee, and the intimate Partner Violence Subcommittee. Approved and issued on 10/1/2010.

Saturday, November 6, 2010

Solving the Mystery of Preeclampsia

As a storyteller myself, there are few things I love more than a good story, even more so if it is a good medical mystery. I recently attended a day long continuing education seminar on pregnancy complications presented by Jamie Otremba CNM. I found both her style and content very appealing, but my best and juiciest learning came during the segment on preeclampsia (the segments on domestic violence and late pretermers were very good also). Ms. Otremba gave me my money's worth when she wove an intriguing tale about a bright young nephrologist whom about a ten years ago noticed something very familiar looking about the kidney lesions he noted in the pregnant women with preeclampsia that he treated. His investigations led him to discover the pathogenesis of preeclampsia. Ms. Otremba regaled us with the story of his adversity as he tried to get attention for his very important discovery- outside of his specialty area. So intriguing was the tale of Ananth Karumanchi that I decided to do a little detective work of my own. I started with the article in New Yorker magazine that Ms. Otremba mentioned.
A physician and staff writer by the name of Jerome Groopman published an article in 2006 in New Yorker magazine finally giving Ananth Karumanchi broad exposure to his work. Theories about preeclampsia abounded, but the true cause continued to allude the scientific community. For those who are unfamiliar, preeclampsia is a disease of pregnancy that manifests as high blood pressure (greater than 140/90) and proteinuria (protein in the urine). Edema (swelling) and neurological changes such as visual disturbances and hyperreflexia (brisk reflexes) can also occur. If left unabated, preeclampsia can lead to seizures (a condition called eclampsia) and liver damage caused by HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). The only known cure is removal of the placenta (delivery of the infant), at which point, the symptoms quickly reverse, and the woman gets better (if no permanent organ damage has been done to the liver or kidneys). If preeclampsia manifests late in pregnancy (as it most often does), a preterm infant is delivered. If it manifests in early pregnancy, the fetus may have to be sacrificed for the mother's wellbeing.
It was known that the placenta was the crux of the problem, but how? Groopman details how Karumanchi's careful research isolated two anti-angiogenic proteins (they prevent blood vessel growth) made by the placenta. These proteins, serum fms-like tyrosine kinase 1 (sFlt1) and soluble endoglin (s-Eng) are made by the placenta to control placental growth, and counteract the effects of pro-angiogenic proteins, vascular endothelial growth factor (VEGF) and placental growth factor (PIGF). In preeclampsia the sFlt1 and s-Eng overwhelm the maternal blood stream and cause blood vessel damage throughout leading to widespread vascular permeability and increased vascular resistance. The sFlt1 ultimately causes the hypertension (high blood pressure) and the s-Eng is responsible for the decreased platelets and liver damage seen in the more severe forms of the disease. The amount of these substances increase over time which explains why this is mostly a disease of late pregnancy. It appears to come out of the blue, but in fact the placenta was damaged from the beginning.
Following conception when the fertilized ovum (egg) is a blastocyst (about 100 cells) and starting to imbed itself in the uterine wall (the decidua) small fingerlike protrusions called trophoblasts (precursors of the placenta) grow into the decidua and reorganize uterine spiral arteries in order to set up a good blood supply for the developing fetus. In preeclampsia, this invasive network of trophoblasts and spiral arteries is incomplete, and sets in motion the abnormal release of anti-angiogenic factors leading to ongoing placental insufficiency for the fetus, and vascular insufficiency for the mother, both of which manifest increasing damage as the pregnancy progresses.
Karumanchi after several attempts, was able to publish his findings (increased levels of sFlt1 and s-Eng in the blood stream of women with the disease) in scientific journals and now heads a prestigious lab at Beth Israel Deaconess Medical Center in Boston, complete with government funding. Dr. Karumanchi and his team are now hard at work on what seemed impossible 20 years ago, a treatment for preeclampsia. His research also has implications for cancer treatment interestingly enough, since tumors, like fetuses are dependent on diverting and establishing rich vascular networks.
Preeclampsia and eclampsia continue to plague African-American women at higher rates along with diabetic women and women with preexisting hypertension, obesity, or previous preeclampsia. Those older than 35 and younger than 18 (of all races) are also at a higher risk. No one is sure why, but theories abound. There is still much about this disease that is a mystery.
Last week, my friend Dotty's daughter-in-law delivered a baby boy at 36 weeks due to induction for preeclampsia. She was not in any of the high risk categories. I assured my friend that for preeclampsia, induction is often indicated. Dotty remarked on the small placenta, and the feeding difficulties that are typical for late preterm gestation (more on that in a later post). I am delighted to see inroads being made. They are looking not only at methods of treatment, but early diagnostic tools as well (though the discovery was made 10 years ago and there are still no medications or biologic markers on the market, but I understand that these things take time). I suppose we are all still waiting for the happy ending to this story.

Narrative Report of Research Activities in the Karumanchi Laboratory

Role of angiogenesis in the pathogenesis of preeclampsia (PE) (currently the major focus of the laboratory): Our laboratory has identified sFlt-1, an antagonist of circulating vascular endothelial growth factor (VEGF) and placental growth factor (PlGF), from preeclamptic placentas and has confirmed that it is released into the blood stream in vast excess in patients with preeclampsia. Exogenous administration of sFlt-1 into pregnant rats reproduces the phenotype of preeclampsia, namely proteinuria, hypertension and glomerular endotheliosis, the classic lesion of preeclampsia. These observations suggest that excess circulating sFlt-1 contributes to the pathogenesis of preeclampsia. We have also demonstrated that circulating sFlt-1 and PlGF levels can be used for the clinical diagnosis and the prediction of preeclampsia. Work is in progress to understand the regulation of sFlt-1 production by the cytotrophoblasts of the placenta. We are also testing the effects of antagonizing excess sFlt-1 with growth factors and small molecule compounds in our animal model of preeclampsia with the goal of finding novel treatment options for this disease. Additionally, we are currently characterizing other gene products that are elevated in preeclampsia and which may be synergistic to sFlt-1 in the pathogenesis of preeclampsia and may serve as biomarkers for the early diagnosis of preeclampsia. This project is part of our interest in studying the contribution of endothelium in the pathogenesis of proteinuria and other vascular diseases.

Groopman, J. (2006). The preeclampsia puzzle: making sense of a mysterious pregnancy disorder. The New Yorker.

Karumanchi, S.A., et el. (2008). A longitudinal study of angiogenic and anti-angiogenic factors in normal pregnancy and patients destined to develop preeclampsia and deliver a small )for gestational age neonate. The Journal of Maternal-Fetal and Neonatal Medicine. 21(1). 9-23.

Levine, R.J., Qian, C., Maynard, S.E., Yu, K.F., Epstein, F.H., Karumanchi, S.A. (2006). Serum sFlt1 concentration during preeclampsia and mid trimester blood pressure in healthy nulliparous women. American Journal of Obstetrics and Gynecology. 194(4). 1034-41.

Silasi, M., Cohen, B., Karumanchi, S.A., Rana, S. (2010). Abnormal placentation, angiogenic factors, and the pathogenesis of preeclampsia. Obstetrics and Gynecology Clinics of North America. 37(2): 239-53.

Staff, A.C., Braekke, K., Johnsen G.M., Karumanchi, S.A. (2007). Circulating concentrations of soluble endoglin in fetal and maternal serum and in amniotic fluid in preeclampsia. American Journal of Obstetrics and Gynecology. 197(2). 176-8.


Friday, November 5, 2010

Welcome to the new and improved LaborPayne Epistles

Welcome to the new look and mission of the LaborPayne Epistles. While I am in graduate school and preparing for the IBLCE exam, I will use this blog to discuss maternal infant health issues relevant to current practice and culture. My goal is to stimulate thought and discussion on topics that impact patient outcomes, through weekly postings of selected topics. I invite your thoughts and ideas.

Monday, October 4, 2010

Day 8- Operation Haiti

We are back home after and exhausting entire day of travel. I will write when I have had some recovery time. The five of us talked a lot about the trip during our plane rides and were able to spend time processing the entire event and what it means in each of our lives. It's good to be home.

Day 7- Operation Haiti

Today we all got up early and headed off to the Bel Aire Clinic in Port au Prince. I have gotten a better look around the neighborhood here in Petionville and it actually is full of gorgeous mansions. The neighborhood is nicer (ie cleaner) and I see more businesses that are transnational chains, more restaurants, more nightclubs, more grocery stores etc. Here is evidence of the class distinction. So far I had only seen poor and poorer and poorer still. I still don't know any Haitians who live in these mansions. However I have met far too many Haitians who are intelligent, and civic minded who are unsure of what the future holds for them. Many of or interpreters such as George, Innocent, Mose, Reginald and many others are bright and energetic young men with unlimited potential, but very limited opportunities. Their is no clear cut route for them to attend college (especially now when many schools were lost in the earthquake). Haiti seems poised to lose its best hope for the future if there are no educational opportunities for these young men (and women). I cannot say what will become of them. If the potential of this generation is not fully exploited, that will be the true tragedy.

The Bel Aire Clinic is housed on the second floor of a church. We had four physicians this morning seeing patients. My students, Rebecca and Sr. Marie did triage, I worked with two nurses in the treatment room (patients came into us to get shots, private exams, wound care, or other special treatments. We had a constant flow of patients. Three other nurses worked the pharmacy including Chris who teaches pharmacology. He really worked hard during the week and got the Bel Aire pharmacy organized and cleaned. I helped, remove a rock from a child's ear, cleaned and redressed some pressure ulcers, dressed a burn, did some bandage changes, assisted with a GYN exam, and cleaned and organized the treatment room, labeling and organizing supplies. I should not use the term room since there are no walls on the second floor and room divisions are by function or walled off petitions. As usual, you make do with what you have. My work to day in the the clinic was my most enjoyable clinical experience. After we finished we went shopping for souveniers. We stopped at two separate market places and purchased paintings, boxes, wall hangings, and Haitian flags. Some of the more adventurous (ie younger) folks then went out to eat at a restaurant while the rest of us came home. I had a nap and got back to the business of blogging. Its been a busy week, We take the plane out in the morning and will take 12 hours to reach home. I wish I had down time to 'recover' but first thing Monday morning, I start teaching again and I have a test to take, and a second draft of my thesis due. No rest for the wicked I suppose.

Day 6- Opertion Haiti

Today we took the road into Fondwa. What an amazing day! It started early as our tap tap arrived from Petionville with Chris and Rebecca, and Jessie ( the rest of our little party of five, that had remained in Petionville). They were going to make the trip to Fondwa with us. We climbed into the back of the caged truck and headed up and into the mountains. It was an hour''s drive into the most spectacular mountains. The entire trip was worth the view of those mountains. However. The trip was death defying. Imagine (if you will) a two lane paved highway weaving in and out and up the mountain. On the highway are vehicles of all types and sizes going at speeds of their own discretion, ox carts, tap taps with passengers sitting on top and hanging off the side, pedestrians, bulldozers, whatever, you name it. The view was magnificent- if you didn't look down. Once we all arrived (safe and sound) we set up clinic at a 'clinic in a can' . We had 75 patients already waiting when we arrived. We had two docs, and three nurses, and two nursing students in our group, along with Rebecca and Sister Marie (who came along to visit. the orphanage at Fondwa). Two nurses went to work in the pharmacy, and I did triage with the two students. We got through about 50 patients before we had to pack up and leave. Because I was in charge of the triage, I personally had to turn away folks and say no, Madam, no doctor, after they had been waiting all morning- not a pleasant experience. I felt like a captain leaving people off the life raft.. I had to decide who of those remaining would see the doctor. I went between the rows looking at their intake sheets. I decided my criteria would be, febrile infants and children, hypertensive elderly, and obvious skin conditions. All the rest I had to turn away. One of the nurses thought it would be a good idea to pass out bottles of pedialyte as "consolation prizes". It wasn't. Mass chaos ensued. Its never a good idea to have a mass giveaway in Haiti. Crowds will swarm. The giveaway quickly ended as we finished seeing the last of the patients, and got on the truck and headed to the Orphanage for lunch. We had to be out of Fondwa by a certain time to avoid the afternoon rains which could leave the road undriveable. The sisterswho ran the orphanage were all in Port au Prince for a retreat. We didn't get to see much of the orphanage at all, but I understand that they lost all their buildings and there was loss of life among both the nuns and the orphans. I t appeared quite a dismal place from what I could see, but at least in the mountains there was clean air to breathe. Down in PaP all the kids had crappy lungs full of who knows what from breathing in very polluted air. Lunch was prepared for us anyway and served by the ladies that work at the orphanage. It was a beautiful feast. There was fried chicken, beans and rice, a corn and pea salad, fresh tomatoes and plantains, a chopped vegetable salad, and green beans. It was both beautiful and delicious. I may have made a critical misstep by drinking the water placed on the table. I didn't want to go out to the truck to get my water bottle, and I could taste the bleach in it used to purify it. Even so, I drank two glasses. Time will tell if I get Toussaint L' Ouverture's revenge! The drive out of Fondwa was marked by stopping for crews to remove dirt off the highway from frequent dirt slides (horrors to think if it had rained while we were there- mud slide anyone?) You really can see the work of deforestation in the mountains. It is still lush and green and beautiful to behold, but it is also obvious that it would be a lot more lush and green if so many trees had not been removed. I'm sure the road is out many times with fall out from mud and rock slides that without tree growth permit soil erosion. The trip back down the mountain was just as death defying. It did not rain, but the clouds moved over the landscape as if it would. You really feel like you've accomplished something if you survive the trip to Fondwa! We stopped in Leogone to get our suitcases and say goodbye to our hosts. I will miss George and Dr. Denton and the family of kittens, and the Dr.'s three little ones, and the Dr's wife's good cooking, and my big queen size comfortable bed. We get back into the truck and head for Petionville where we'll spend the rest of our time. Unfortunately we hit Port au Prince at evening rush hour coming back into town and it takes us nearly five hours to do a drive that normally takes about two hours. We move at a snail's pace through the Friday evening traffic in which the Haitian's obviously aren't in a hurry to get anywhere. Of course, it doesn't help that things such as lanes, traffic lights, rules of the road ect, don't exist here. You move along when you can, where you can. Back at the air-conditioned mansion in Petionville with almost reliable internet and almost reliable electricity seems a luxury. Back in Leogone we lost electricity on Tuesday and got by the rest of the week on Dr. Denton's generators! We kept thinking the 'state run electricity' would come back on, but it never did. The house in Petionville has its own backup generators as well. Its now nearly 11:00 and time to head to bed. We have a half day of clinic in the Port au Prince clinic and then shopping at the market and a happy hour. For me the hour will be sad, because it will mark the end to this remarkable journey. We leave for the airport at 6am on Sunday.

Day 5- Operation Haiti

Just when I think I've seen the most poverty possible... When we went out to clinic today, we went to another remote area waaaay off the beaten path, in fact it was off any real road. We jumped into our rented tap-tap (a taxi truck with benches in the back that we ride on) with our suitcase pharmacy and headed down the paved highway, then turned off onto a cobblestone street, then onto a mud road. The road (and I use the term loosely) led us through a low lying area that must be flooded ankle deep a good part of the year, as it was today, and yet people were living there. Walking around in the ankle deep muck and carrying on their daily business. The houses were mere shacks and more pieced together tents. I couldn't imagine living under such conditions. Water from an overflowing river mixed with what ever was in the open sewers and all was carried along in a constant stream of fluid slush. The people don't drink the water but they do use it routinely for both bathing and toileting. This is a natural breeding ground for disease. We kept driving to a point where the road literally led into the river. We stopped on the side and watched as vehicles just drove right across the quickly rising river and as one enterprising entrepreneur made a quick business of carrying people back and forth from one side to another on his back. People would drop small coins into his and and then leap on his back as he shuttled them across. Others would just remove their shoes, hike up their pants or skirt, and move briskly through the swirling rising brown water. Our driver contemplated for a few minutes if his tap-tap would make it, and we contemplated if we would be safer riding across the river or walking! I thought about paying that guy to carry me! (He would have charged me double!) Finally we all got into the tap-tap, said a quick prayer, and whoosh, down a steep embankment, across the river and up a second steep embankment where the road continued on undisturbed. Undisturbed for a mud road full of deep pits (the term pothole does not apply here). Drivers in vehicles, motorcycles, bicycles, horses, ox drawn carts (whatever!) zoom quickly from one side of the road to the other avoiding the million pedestrians also crowding the road as well as the mud and water filled pits and the other drivers. Whew. I get tired just recalling that drive. The mud road continued on leading us to a little village I have dubbed, "scabiesville" (since almost every child I saw today had track marks on their arms and legs where the little critters burrow under the skin). This was the most impoverished place I've been to date. How they eek out a living in this remote mud encrusted place I don't know. As at home, rural poverty trumps city poverty, and it broke my heart to see children living this way. We set up our clinic in a 'church' really just a tin roof over a concrete slab with open sides and lots of wooden benches in it. As they came through my triage station, I made them 'balloons' from my latex gloves. Word must have got out because soon even children who weren't being seen came to the entrance of the church and looked at me slyly until I blew up a glove for them. Again, we saw lots of sick babies with fevers and lots of elderly with sky high blood pressures. I saw one elderly woman with a blood pressure of 240/120. It would not go down after even two doses of antihypertensives (prolanolol). She hobbled away with her baggie of medication after being told to return in two weeks when the clinic returns. We finished quickly seeing everyone amid reports that the river was rising. Not wanting to be stranded in scabiesville, we packed up and headed once more across that river pretending to be a road. Sure enouygh the river was moving faster and the trip back across was even worse! George, our interpreter thought it great fun and wanted to do it again. George, I said, do you want to drown me in the river, or have me float out to sea? We arrived back home safe and sound with the most exciting thing about today being the drive to and from the clinic. My colleagues are out seeking adventures but I am content to nap after our return and journal, and waiting for what I'm sure will be another delicious Haitian meal.

Day 4- Operation Haiti

Today, my four colleagues went out to do a community clinic, while I stayed at the clinic in the can, just down the road a few feet. It was a routine, uneventful clinic with the Haitian doctor. We saw about 30 patients, mostly sick babies, and elderly with chronic conditions. There is so little we can to about the chronic conditions, but because the clinic in a can (a trailer building, built in China and 'mailed' here to it's current location), is more/less permanent, folks can come back to get refills on their high blood pressure medication (lots of hypertension and heart disease). Today was a very eventful day, however, not because of the clinic. We finished up around 1:00 and I headed home to the maternity clinic for lunch. Soon after, my peers returned from their clinic as well, and we also decided to take a walk with our interpreters, George and Mose. George and Mose are 21/22 years old, the typical age of interpreters, young, strong, handsome, and outgoing. As we walked, nurse Linda told me about her most challenging case of the day:

Linda saw a pretty, petite Haitian young woman of about 20 years of age. She administered a pregnancy test to the girl and it was positive. When she found out she was pregnant, she became upset because her parepnts would be angry with her. She said that she would seek an abortion. When Linda tried to talk to her about it, she would not be dissuaded. Even the interpreter told her the girl was determined to do it. Linda gave her birth control information and discussed other options, but in the end gave her a course of antibiotics and made her promise to take them after the procedure was done. Hearing this story was heartbreaking, and Linda was obviously still shaken by the encounter. I'm so glad Linda thought to give her antibiotics. The greatests risks with abortion are hemorrhage (which will kill you quickly) and infection (which will kill you slowly). In a country like Haiti that is very undeveloped and very Catholic, I think she will have a hard time finding a safe practitioner to give her an abortion. Most hospitals are owned by religious organizations which won't offer them. She told Linda she would do it herself if she had to, by pills or by 'other means'. I teach about abortion as a part of my OB lecture so depending on how far along in her pregnancy, pills won't do the job after between 9-12 weeks gestation. If she uses an instrument on herself she is at very high risk of hemorrhage or infection or both. In other words, there are no good forseeable outcomes for this young woman. Attempting an abortion could very well be a death sentence for her. A very sobering thought indeed. Tomorrow I'll ask Dr. Denton (our host) about this. I'd like to know the frequency of abortion here and what options she has to get it done safely.

As our walk continued,we wound our way around the 'neighborhood'. It was quite unlike the view from the road in a tap tap. As we walked we saw up close and personal how people lived. Even after a previous trip to Haiti, I found it shocking. People living in tents and shacks along side their cattle, goats, and pigs. How they lived this way was inconceivable to me. No electricity, no running water. I felt as if I were seeing the real Haiti for the first time. All the people came out of their houses to see the 'Blancs' walking by. No doubt very few whites/westerners ever see what we saw. George and Mose greated all their neighbors graciously and if I smiled and said "Bonsua" they smiled and said it right back, We passed lots of new wooden small shacks that various organizations had come in and built, they were tiny little houses but far superior to a pieced together tent. George took us to his home to meet his family which included a grandmother, a cousin and her three children and another cousin, sister to the first. George's mother died when he was young, and he lost his father in the earthquake. George and his cousins and grandmother lived in a tent outside their home which had sustained lots of earthquake damage and was being repaired by several men walking around and hammering on the roof. 'The men climbed into the trees to get us coconuts, which George's cousin slashed open with a machete and we all drank fresh coconut milk and ate the coconut out with spoons. We stayed about an hour and George and I talked a long time. He wants to go to school in the US and study law and then return to 'do something great for Haiti'. I believe that someday, George will do just that.

We had other adventures on the walk, including seeing an abandoned sugar cane factory, that George says will open in October and employ 2,000 Haitians (may it be so). I lost a flip flop during the walk, and could not continue, so George hired a motorcycle to drive me the rest of the way back to the clinic. I was very nervous, (folks use motorcycles for taxies here, and it was not unusually to see four or five people on a bike zooming by in one direction or another) but as I was the only rider on a privately rented bike, and Mose did the driving (the driver stayed behind with our group) and he headed my admonishments to 'GO SLOWLY MOES" it went pretty well. Remember there were no paved roads where we were, only dirt and rock streets (that's why my flip flop didn't hold up) and of course full of huge holes! So there was Mose driving slowly with me on the back, while he weaved in and out of traffic and gigantic pot holes. That was my adventure for the day. I got back in time to wolf down dinner (a potato, carrot, and greens stew, flavored with meet of an unknown origin, and served with (you'll never guess) beans and rice. All delicious. Then I accompanied Dr. Denton to the hospital to visit a post op patient, which I will write about tomorrow.

Day 3- Operation Haiti

Today saw another early start, as four of our small group took a short tap-tap ride to the beach and set up a clinic under the palm trees. We saw about 50-60 patients, some we could help and as always, some we could not. After we had seen every patient, my colleagues took a dip in the ocean while I enjoyed the scenery (I'm not a swimmer). We rode back 'home' to our little maternity hospital and I took a nap until dinner. Tonight we were served a potato, yam and beef stew and white rice with a pureed bean sauce. I've since spent 3-4 hours reading homework (I have a pathophysiology test when I return home) and am finishing a long day with my journal. I'm short on detail because I'm tired and in need of sleep, but it has been another amazing and thought provoking day. We had great discussion over dinner processing what we are seeing: the nature of health and wellness, the geopolitial and socio-economic basis for health, the upheaval of Haiti, the nature of family, the meaning of hope and happiness. Sometimes it is all too much to take in at once. Thank goodness for interludes of blessed sleep.

Addendum: Now with some sleep, I'm ready to reflect upon a couple of events yesterday.

Most interesting case: We saw a boy of 12 years yesterday with severe cahexia (not just lack of fat, but lack of muscle- literally skin and bones.) He was with his mother and younger brother and sister all of whom were well nurished and looked fine. His mother stated that he had been sick for two weeks and had no appetite and diarrhea, but his severe state looked like it took a lot longer to produce than two weeks. He was flaccid and lethargic (not surprising- we produce our energy (ATP) in our muscle fiber and he had very little) and had a very flat affect. He was given a referral to the hospital for follow up care. He was heartbreaking to behold, and difficult to even look at. I felt this child might be dying and there was so little we could do. We talked about him long after clinic. We have no diagnostic equipment to diagnose so we can only guess at what the problems are based on clinical manifestations. Did he have severe and prolonged intestinal worms? Was it neonatal transmission of HIV/AIDs? Did some combination of opportunistic infections tax his immune system to the point it wasn't fighting back? Sadly, there is no way to tell. Worse still, no way to tell if his mother took him to the hospital. You need money to pay for healthcare up front. Without money, they'll be turned away, no matter how dire the situation. The hospitals here do turn people away for all kinds of reasons. I can only hope that emaciated boy with the haunting eyes gets the medical attention he so desperately needs.

Most interesting observation: In Haiti everyone breastfeeds. It is a given. However, based on my observations, they don't breastfeed nearly long enough. Now they do nurse their babies for the first year, maybe two, but in this healthcare environment it is not nearly long enough. The reason I say that is the sheer number of sick and compromised babies I see once they are weaned from the breast. If ever anyone doubted the immunological benefits of mother's milk, they should come to Haiti. The minute these babies are deprived of their mother's milk, their immune systems struggle to handle the daily assault and onslaught of disease bearing pathogens. Breastmilk is their best protection, and once deprived of it, they become ill, very ill. I heard one of the nurses say that doctors are telling Haitian women to wean earlier, like at six months. This would be disasterous. I asked why would anyone do such a thing and she said because of the risk of HIV/AIDs transmission. This set my blood to boil. Not only are the benefits of lactation proven (if anyone would bother to read them) but the who relationship between lactation and AIDs is still up for debate. To deprive these infants of their best immunological defense seems, well, indefensible. I make a note to ask every mother of a baby if she is still breastfeeding and encourage her to continue if she is.

Day 2- Operation Haiti

Today was our first full day in Haiti. Two of us, Pam and I got the coveted spots to Leogone. Chris, Rebecca, and Jessie remained in Petionville to work in the Port au Prince clinic. I say 'coveted' as tongue in cheek. To get these slots we had to get up at 5am, take a very long 2 hour drive up into the mountains and work in an outdoor clinic in the tropical heat. Pam and I are part of a group of 5 (1 resident, 3 nurses, 1 nursing student) selected to spend the week here in Leogone, a small impoverished mountain town. From Leogone we will visit other villages on other days to do one day clinics. We are hosted by a local Haitian physician that has a small maternity hospital. Dr. Delson and his wife and three small children lived next door to the hospital, but their house was demolished by the earthquake, and now they live in the hospital. The have given us quarters in their hospital. The other four women share a large sunny room with four beds, but I got a private room with an attached bathroom! Quite the luxurious accomodations! We worked in a 'clinic in a can'. This is a trailer buidling delivered here by Heart to Heart. It is airconditioned and has three rooms in it, a pharmacy and two exam rooms. Pam and I triaged patients in the courtyard, while the two docs saw patients in the exam rooms. Everything went very smoothly and it was a great clinic day. Our most interesting case today was a man getting follow up wound care after being in a motorcycle accident two weeks ago. We tentatively romoved his bandages to find great looking granualation tissue- a sure sign of good healing and no signs of infection. Pam and I worked triage today. We did weights and vitals on each patient prior to their seeing one of the doctors. The clinic was well organized and everyone was seen by 1:00. I took an afternoon nap while the others walked to a gas station to buy beer and soda. We were served a delicious dinner of savory stew made with pumpkins, and beef and lots of varieties of beans served over (guess what) beans and rice. It tasted so good, we all had seconds. I plan to spend my evening studying (I have a test the day after I return). Tomorrow our group of five subdivides again while some stay behind to work in the clinic in a can, and the others of us will go further up into the mountains to more remote villages. We have to pack up our pharmacy and take everything with us. If we don't carry it in, we won't have it. I'm eager to learn how things are going for Chris, Rebecca, and Pam back in Petionville. I hope their first day went as well as ours. Looking forward to more of the same tomorrow.

Day 1- Operation Haiti

We made it safe and sound! I can't believe that am once again in Haiti. It all seems so familiar, like another home. After foregoing sleep last night and catching a 6 am flight, we arrived intact after 3 uneventful flights. Our courier met us at the airport and took four suitcases of diapers and pads, and infant clothing. Kicko, my Haitian son, also met us there and I presented him with a refurbished laptop and an I-phone. It was so great to see him. He looked great- maybe a little skinny. Our host was also there to meet us and we all piled into the tap-tap (along with Kicki- we gave him a lift- he lives in Petionville where we happen to be staying). We arrived at a lovely air-conditioned mansion to a lovely dinner made by the Haitian cook. We had a meeting to decide who would go to Leogone in the mountains for the week and who would stay here in Port au Prince and work. Our team was split in half. Pam and I will go into the mountains tomorrow morning. Rebecca and Jessie were dissapointed to be left here (in the air-conditioning) but they will have a busy week here as well. I'm off to bed, very much sleep deprived, and am hoping for internet in the mountains so I can keep up this blog. Haiti is beautiful. Her people are beautiful. I remind us all that we are here to not only give, but to receive- the love of the Haitians, the beauty of the land, and the ceaseless grace of our creator.

Thursday, September 30, 2010

When in Haiti...

I am keeping a blog of my trip to Haiti but blogger won't let me copy it into here, so you must follow my link to Operation Haiti to read it.

Saturday, September 18, 2010

Haitian Donations

Eights days until my return to Haiti. I look forward to seeing Port au Prince again, and also traveling into the mountains to Leogone (the epicenter of the earthquake). I don't know what to expect, so I have no expectations. I know things will not be very different from what I encountered before. Our final team includes two students, one other nursing instructor, a photographer, and myself. We are small but mighty. We will be delivering medical supplies to our hosts (Heart to Heart International), and cloth diapers and cloth sanitary napkins to a courier who will take them to Maisson de Naissance, a birthing center several hours outside of Port au Prince. We also will bring gifts of clothing to an orphanage. If I raise enough funds, I will also take a refurbished laptop to my former interpreter, Kicki, to use as he grows his cyber cafe business. The outpouring of support for this trip has been phenomenal. A group of ladies in central Missouri has hand sewn all the sanitary napkins for us (Thank you Womb Room). The Phi Beta Kappa of Brown Mackie held a fundraiser all of July and purchased 300 cloth diapers for us to donate. We held a big fundraiser party with drummers and dancers and donated Haitian food (thanks Women of the Drum, Lon Lane's Inspired Occasions, and Josie's Sweet Treats) and raised $500. Between our fundraiser events and our individual donation solicitations, we have raised over $4,000 for this trip. We have also made wonderful new friends. Joseph and Glory Idalbert are Haitian Americans who run a local nonprofit to assist their fellow Haitians with adjustment to American life. They offer language classes and job training. We reached out to their organization, Glory House Services, and found our local link to the Haitian community of Kansas City. Joseph and Glory accepted a donation of 3 large crates of infant and children's clothing that we could not carry into Haiti due to the limits of what we could carry. We hope folks will be content to know that even though their donations didn't make it to Haiti, they will benefit Haitians. I also met Captain Jose Belardo of the Public Service Corps. I visited with him before my March trip to Haiti and now he will make a presentation to our group to prepare us for the diseases we will see and how to treat them. It has been an amazing ride, preparing for this trip. I didn't know we would impact so many- and we haven't even left yet. I was asked to prepare a presentation for a meeting of college presidents of all the Brown Mackie Colleges around the country. I made a plea for service learning to be incorporated into all the nursing curriculums. We are planning a joint party with Glory House Services when we return to share our experience and everything we learned. Never could I have imagined that a single thought I had while in Haiti back in March (to bring my nursing students back to Haiti with me) would yield such a response. If you want to keep up with the trip as it happens, visit our website where we post daily at http://www.operationhaiti.webs.com/ It is a fitting present on my 48th birthday today, to reflect back on what has transpired over the past seven months to make this trip happen. I just love to see vision made manifest.

Saturday, July 31, 2010

Clinical Lactation

It's official. There's a new journal in town. It was revealed last week at the ILCA conference by Kathleen Kendall-Tackett. Clinical Lactation is a new peer reviewed journal specifically geared towards lactation consultants. I am honored to have been selected to be on their Editorial Review Board. Clinical Lactation becomes the second of its kind after the Journal of Human Lactation (another favorite read of mine). I'm excited about this new adventure in my life and look forward to receiving my first article for review. Thank you to Kathleen and the other editors for this honor.

Tuesday, July 20, 2010

Team Haiti

The return trip to Haiti is well under way. It is not as I envisioned it at all. It is better. I don't have a final head count yet as to who all is going, but there will be about 6 student nurses and 4-5 nurses and maybe a physician on our team. We are being hosted by Heart to Heart International. We will work for a week in their clinic and stay at their house in Port Au Prince. They will provide room, board, transportation to and from the clinic, and interpreters, all for $25 a day per person. We have many organizations collecting (or making) items for us to take with us to give away such as diapers and vitamins. We also have a couple of fundraisers underway and a grant pending. I put up a facebook event page and started a website for the trip. (operationahaiti.webs.com) The project has grown so big, it has taken on a life of it's own. I'm very excited to be a part of this project, and of course I can't wait to return to Haiti. Students are putting together their applications to submit by the end of the week. I'm working on a book signing fundraiser event with a local author and a superb caterer. It's so much fun to put this all together and watch it happen. The best part will be to see lives transform through international medical/humanitarian service.

Monday, July 19, 2010

Scenes from the Holy Land











I spent a recent weekend in seclusion at my friend, Morningstar's retreat center in the Ozarks. I enjoyed silence, worked in her gardens, read, feasted on vegetarian meals, and rested my soul for the work ahead.
Pictures: Morningstar's tipi where she holds many of her ceremonies, the Gaia Garden, Casita: my cabin in the woods, Morningstar's home: Rose Cottage, a view of the meadow that includes a vegetable garden that helps to feed us.
My times of silence and solitude become more important to me as the work load grows heavier. I am grateful for times of refreshment.

Friday, May 14, 2010

Haiti Here We Come- Again

Just recieved permission from the powers that be, that taking nursing students to Haiti has been approved! This will be such a great experience for them. Now the fundraising can begin. It's a little too soon to recruit students, that will begin next month. For now, I'm seeking foundations who would be willing to let me apply for grant monies to cover student expenses, and any other simple, yet effective fundraising ideas. The trip is set for the end of September. Now to make it happen...

Wednesday, May 12, 2010

Some Things Never Change


As I gave my Haiti presentation to the local doula group on Monday, I tried to explain the beauty of birth as I saw it manifested in the Haitian women as they birthed their babies. What struck me was a story I have not yet shared about my experience in Haiti on this blog. The story of how 'some things never change.' I was at the hospital on day 4 with one of the American midwives. She was quite a lively animated person, and I enjoyed both talking with her and watching her work. I could tell she loved being a midwife- she was really into birth. She really showed me what was possible and under her tutelage I saw the most remarkable things. Well we were in the thick of laboring a woman. She was dilated to 9, and we had her in the small delivery room along with her aunt and cousin to help her (her cousin spoke English so we used her as our interpreter). She was all over the floor laboring in the most amazing positions, really working hard and effectively bringing her baby down. I was utterly amazed by this labor and how well this woman was working. Then he came. The Haitian obstetrician chose this time to make his rounds. He spoke English and was young and handsome (looked a hellava lot like Taye Diggs). He swooped down on the unit we had been running all day and started to take over. The midwife was miffed to say the least. Prior to his arrival she had given me this sweet little speech about how we were guests here in Haiti and should not behave like colonialists and take over everything. However when that Haitian OB came in and told the family members to leave and our patient to get off the floor and up on the delivery table, I could see the mama bear come out of this tiny little woman. She got right up in the doctors face and said, "Is this my patient or your patient?" She wanted to know who was going to do the delivery. They toussled for a while, there was some give and take. My midwife shook her finger in his face, 'don't you cut her' (referring to the routine episiotomy she thought her patient might get from him.) We slowly allowed the aunt and cousin back in. However we also got the patient on the table and put in an IV at the doctor's request. The doctor had brought along a little patient he intended to do a cesarean on, and I prepped her for surgery as well. While he was over in the main hospital building preparing his OR, our patient delivered, with her female relatives at her bedside coaxing her on. It was a fantastic birth, that almost didn't happen that way. It was because the midwife did the very thing she said she would not (get all colonialist on his ass) in an effort to protect her patient. How many times do we as midwives, doulas, nurses have to put our bodies between the patient and the physician to protect birth and keep it sacrosanct? I could feel the burden of this midwife. I too wanted him to get the hell out of our little delivery cocoon and leave us be. Technically these were his patients. Technically his western-infused ideas about how to conduct safe childbirth came from his American-influenced education. He was puzzled by why and how we were allowing sacred space for this woman to birth in her own body in her own way. He only knew his way, the way he had been taught, the way that didn't allow for individualities of person or cultures. (By the way, this application of western medical values into third world realities leads to some pretty brutal births- think pit induction without epidurals, or cesarean births without post op pain meds.) I understand that a lot of physicians Haitian, American, and otherwise think this mechanization of birth is the key to good outcomes. I understand it, I just don't happen to agree. Watching my little midwife go toe to toe with that physician reminded me that some things just never change- without a revolution. And in the midst of revolution you may find yourself saying and doing things you thought you never would.

Wednesday, May 5, 2010

Photos from the Mother's Day Luncheon






Here are photos from the luncheon yesterday. Midwife Cathy (white hair, pink shirt) was honored as one of the 25 Shining Stars (always been a star in my book!) next to Rachel (another midwife) determined to open the next birth center here in town. There's a shot of my table and all my guests. Dr. Palmer a dentist who has done some kick ass research on the relationship between breastfeeding and good dental health (brianpalmerdds.com), Pat, my partner in crime who teaches pediatric nursing, Airick West, president of the KCMO school board, Pakou, local birth activist writing a book of birth stories of women of color, Liz, mom extraordinaire and fellow nursing educator, Mariah (my mini-me) all around birth and breastfeeding advocate and professional volunteer. The final photo is of Liz and I. Another nicely done luncheon, honoring folks who deserve the recognition.

Travelogue Announcement

I will be giving another travelogue on my trip to Haiti next Monday, May 10th at the Doulas of Kansas City meeting, at 1pm. They meet at Cornerstone Community Church at 74th and Metcalf. Everyone is welcome. I'm actually more busy planning the next trip. I'm taking a couple of collegues and some nursing students to Haiti in September. The honor society would like to collect items for me to take based on the presentation I gave at school. They want to have a 'pad drive'. Now I am thrilled that they want to collect sanitary napkins, however my problem is that ecologically, it may not be a good idea. I'm going to research companies that sale cloth pads and see if we can do some fundraisers to purchase cloth ones instead. I may also steer them toward the purchase of cloth diapers. I'm busy trying to set up birth centers, hospitals and clinics for us to visit. Its fun to watch a new trip take shape. And... I'm also open to doing more travelogues!

Sunday, May 2, 2010

Late Preterm

I used to hear the term 'late preterm' and wonder, what are they talking about? Now I know all too well. Now that I've had a week to ruminate about the speaker last Saturday at the birth conference (not Ina Mae, the neonatologist, or was she a perinatologist, I can't recall). Anyway, she gave the most compelling presentation on late pretermers, that is babies born between 34 and 37 weeks pregnancy. Almost all the students that come into my classroom thinks that 37 weeks is full term. Some think 36 weeks is. How can this be? Easy, when our casual practice of inducing every woman anytime after her 36th week of pregnancy for every reason imaginable has made preterm birth commonplace. Even the March of Dimes is finally going after physicians for it's massive social induction rates. It's absolutely startling that folks are beginning to forget that babies need 38-42 weeks to gestate. I quiz every class of students about how long a normal pregnancy should be- and I always hear 36 or 37 weeks. These babies are actually premature, and belong in a class known as 'late preterm.' The speaker spoke compellingly about how these babies may be endangered by the fact that they appear physically mature, and as a result monitoring things like respiratory status, thermoregulation, serum glucose and other measures of neonatal wellbeing may not be as diligent. There is no doubt as to the cause of the spike in preterm deliveries. The culprit is inductions. Women have become intolerant of their pregnancies. Physicians can't resist the ability to jumpstart labors for the least provocation, sometimes for no provocation at all! All this belies the fact that babies still need the same amout of gestation time that they always have. Having babies be born prematurely for any reason other than medical imperative should be considered unethical. Yet it is so common, the practice of induction has slowly but surely redefined the public perception of what constitutes, 'full term pregnancy.' Many women now consider the presence of a NICU an important consideration in selecting a birthing facility. Well if they submit to induction technologies used prior to the start of true labor, they are probably going to need one.

Saturday, April 24, 2010

Old Hippie, Talking Smack

Ina Mae is here in town! She is speaking at a conference here in town. Here is a snapshot of her I took in California last Fall. For those who don't know, Ina Mae Gaskin is a pioneer in birth here in the US. She and her band of hippie followers started a commune in the 1970s in Tennessee devoted to (well lots of things, but one was natural birth) that triggered the homebirth movement here in the US. When I read her book, Spiritual Midwifery in 1978 as a 15 year old pregnant teen, it transformed my thinking on childbirth and truly set me on the course I am today. Her recent work on maternal mortality is, like her work on homebirth, ahead of it's time. She is a true hero to me. I've seen Ina Mae speak lots of times, but never here in my city. She rambled on the way she does in her stream of consciousness style of speaking. Her photos and stories of the commune days are always enjoyable. Her rantings about the benefits of 'socialized medicine' don't play as well here in the conservative midwest. A natural born storyteller, she was at her best, telling birth stories and spouting 'old folk' wisdom. What was best about the presentation was actually her audience- the people she drew to her. The audience was chock full of nursing babies and moms, as well as every type of midwife imagineable. That in itself is a feat. Ina Mae is one of a few people who can draw CNMs, CPMs, and DEMs, all to the same table together. I loved that audience. It was full of MY people. I wanted to rush around and hug everyone. I know all those women (and some men) are out in the world doing their thing to make birth better. I'm looking forward to the second day of the conference today and the learning and networking that will take place.

Tuesday, April 13, 2010

Travelogue Today


Today I will be holding the second of my three travelogues about my trip to Haiti at Brown Mackie College in Lenexa at 12-1. Anyone is welcome to attend.

Sunday, April 11, 2010

Infrastructure

Since I have returned from Haiti, folks often asked me, what is the single greatest need. My answer is always, unequivically, infrastructure. Like the bones of a body or the steel beam skeleton of a building, infrastructure is what you hang everything else on. Haiti lacks a public healthcare infrastructure from what I observed. This is why I fear there will be many more deaths to come. With the advent of the rainy season, standing water means disease, and in the tent cities, disease will spread like wild fire. Public health requires a preemptive strike such as immunizing against possible communicable diseases. Secondarily, you enact measures to control the spread of diseases that are not preventable, such as treating disease as it occurs. Third, you can teach prevention, such as teaching the public to cover their coughs, not share cups and glasses, wearing masks, etc. I see these kinds of public health teaching and public awareness campaigns as very difficult for a country that can't even keep electricity going throughout the day. Public health is built on a healthy infrastructure of rapid public communication with common goals and mission. Just the fact that so many countries have swooped in to help without a Haitian bureacracy to oversee it, betrays a lack of organization. I saw very little structure to the relief effort. My experience at Diquini Hospital was a prime example. On my last day, with the two American OBs, they sought to impose structure. I numbered all the beds and all the charts at their request. But the Haitian nurse saw it all as a nuisance. She had her own order, and it had nothing to do with ours. There is no consistancy in place to ensure that the 'order' we imposed on the unit will remain. When we left, it most likely went away as well. That is what Haiti needs, an imposed authoritative systemic order for delivering healthcare to a population that continues to have chronic healthcare needs apart from the acute ones imposed by the earthquake. A woman should not have to have her yeast infection treated at a temporary tent clinic. There should be a healthcare structure for that. How does Haiti acquire this public health infrastructure? Well that's another post entirely.

Friday, April 9, 2010

Travelogues


The dates are set. Here are my 3 upcoming travelogues about my trip to Haiti:
This Sunday: April 11, 2010
Cornerstone Community Church
74th and Metcalf
Overland Park KS
12:45-1:30 pm
Next Tuesday: April 13, 2010
Brown Mackie College
9705 Lenexa Drive
Lenexa KS 12-1pm
Next Sunday: April 18, 2010
New Life Community Church
16111 Vicie
Belton MO
1:00- 1:30
I'll also update everyone on my plans to return, and hopefully take a team of folks (including you) with me.

Thursday, April 8, 2010

Church Clinic





All these images were taken at our clinic held in a church. We didn't know at the time how luxurious our accommodations were. We were sheltered in a building out of the heat with private areas to talk to patients and give exams. Our entire team is pictured along with our interpreters. YaVonne in pink is a cardiac nurse, Emma ran our pharmacy, the other woman in green is a neurologist from New York, and my interpreter Kicki. We all worked well together and saw about 100 patients that day.





Quisqueya Calling

What a week. My students have been wonderful and clammering for a trip to Haiti! I even got the idea into my head to ask some local philantropists for the money to take them. I may be getting a little ahead of myself. My proposal for MANA was turned down. It wasn't very good anyway, and my book won't be ready by this Fall, so it's just as well. I am submitting a proposal for City Match though about Lessons from Haiti. All my speaking proposals for the next year will be about lessons from Haiti frankly (fined tuned to each conferences theme of course). Right now I'm busy planning at least 3 travelouges. Look for them on Facebook events. I really want to go back to Haiti as soon as possible. I recieved an email message from Quisqueya asking for medical teams to come. How can I make this happen?

Sunday, April 4, 2010

Haitian MD

I learned about a phenomenon that is probably ubiquitous in international medicine, and relief circles. It was however, new to me. On this particular trip, it was referred to as 'getting your Haitian MD.' I'll tell you a story that illustrates this phenomenon.
While at the Haitian Family Mission on the fourth day, we were in the midst of our outdoor clinic, under the almond tree. A man arrives carrying his crying little boy. Being in acute distress, they are ushered to the front of the line. The little boy has lacerated his finger while playing atop a building debris pile. (Remember, the piles of rubble are everywhere. Most of the buildings appear to be built of concrete, and it is piled mountain high with wires and metal pipes shooting out all over. They must be very tempting for a little boy.) It is a very severe cut requiring three or four stitches. There is no doctor with us on this particular day. I am on a team with a pharmacy tech, a couple of medics, an EMT, and a non-medical. The doctor working with the mission is on vacation. I am selected to do the stitches. Now I have only done stitches on uncooked chicken breasts. But thats more experience than anyone else on the team. We could send him to a hospital, but he might wait hours (even days). He's at the top of our clinic list, but he would be at the bottom at a hospital. So I resign myself to doing my first stitches on a real person. I draw up the lidocaine after locating a suitable needle and syringe and am about to administer it when I hear, "Here comes so and so, she can do stitches. She does them all the time." Talk about saved by the bell. I happily hand my syringe off to so and so and proceed to assist her as she administers four neat and tidy little stitches into the tiny finger. After she's done I wrap the finger in guaze and with the help of an interpreter, give Dad instructions on care and returning to have them removed. This shouldn't be a problem since the stitcher lives at the mission. Later in the day, when I ask the stitcher what specialty of nursing she practices, she stated matter of factly that she wasn't a nurse at all. Taken somewhat aback, I asked her what her training was in. She told me her formal training was something akin to a medic (I'm not sure what that training is.) I ask her where she learned to do stitches. She told me that even though she has very little formal training, she learned her skills from various doctors and nurses that pass through the mission. They let her observe and try skills out as they guide her. She got her training informally, hence, the "Haitian MD." She wore a white lab coat and had a stethoscope around her neck. It's true that even I was diagnosing and treating in the tent cities. I was treating diseases I had never even seen or heard of before. Does this sort of thing result in subpar care? I'm sure it must. Twice, my interpreter KiKi diagnosed my patients when I had no idea what I was looking at. A child came with a hard white plaque on her tongue and upper palate. I thought it was yeast until I palpated it and found it hard and unmoveable. I had never seen anything like it. I asked the other healthcare providers. They didn't know either. Then KiKi spoke up. "I don't know what the name is in English, but in Kreyol, we call it 'shunk' and they treat it by rubbing it with lemon and salt until it is rubbed off. It comes from kids putting all kinds of dirty things they find into their mouths." Well that was good enough for me. "Kiki, tell the Dad what you just told me, and tell him the treatment." I was horrified to think what that pretty little girl had put in her mouth to cause that awful looking fungal growth. She could no longer eat, and could barely talk. I shuddered even more to think of her Dad scrubbing her tongue with lemon and salt until it bled. But hey, I couldn't come up with anything better. The home grown cure seemed reasonable to me. We didn't have any antifungals except those to treat a yeast infection, and this was no yeast infection. In that moment I didn't think of KiKi as overstepping his bounds as an interpreter. I was very grateful to him for giving guidance on something I had never seen the likes of. My trip had been filled with many moments when I was looking around thinking, 'should I be doing this?' (things I would never be allowed to do 'back home.' But I wasn't at home. There was no one else to do it and I was knowledgeable (sometimes) and willing (everytime). In those moments, I know I too was getting my "Haitian MD."

Saturday, April 3, 2010

Art and Miquette


This lovely couple were our hosts at Quisqueya. Art ran the day to day operations, and Miquette gave us our daily assignments. They kept everything running smoothly for all the relief workers. Thanks Art and Miquette for all your hard work.



Friday, April 2, 2010

Kickolito- The Hope of Haiti

My interpreter, KiKi, is a 21 year old young man, with an earnest face and wise, old eyes. He is seated next to me in this photo with the baseball cap. I fell in love with KiKi. Unlike many of the interpreters (all bright young men from 19-25 years old) who joked and laughed, KiKi was always serious and focused. When we finally got a chance to chat, he told me his father was deceased, and he lived with his mother, and two younger brothers (18 and 14). He also has an older sister, but she lives on her own, so at 21 he is the man of the house. He spoke about the restoration of Haiti. How he wants to be a part of seeing her restored. I asked him what he wanted for himself. He said he is interested in designing energy efficient automobiles. That he plans to attend college here in Haiti. He thanked me for coming to help the people of Haiti. On our last day together, I wanted to take him out to dinner, as a thank you. He refused, stating, "If I come home late, my mother will worry." I thought of him riding home, an hour away in those crowded city tap taps. I asked him if his home was damaged by the quake. He said no. I can't imagine what life is like for him, and yet I feel such an affinity to him. Kiki is Haiti to me. If and when I return to Haiti, it will be partly to know that he is well.

Thursday, April 1, 2010

Images from Haiti




These are my first few images to post, in no certain order. There is a picture of me and my interpreter, Ki Ki, in a tent city clinic. I am giving instructions to a Dad on how to administer a medication to his child.
There is also a photo of me standing in front of our tap-tap that took us out to clinic everyday. The cages were for our safety. Driving over those bumpy roads could cause someone to fall out.

Position, Position, Position

I just have to say that those Haitian ladies really know how to move in labor. Without medications to keep them drugged and bedridden (they are no beds either after all!) they get up and move throughout their labors. In early labor we have them walk and drink water. During active labor I saw them sway their hips, kneel on the floor, get on all fours and sway back and forth, crawl around, stand and squat repeatedly, bend over holding on to beds and tables, lean against loved ones while squatting between their knees, tailor sit, and on and on and on. Because the women squat a lot while doing chores and cooking, they found it really easy to get into positions I can only dream of getting into. I was really impressed. The positions they were using as they labored, really allowed the pelvis to open and the babies to come down. More than once I suggested (to the OBs, not the midwives) to let the moms off the delivery table and let them move around. I did very little to direct their movement. I let them do what felt good to them and they sure showed me some new stuff. They were all over the floor. No birth ball needed! I never saw American women do the kinds of positioning I saw the Haitian women doing. Some were absolutely silent, but others were very vocal with their contractions. They chanted and even sang throughout their labors. I learned so much about the wisdom of the body in labor as I observed and worked with the Haitian mothers. My homebirth experience really prepared me to be useful in this kind of birthing environment.

Paradise for Babies

I was en route to Diquini hospital on my fourth day in Haiti when I passed a huge billboard that read: " Paradis Du Petites." There was a picture of a lovely Haitian mother holding her beautiful baby. Paradise for Little Ones. I assumed it was advertising a school or daycare center. But in truth, Haiti is not paradise for babies. The infant mortality rates are among the highest in the Western Hemisphere. (Maternity mortality rates are high as well.) I still wonder if that baby I saw on the first day with typhoid fever and a temp of 104 ever made it to the hospital. I understand the obstacles that keep families from going to the hospitals. First they need a way to get there. The hospitals are few and far between. Then they may wait many hours to be seen. If their child is then admitted, the family has to stay as well. Hospitals may not provide linen for the beds, or meals for the patients. Some may not give medication unless is is paid for first. Speaking of pay, financial burden is a big barrier as well. The hospital will insist on being paid and the family may not have the resources available. Babies with fevers and diarrhea are in a race against time. They may succumb to the dehydration before the fever breaks. Most of the babies I saw were on the downside of the disease process and were already afebrile. I was told that often if a mother sees her baby is ailing, she will emotionally detach from it. I was also told that if a hospitalized child appeared to be failing, the parents would leave the hospital and not return. I cannot judge how people find a way to cope in the face of such overwhelming challenges. I noticed that it took some work on my part to get the new mothers to warm toward their babies. Fortunately the grandmothers or aunts or female cousins were there to model bonding behavior. We often broke with hospital protocol and allowed the families to be with the laboring mothers. The Haitian doctors would shoo them out of the room, but when they left, we would let them right back in. I loved it when one of the midwives greeted each new baby with, "Welcome to the world, you are the hope of Haiti" and indeed they are.

Wednesday, March 31, 2010

Vaginal Breech

I arrived at Diquini Adventist Hospital for my last day in Haiti, this past Saturday. I knew the 3 midwives that I enjoyed working with would not be there, as it was their day off. Instead I found 2 young American OBs. Since it was their first day and they were getting acclimated to where things were, I was able to give them a quick orientation to where things were located. (I had helped one of the midwives organize the supplies a few days before- so glad we did that.) The maternity unit is located in a separate building from the main hospital. It is just adjacent to the hospital in a little one story building that houses pediatrics, maternity, and the GYN clinic. A cloth curtain separates the pediatric section from the maternity section. To reach the GYN clinic, we have to exit the building and walk around to the other side. There is much construction going on that separates the two ends of the building. The GYN clinic is basically done on the 'back porch' of the building. The maternity clinic has a 4 bed 'ward' with 4 more beds added in the hallway for a total of 8 beds. One of the OBs has a great idea to number the beds and locate all the charts for each patient. Simple as it sounds, this has not been done. I set to work making signs from masking tape and markers. I locate current patient charts stacked on the nurse's desk. We file away the patients that are no longer there, and place signs on the charts denoting which bed each patient is in. Now that we are organized (somewhat) we can better manage our care. Miraculously, the Haitian nurse assigned to this unit, seems to know all her patients, where to find their charts, and is very on top of the patients assessment and medication regimens. She carries on with her duties quite oblivious to us, and seems more annoyed than amused by our attempts at 'organization.' I decide not to give any medications because I'm afraid they'll be given twice, as she has not missed a dosage for any patient. Instead I assess new patients coming in who think they might be in labor. As usual it is a busy day. I set up for deliveries in the delivery room. Our delivery room, and the three surgical suites in the hospital are the only air conditioned rooms to be found in the hospital. As result, we get lots of staff wanting to 'visit' us. But its nice to meet and talk with folks when we have the time. Today the pediatric unit is staffed with ER nurses that came from Quisqueya with me this morning. We had a group of about 14 providers come to Diquini today- a huge group, including several physicians who will be kept busy all day in surgeries. There is never an inactive moment on the maternity unit. I do labor checks on the pregnant women, and postpartum checks on the recovering mothers. I make sure babies are getting on the breast, bleeding is under control, and that vital signs are normal. I chat with the two OBs who are adjusting themselves to the circumstances. One OB orders pain medication for a laboring patient. I assure her I have seen no such meds and that all labors are unmedicated. The other OB goes over to the hospital and brings back one small vial of nubain (1 vial!) It was all he could find. We treat it like gold. At one point, early in the day, the two OBs go over to the hospital to scout out the facilities, while I hold down the fort. While they are gone, one of the ER docs (whom I met at Quisqueya this morning on the truck) comes running in to tell me that a woman just arrived in the ER on the back of a truck in obvious labor. They didn't even get her out of the truck, they are just driving her right over. Do we have a stretcher to bring her in? Well, of course we don't, but no worry, a minute later she comes walking in between two of her relatives, and get on the delivery table (which is really just a rickety old GYN examining table without the stirrups attached.) I shoo everyone out so I can check her, one of the ER nurses from pediatrics stays to help me. I do a vaginal exam to check for dilation (she does appear in great discomfort) and the following thought pops into my head: "What the fuck is that?" I'm feeling something that I have never felt before after doing hundreds of these exams. It was bony and angular and I could not find cervix no matter where I "looked" (ie. touched). I'm not entirely sure what I'm feeling, but I know it is not a head. Besides that, mom was making pushing sounds. I check for cord, but do not feel that either (thank goodness). It occurs to me that I have never felt and actual breech presentation before, because in the US these patients are scheduled for cesareans before they start labor, typically. I withdraw my hand and attempt to find heart tones. Not sure of what exactly I felt, I placed the doppler at the base of her belly, and find heart tones of 110s. At this point the ER doc comes back in, and I relate to him my heart tone and exam findings. Did you check mom's heart rate, he asks. Great question. I get my stethoscope and get an apical pulse of 90s. What I heard on mom's lower belly could have been her. I had placed the fetoscope on her upper belly earlier and couldn't find heart tones. The ER Doc picks up the doppler and finds heart tones on her upper belly in the 130s on the first attempt (shoulda used my Leopold's!). We say simultaneously, 'breech'. Where are my OBs? The ER guy asks, Do you think they'll want to do a cesarean? I said, I'm sure they will. It just so happens I overheard a conversation they had with one another earlier about breeches. One asked the other if they had ever done vaginal breeches, and the other answers they had done 3 or 4 but that they would rather not. ER Guy leaves to scope out the possibility of a surgical suite for a cesarean. I get vitals on the woman and hope the OBs show up soon. I still don't know if she's complete or if I just can't feel the cervix, but I do know she is pushy. If there's going to be a cesarean I'll have to start an IV and foley. Just then, they return, I explain what's going on. (There's been a lot of commotion in the hallway with relatives, ER staff, interpreters, and pediatric staff). They both want to do a cesarean, but when the male OB checks her again, he says, it's too late. The pediatric nurses rush in and set up the warmer (newly arrived and circa 1980s) for infant resuscitation. They spend the entire delivery trying to figure out if and how the thing works, and getting the oxygen going (bless their hearts, they were working really hard with such limited supplies- they kept bringing in supplies from their area when they couldn't find them in ours). The male OB preps for delivery, sending me on a frantic search for a gown. (The midwives didn't bother, but both OBs insisted on being properly covered for deliveries.) I found one, helped him get it on and gloved and the patient is still pushing. We get her into pushing position (I hold one leg, the other OB holds the other) and on the first push like that, out pops a little leg. A couple pushes later, we get the other leg, and the OB delivers the baby to the armpits and wraps a blanket around the body (baby blankets are hard to come by around here, its really just a square piece a fabric we found). Next the OB doing the delivery (the male OB) reaches in to manipulate the arms out. With that done, the baby is out except for the head. We expect baby to be born any minute, but that is not what happens. It takes at least a full 10 minutes of manipulation, praying (The OB doing the delivery was praying audibly right next to me as he worked frantically to get the baby out. At one point the ER doc returned to report back about the availability of an OR. There are no phones, no intercom system, no pagers, nothing. The only way to communicate with another part of the hospital is to send out runners. That's why folks just walk back and forth when they want to find something out. So the ER doc comes back to say that there won't be an ER available for at least 30 more minutes. (Either its still in use or being cleaned.) The OB had just a few minutes before mentioned again the possibility of a cesarean and pushing the baby back up,but now without that as an option, he redoubled his efforts at manipulating the stuck head. I remember shouting to the ER nurses where things were located as they frantically tried to put their supplies together while I held on to mom's leg, tried to comfort and reassure her (in a foreign language!) and instructing our interpreter to glove up and hand the OB whatever he asked for. The other OB offered to do fundal pressure. Not sure about the merits of fundal pressure, I offered to apply suprapubic pressure. He said okay to both. We both applied pressure, the OB on the top of the fundus, and me with a fist right above the pubic bone, with mom's pushing. This made a little progress, then, with time quickly ticking by, the OB handed the wrapped baby to me (limp and blue in my hands) and cut an episiotomy and with a little more manipulation, baby's head finally came, followed immediately by the placenta. (more on that in a minute). We were all holding our breaths and praying. We all thought the same thing, this poor baby probably won't make it. He quickly clamped the cord and passed baby off the the waiting team of nurses at the warmer, two ER nurses and a family nurse practitioner leading the team. (Not a NICU nurse in the bunch!) I quickly turned my attention to mom as the OB and I worked to control her bleeding. I gave her pitocin IM and then set up supplies and lidocaine for a repair. I had the interpreter scrub into the sterile field and hand instruments to the doc because I ran between mom and the baby fetching supplies and equipment for both teams. Several minutes into the repair, we heard a baby start crying! Incredible. Surely this baby was snatched back from the jaws of death. I was amazed that our hodge podge team with our pieced together supplies and equipment had been effective. Even the OB was startled to hear the baby crying, and looked up from his repair with surprise and relief. Later as we all tried to piece together the delivery summary with the correct times (keeping track of the time everything occurred was actually MY job as the delivery nurse, but I had not looked at the clock even once during the entire ordeal) we mused about the placenta. It was worrisome, because we had no way of knowing how long that placenta was dislodged prior to the baby being born. It appeared to already be right there after the head was born. There was some risk of hypoxic injury to the baby, but we could ony speculate. The female OB thought there might have been an placental abruption, but I still wonder if fundal pressure might have had a role in dislodging the placenta prematurely. After mom and baby were stabilized, they were placed in a bed and left to breastfeed. We went on to another delivery.