Puzzle pieces

I've been back home for over a month. The first few days I had moments of crying hysterically for no reason, but then it stopped. As usual, I pushed it all down. Classes were starting, and 3rd year of medical school is no joke. 

So every once in a while, I find myself staring into nothing, feeling numb, wondering why. Then I remember. Chad. Dead babies. Hysterectomies. Faint heartbeats getting slower, then stopping, while I listened, knowing there was nothing I could do. 

These memories haunt me. I'm not thinking about them all the time, but one word, one picture of a healthy baby, and it all comes rushing back.

I'm not planning on going back to Chad, at least for a long while. And if I do, I'll try and steer clear of Ob/gyn. I can't handle it. It's too much for me. And like the advice on airplanes say, you have to put on your own oxygen mask before you can help others. I'm no good for anybody if I'm broken. 

So now I'm slowly putting myself back together. 

Maternal/fetal mortality and the wonders of modern medicine

I got called in at 2:56am for another c-section for a dead baby with a ruptured uterus which ended up needing a hysterectomy. I have lost count of how many of those I've assisted on in the 6 weeks I've been here. I bet most OB-GYNs in the developed world have never even seen one. (Feel free to correct me if I'm wrong).

I read somewhere recently that late fetal/newborn death rates were around 40% in the 1800s, and only with the advent of modern medicine, pre-natal care, ultrasound, etc., has it decreased as much as it did (to something like 4% globally-- I can't find the article now). According to Unicef data: "The lifetime risk of maternal death in high-income countries is 1 in 3,300, compared to 1 in 41 in low-income." http://data.unicef.org/topic/maternal-health/maternal-mortality/

Well, you might remember from an earlier post, that I said Chad was stuck in a way of life from 2000 years ago. And that means, maternal/fetal/newborn death is still ridiculously high. Unacceptably high.

Call me a wimp, call me a weakling, call me whatever you want, but it's been really hard for me, dealing with it all. Last week I only went to the OR one day, and dedicated myself to teaching at the nursing school. This is my last week, and honestly, I'm glad it is. 

Since I have been trying to push it all down and not think about it, I guess my brain decided to make me deal with it at night, in my dreams. So I've been having terrible dreams, waking up crying, and sleeping badly. Consequently, I'm tired all the time.

I'm glad and always in awe of people  like Dr. Danae, Dr. Olen (her husband), Dr. Bland (her dad), but I don't have what it takes to be a full-time doctor in a place like Chad. I'd last a month, maybe two, run away screaming and move to an island in the middle of the pacific, preferably populated by only nuns and cats (therefore no ruptured uteruses, dead babies, ectopic pregnancies, etc., etc., etc.).

So for those of you who might be wondering if I intend to be a full-time doctor in Africa someday, the answer is no. I couldn't handle it. I'm not strong enough. And that's ok. 

(That's a ruptured uterus, so badly ruptured that it was impossible to save. I think this is the one we gave 5 bags of blood cuz she just kept bleeding)

An Ode to Nurses

An ode to nurses

For the past 2 weeks, I've been giving Anatomy and Physiology classes for the nursing school attached to the hospital. It's just 2hrs a day, before I go to the OR. 

I love it. It has helped take my mind off things for a little while, and preparing the classes has been a great way to review stuff. 

But today, at the end of class, I stopped everything, turned off the powerpoint, and told them to pay very close attention because I was going to tell them the most important thing they need to learn about nursing: 

The doctors see a patient at rounds, for maybe 5 minutes a day. The doctor is the detective, that discovers what is wrong, and decides the treatment. But the nurses are the ones who actually treat the patients. The nurses are the ones who realize if something is wrong, and the patient is getting worse. Or if the treatment is working or not. 

If something goes wrong, the nurse is the first one to notice, and it is their responsibility to tell the doctor. The doctor can't guess or devine what is going on. The nurse is the eyes, the ears and the hands of the doctor. 

Nurses: don't underestimate the importance of your work. The doctors could never treat patients without you. 

Doctors: never forget that. Treat your nurses well, because the quality of patient care depends on your interactions with them.

Sadness

I'm not sure what to write. I think I'm a bit numb, pushing it all down, so I don't start crying every day. So many dead babies, ruptured uteruses, hysterectomies. Here, the value of a woman is measured in pregnancies. Some will agree to anticonceptives, because they know it's just for a while. Few want to tie their tubes, and that only if they've already had... 7-8 kids. We had an uterine rupture back to back with an ectopic, both women in their 13th pregnancy. One had 7 alive, the other 4. Can you imagine being pregnant 13 times and have only 4 living children? I don't know if they were all to term, some might have been miscarriages. But truth is, a lot of them die in their first week, or before they turn 5. The prevailing culture is that it's good to give water to newborn babies. We hammer into their heads that they cannot, under any circumstance, give them water before 6 months, but it happens. And the babies who are born at home (by far the overwhelming majority) don't have us hammering into their mom's heads not to give them water. 

There is no water/sewage system here. You walk around and see people defecating on the ground. Waterborne diseases are rampant, and we treat ALL our pediatric cases for parasites, regardless of presentation. Imagine what that does to a newborn baby, who should be safe and protected from any food/water borne disease by drinking only breastmilk. But isn't.

Yesterday I was out of commission myself, having eaten something someone kindly made for us, but gave me diarrhea. Today I was better, so I walk into the OR to see Dr. Danae in the middle of a hysterectomy. Ruptured uterus. The patient went to a village health center 40km away on Tuesday evening for prolonged labor and they referred her here. Who knows how long she had been in labor up to that point. Today is Thursday, and that's when they brought her here. The baby was dead, she was hemorrhaging, and a little longer, she would have died too. The baby was long dead, skin peeling off, flacid, like jelly. 4.2kg worth of a baby boy, who would have been big and strong, if only... so many things. 

She asked to see the baby. I wrapped him carefully, trying to cover the worst parts and took him near her face. A tear ran down from the corner of her eye. I almost lost it. 

Being in Chad is always hard. There are always cases that get to you. But the previous two times, I was working at a hospital with no OB-GYN. No ruptured uteruses, no ectopic pregnancies of 10wks with bellies full of blood, no hysterectomies, no dead babies. I've lost count how many we've had, and Saturday will be only 3 weeks since I got here.

There are good cases too, of course. To finish on a ligther note, I'll leave you with a picture of darling twin girls, born by C-section (mom had pre-eclampsia). My first (and so far only) set of twins. 

Being a doctor (or med student)

Being a doctor (or in my case, a med student) is a privilege and a responsibility beyond what I can actually fathom. I think if I stopped to think about it too much, it would overwhelm me. 

We are allowed access to people's bodies in a way nobody else, ever, is. We stick tubes down body orifices (urinary catheters, nasogastric tubes, ventilators). We insert our fingers and hands in those orifices and others that we make, by cutting them with a scalpel. We stick needles in their arms, back, groin, neck, feet, scalp. 

All of those "assaults" are allowed, because we want to make them better. Cure whatever is ailing them. Help them breathe. Help them eat. Deliver their babies. Fix that strangulated hernia. Remove that ovarian cyst. 

But what happens when medicine is not enough? When there's nothing we can do to help? 

We're there still. We hold a tiny hand wrapped around our fingers, and listen to a newborn's heartbeat slowing down, until it stops. You check your stethoscope. You reposition. You try to stimulate the baby, but you know he's gone. That tiny little life breathed only a few minutes, then stopped. And you were there. 

It is a privilege and an awesome responsibility to be a doctor (or med student). 

Babies

The maternity ward here is full to overflowing. There's people sleeping on the floor (they don't mind, sometimes they even prefer it, because that's what they're used to at home. Nobody has beds at home.)

Yesterday I finally had dinner at 9pm, only managed to sneak a couple of bites of chocolate around 4:30pm to avoid a hypoglycemic episode. We were in the OR until 8:30pm, which included a ruptured uterus where the sac was out of the uterus but intact, the placenta was in the uterus, but the baby was dead. We had to do a hysterectomy, the uterus was unsalvageable. 

Then an ectopic pregnancy with removal of fallopian tube. 

Then lots of other things (prostatectomy, giant lipoma, etc., and finished the day with a pre-eclampsia lady with twins at 33wks 4days. My first set of twinsies!! So adorable!! Mom and baby girls doing great this morning! 

But today I'm feeling like Izzie on Grey's Anatomy, when Addison has her taking care of a baby everyone knows is going to die. I'm monitoring this 1wk-old baby who probably has pneumonia, gasping for air and having very low sats even on O2. She's on antibiotics and I'm just sitting here making sure the nasal canulla doesn't fall out. The pulse ox we have is too big for little baby fingers, so it's impossible to keep it on. There's nothing else I can do, except watch her. She'll either get better or die. I can only hope and pray her little body is strong enough to fight whatever infection is ailing her. 

Surgery on steroids

Thursday we did two mastectomies, two hernias, a hydrocele, a lipoma, drained a neck abscess and I don't remember what else. Today we did a prostatectomy, two hernias, a tube ligation, sutured an eyelid, saw a kid eviscerated by a bycicle (seriously!) and put it back together, and sutured an arm that was hacked to pieces in a machette fight. Not to mention the consults. And rounds. 

I get to practice my subcutaneous sutures on every patient, my LPs while doing the spinal anaesthesia, and generally have a great time sticking my hands inside patients, looking for a prostate here, a fallopian tube there. To me, this is kinda like Disneyland: you stand around for hours but you have fun anyway. My legs and back are always killing me at the end of the day, I'm basically standing up from 8am-6pm straight.* No pause, no lunch, no bathroom break. And I love every second of it. I don't even remember I'm hungry until we finish the last case. Then my stomach wakes up and screams at me, demanding to be filled. 😂😂😂

We saw a baby with a meningocele on the lower back and hydrocephalus. He already had trouble opening his eyes. And there's nothing we can do. We sent them home. The baby will get worse and worse, without any way to relieve the pressure on his brain, and he'll die. There's no neurosurgeon here. No imaging (beyond ultrasound). No instruments or materials to insert a shunt. 

Neurosurgery is not an easy specialty to practice in Africa. At least, it seems impossible in Chad. Hence why Danae is trying to convince me to do OB just like Dr. Scott tried to convince me to do general surgery. But just touching that baby's soft spot, knowing his brain was right there, gave me a chill. I really don't think I'm gonna change my mind (although the only thing that could possibly do it, is cardio). 

We also saw a little one with a hemangioma on the left hand. We're going to operate on Monday. Should go well, but we might lose the little finger. Hopefully we can save it though. 

Anyway: lots and lots of work, every day, from morning 'till night. I'm not complaining. 😊😊😊

*I guess surgery rotations in the US are worse, you have to be there at 4-5am. We start rounds at 8am here and OR after that, usually around 10am, until 6pm and doing consults in between surgeries.

Mastectomy for advanced breast cancer. Non-curative, her lymph nodes were already involved, but hopefully this will give her more time.

Loosening a prostate with my fingers. There's no way to do transurethral prostatectomies here, so it's still done old school, through the bladder.

That was only the first half of the prostate!! 

Concentrating on my sutures! :) 

The thing about Tchad

Being here is a crazy mixture of awesome and heartbreaking sadness. I was talking to Dr. Danae today, about the fact that I don't plan on coming to work in Africa full time once I graduate, because I don't think I could take it. I would eventually just want to crawl into bed and cry myself into oblivion.

Take today for example: we started with a woman who got to the hospital at 5:30am after many many hours in labor at home. Baby no longer had a heartbeat. Uterine rupture, and so badly ripped that she needed a hysterectomy. She had had 5 kids (including the baby this morning), but only 2 were still alive. After the surgery, we asked if she wanted to see the baby, and watching her hold it just broke my heart. I can't imagine going through that. 

The very next case was a 27yo with advanced breast cancer. We did a mastectomy, but only to give her more time, as it has already spread to her lymph nodes and there's really nothing more we can do. (Pictures at the end, scroll carefully if you don't want to see it).

Then an elderly man came to say his wife, who also had had a mastectomy for advanced breast cancer was having trouble breathing and was complaining of pain. Nothing we can do, except give her some pain meds. 

Then a woman with a urovaginal fistula, who had it for 10 years. Imagine leaking urine 24hrs a day for 10 years. Imagine it for just 1 day. 1 hour even! Not being able to sit down without leaving a puddle. Walking and having urine run down your legs. Your clothes, constantly soaked. The smell of urine like your shadow, always there. 

That was an incredible surgery. It took 4hrs. It was hard and physically challenging, but also very rewarding. Barring any complications, this woman will soon be able to hold urine in her bladder, and void it only when she wants to. I'm really excited for her! 

You see what I mean? It started with a couple of really sad cases, but ended on a happy note. Plus, I get to be in the OR all day, every day. The OR is definitely my happy place. I get to do stuff, like stick giant needles into people's backs (spinal anesthesia), or suture the skin at the end of a case (I'm already getting faster! Closed a hernia in 5 minutes today!!) 

So yes, I love coming to Tchad. The experiences I have here are invaluable, for my training as a doctor as well as for my growth as a person. I intend to come back every year, whenever I have a chance, but I don't see myself staying here long term. 

But then again, God might have other plans... 

My first day at the Bere hospital in Chad!

My first day in Bere

Chad is always very labor intensive. During my two previous times, there was usually little free time, and that suited me just fine. But we rarely had middle-of-the-night emergencies, if someone came in at night and wasn't bleeding profusely, the nurses dealt with it until morning and didn't call Dr. Scott (or me, of course). 

Now I'm at a different hospital which does *a lot* of Obstetrics. I arrived in Chad at 4:30am Saturday, got on a bus at 5:30am to go 7hrs south to Kelo, where Zach was waiting to pick me up for another 1h30min on a dirt road. I got to Bere at 2pm Saturday (which is our day off). 

At 2am I get a call from Danae, there are 2 complicated labors which will possibly turn into C-sections. I got up and ran, obviously! These would be my first time seeing a birth, ever! 

The first one isn't coming out, but the mom was still trying. Finally, with forceps, the baby came out and did great! So did the mom (although she had a grade 3 vaginal laceration -- if you don't know what that means, don't ask. Just know that it hurts). 

The second just needed more time, really. By the time the first one had delivered, the second was progressing nicely. No forceps or C-section needed!! 

Then back to bed at 5am. Up again at 8am, shower (cold water is great to wake up in the morning!) coffee and rounds. Which took forever. Which also included two other deliveries, one mom with a prolapsed cord (baby didn't make it😰) and one with her 6th baby, at a whopping 4,9kg! I got to cut the cord! 

Then to the OR for a C-section. She also had had several babies and the last one was a C-section. Dr. Danae (the superwoman OB-GYN) was afraid of a uterine rupture, the baby was big and she had not progressed all morning. So it was just the two of us-- I assisted on my very first C-section! And got to close the skin at the end!

We finished by 2pm, and in 12hrs I had watched the birth of 5 babies!!!! Talk about intense! 

But it wasn't over: a guy came in who had gotten on a fight against a machette and had deep lacerations on his arm and thigh, plus broken arm. Had been two days though, and he had lunch before coming, so we cleaned and packed his wounds, and will take him to the OR tomorrow. 

I also watched one woman get a birth control implanted, and immediately after implanted one myself! 

Only the. Did I go home to shower (again!), change and eat. At 5pm. 

So all in all, this was an incredibly eventful and awesome day. 

6 more weeks to go! 😊

P.S.: as fun as this day was, I am *not* going into OB and I'm also more convinced than ever that if I have a baby, it will be by scheduled C-section. My vjay-jay is *not* going through that. 😳😳😳