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Nursing in Haiti - ‘best practice’ here is just doing the best you can

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Nursing Times’ resident Haiti-based nurse Fi Stephenson on helping patients in the earthquake-hit country get back to their normal lives.

It has been rather a long time since I put words on paper so to speak. The days and months have flown by. So a huge hello from me in Haiti! I have been without a computer since April and at times have felt as though my arm has been cut off (metaphorically speaking!). I didn’t realise how much it helps to write things down and reflect on what has been going on, so it is a relief to be able to find some time to sit and scribble down a few thoughts.

I am thrilled to say that after such a long haul, every single one of our patients has now sat in a wheelchair – even if for just a few minutes! What an incredible moment for them. Having been flat on their beds for such a long time it is no wonder this event was celebrated with clapping and shouts of “bravo!” from their friends, families and the staff. Our physiotherapists and occupational therapists from Healing Hands have done an awesome job in helping them take another step towards their new future, and the patients beaming smiles of achievement have been imprinted in my mind.

I have grown to love all the patients who I have had the privilege to care for – they are part of my family. I see each one of them individually every day to say good morning, to see if they slept well, are eating and drinking, find out if they have pain or a fever, as well as other social and psychological enquiries. After a long day, I bid them a ‘bon nuit’ and say that I will see them in the morning; a subconscious habit I have been carrying out every day, whilst here, since they were admitted. I didn’t really realize how much this meant to them until Gordon pointed it out. I guess this is part of the unwritten routine of life here on the ward and something that the patients (and I) have come to depend on.

It is with a mix of sadness and happiness that I feel when I say goodbye to our patients when they go home to port Au Prince. I probably will not ever see them again. I know you could say that about a lot of patients you care for in the west but somehow this feels different. I guess it may be because we have all shared in something truly tragic – catastrophic – but also in their physical and mental recovery and hope for the future. Last week, two patients went home. Tabatha had been admitted with a broken down wound showing the metal work attached to her spine and unable to walk following her spinal cord injury and fixation. She left, able to walk in a straight line, with a straight back, without any aids. Her wound had completely healed. Yeah! She went home to her husband, son, sister and parents.  Jeremy had also been admitted with two broken down wounds and had not learnt to walk again yet. Another success story! Whoo hoo! I have heard from him since he left, which is wonderful. Our Port Au Prince link, Gail, has seen him and visited his ‘home’ (literally a pile of rubble with a tent pitched to the side of it now). He has also been followed up by our Haitian Rehabilitation Doctor who has a practice down there and also works with us 3 days a week. Can you believe it …… continuity of care – fantastic!

Today, Gordon was discharged from the unit. His profession was, and still is – or will be again - (I hope), a mathematics professor teaching 8 to 11 year olds. A gentle, kind, and deeply religious person, with a cheerful smile, and who always gave encouragement to all his fellow patients. He was a mean card player – played all day with his friends and always won! He called me “Fion”. I really cried when he left, and to be honest, it is hard to write whilst thinking about it. He was our first male paraplegic patient to be admitted. I remember planning his room for him and picking him up from another hospital. He had three pressure ulcers, was a diabetic and had an unstable vertebral column. He was incontinent and unable to move himself. He was weak and thin and his friend, Monica, did everything for him. How mind blowing to see him looking healthy, independent, walking with his frame to the ambulance, without a catheter, and with a functioning bowel and bladder!!! Even his diabetes was stable! Awesome!

Thinking about it, I have admitted every single patient here. Started every set of notes. Every care plan. Every wound assessment. It sounds as if I am bragging but I am not. It is just a simple fact, and I guess this is why I am feeling the way I am.

Perhaps today my emotions are linked with a whole load of other stuff that is going on here. The whole area of spinal care in Haiti is starting to evolve as outside agencies come together and the shock of the earthquake has started to subside. The road to better permanent specialist care, although becoming a little clearer, is still very uncertain though. What will happen to the people who need permanent care and/or assisted living? What will happen to our ‘super quad’ and complete spinal cord injury patients who will never walk again? This is something that has never been accepted in Haiti in the past. To have a broken back or neck was a certain death sentence. Most disabilities and special needs were hidden away, and still are. I guess, out of bad comes good. The negative was the earthquake. The positive is that the people who sustained such devastating injuries will have a better future as Haiti now has to face up to this fact. But where do you start? Foreign organizations have the means to finance and build housing …. The problem is obtaining the land. Specialist care can be brought in from other countries. The problem is sustaining it.

The build up to a ‘discharge home’ over here is very different to the type we are used to in the UK. Over in the UK it is more along the lines of ticking the box regarding social services input, maybe a few phone calls, medication to take home, follow up appointment with the specialist and/or GP, etc. Here it is another story. The tick box includes; tent (which we show them how to erect), mosquito net, kitchen equipment, clothing, shoes, money, walking frame, wheelchair, xrays, discharge letter, contact telephone numbers for help in Port Au Prince. Transport home means a helicopter or plane. To travel by road with a back injury would undo a lot of good work for a while, to say the least, and not a good start to sleeping in a tent. 9hrs drive over the worst roads imaginable. (I still remember my trip to and from PAP in the back of an aid truck; the best way to get a whip lash injury and  a good work out through all the bracing to avoid being caught off balance!).

Our patients need to be able to get up off the floor independantly, as they will be sleeping on it. We also need to ensure that they are able to use any type of toilet; whether it is a hole in the ground or a plank of wood with a hole cut in the middle. The terrain around the hospital is an ideal natural test as it is bumpy with pot holes, there are inclines and steps, so we can ascertain if they are ‘fit for discharge’. To walk to the road and back, passing the Maison de Benediction (Children’s home, where I live), across the field in front of the hospital, and down the uneven track to the clinic is the perfect assault course. If they pass that … they get the green light! I am very proud to say that we are able to provide our patients with a ten man tent and equipment for 10 people. Lisa, our Rehab Co-ordinator, has done an incredible job and has been instrumental in raising money so that we can give our patients a financial hand so to speak ……. More needed though …… as we have a lot more patients in the pipe line to discharge!

Another important part of the discharge plan is to introduce them to the outside world again. Since January 12th, they have only been in a hospital environment so it is really important that they get to see the outside world again. With this in mind we take them into Cap Haitien to experience the hustle and bustle of everyday Haitian life. This social integration in itself has definitely been well received and is a definite aid to their recovery.

 It has been a hot, humid and busy rollercoaster. The weather is due to get worse and we are about to brace ourselves for the Hurricane season. A lot of rain has been predicted and we are meant to be getting our share of hurricanes – but weather men are always wrong …. Right? We are on relatively flat ground so should be safe if there are land slides. I have insisted on a Hurricane Policy so that we have a ‘system in place’ just in case we are faced with such an eventuality.

So what else is new? We have 4 baby rabbits, one of the dogs is pregnant! And the cockerel is still crowing at strange unsocial hours!

We go through phases of no running water, no gas and no electricity. So having a bucket wash, cooking with charcoal and using a torch is nothing new and part of normal Haitian life.

Medical teams continue to change every 2 weeks; bringing new ideas - which is not a bad thing - but draining when you have to explain ‘Haiti’ all the time, and why things may not work. It is tricky when one has to ask people to be like sponges – just for a day or two – instead of coming in and trying to change everything. (Is this a human trait as it seems to happen so often?) I know people feel the need to ‘help’ but …… I just feel for the nurses and patients…. Why change something if it does not need to be fixed? A good life lesson; when going somewhere new, please wait awhile, open your eyes and watch, open your ears and listen, and open your mind and learn. Maybe the locals and people who have been there awhile know best given the circumstances ? Medicine and everything linked to it is just not like the western world. To survive you have to adapt and be flexible. Best practice as we know it in the western world is not like best practice here. In Haiti ‘Best Practice’ is doing the best you can given the circumstances, with an ounce of initiative, a dollop of adaptation, a hand full of flexibility and a pinch of lateral thinking thrown in. Anyone who comes here bringing strict policies and guidelines to follow is in for a shock. Just because something is done a certain way ‘at home’ does not mean it will work over here! Enough said!

The other day our Medical Director, Dr T, gleefully came up to me with an envelope that he had been waving in his hand. The contents were beautifully written with a large stamp of authority at the bottom. Having got it translated it appeared that I had been invited as a special guest of honour to attend the Fete de Moisson (Harvest Festival) in the Main Baptiste Convention Church in Cap Haitien; I must say I felt very proud to have been invited! My container dress was dusted off and given a good shake. I borrowed a pair of shoes 3 sizes too big but they were better than my grubby old crocs and flip flops (my only footwear as I had given my walking boots away to Tabatha who had been discharged the week before – not that I would have worn those with my dress!). The Church was packed with everyone dressed in their Sunday best. The inside of the building had been decorated with colourful banners and ribbons, tropical flowers, fresh fruit and vegetables. Donations from the locals included sacks of rice, beans, a painting, 2 cockerels (alive), bottled and bagged safe water, cooked food and so on. We had managed to get hold of 200 mosquito nets so I took them with me as a donation from the Haiti Hospital Appeal. All these donations, were for the very poor in Cap Haitien so each and every donation was an amazing gift as these people had between zero and nothing. Unfortunately my Creole is far from good so it was hard to follow the exact words of the service…. The singing was unbelievably beautifully. The whole of the front of the church was filled with the choir – there must have been over one hundred people singing. Their harmony was mesmerizing. I had a seat at the front and sat with our hospital administrator who had accompanied me. At the beginning of the proceedings I had been introduced to Pastor Voltaire, head pastor of the Baptiste Convention, so I thanked him for my special invitation in my simple Creole. Needless to say I was taken by surprise when, half way through the (almost four hour) service,  Julian nudged me to stand up as Pastor Voltaire was introducing me to the congregation! He thanked me for all my work in helping the people of Haiti and caring for the earthquake victims since January. There was lots of clapping and smiling and I must admit that I felt very proud. I guess because I have been here for so long now, my work has become my everyday normality. I had not expected this, but do you know what, it gave me a real boost and a sense of achievement J. I was also given a Bibla Kreol (Creole bible) with a hand written entry in celebration of the Fete de Moisson 2010. I was chuffed to bits! This meant so much to me as this really is the symbol of the Haitian people’s strength and I know that I will cherish this forever.

When I got back to the ward that afternoon, I shared this experience with some of the patients. Diana heard that I had been given a Creole Bible at the Harvest Festival and told me of a passage to read; Ezekyel 37. I asked Pastor Donny to translate it for me later that day – her message to me was all about keeping hope alive and gaining strength in difficult circumstances. She is right. This is exactly what keeps people going – especially in Haiti, and especially people like Diana, a nurse, with a complete spinal cord injury, and who will never walk again – or will she?

The occasional street unrest goes on. This time it was protesting against the government  and their lack of help for the general population. The UN (Chile) provided us with an escort through Cap Haitien to take the Healing Hands team back to their hotel.  Bottles had been thrown for most of the day. One person had been shot dead by the local police earlier in that day. Our escort was just a precaution as things had settled down by the time the team needed to go home but it was comforting to know that we could call on the UN if we needed them. Civil unrest  seems to bubble under the surface and it does not take much to fire people up. The Cap Haitien population has swollen to well over a million now as people move to their extended families, out of Port Au Prince, to find jobs and a new safer life. This has a knock on effect and street crime has risen amongst other things that goes with an over population. The local public hospital is full, there are more homeless adults and children on the streets….

But to end on a good note, the sun is shining here and it was Mothers Day in Haiti the other day. Our physio aid’s wife had a baby boy – mother and son doing well J– bonne fête!

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Readers' comments (1)

  • Latterlife Midwife

    Absolutely lovely! I can 'see' and 'hear' it all just from your descriptions, though that's probably just one half of how it really is.

    Fresh Eyes can be a good thing, but I can imagine how every new arrival is taken aback by the reality and starts spouting off suggestions before they know what's realistic, so why not just print this out and hand it over each time? You've said it all! "A good life lesson; when going somewhere new, please wait awhile, open your eyes and watch, open your ears and listen, and open your mind and learn. Maybe the locals and people who have been there awhile know best given the circumstances ? Medicine and everything linked to it is just not like the western world. To survive you have to adapt and be flexible. Best practice as we know it in the western world is not like best practice here. In Haiti ‘Best Practice’ is doing the best you can given the circumstances, with an ounce of initiative, a dollop of adaptation, a hand full of flexibility and a pinch of lateral thinking thrown in. Anyone who comes here bringing strict policies and guidelines to follow is in for a shock. Just because something is done a certain way ‘at home’ does not mean it will work over here! Enough said!"

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