Merry Christmas!!

I haven’t written here in forever. This year was one of the hardest years of my life, and I had too much going on trying to keep my head above water, to think about writing. 

But now that the year is almost over, I figured I should write something. Because I survived. Not only that, I’m actually OK. 

This year started with me buying a house-in-ruins, that I planned to finish demolishing and rebuilding it as my house. While I rebuilt it, I moved in with a friend who kindly offered to host me (for free!) while I made my house habitable. 

In med school, I started rotating through OB/GYN. If you remember my traumatic experience in Chad from last year, you can imagine this was not easy. It brought back memories. There were times I had to distract myself, or literally leave the room, in order to not start crying. 

Med school is a full time job. Building a house, is also a full time job. And I was also working as an English teacher, a few hours a week. I was physically and emotionally exhausted. 

Then I moved, while the house was still a construction zone. And started rotating through pediatrics, at a hospital 1.5hrs away. Then I ran out of money for the house. So now I was getting no sleep (because I had to get up at 5am) and I was very stressed and regretted buying the house. 

Pediatrics was, in a way, worse than ob/gyn. I had PTSD from my time in Chad about ob/gyn. But I want to have children, and seeing and interacting with these precious kiddos day in and day out, and seeing many of them being mistreated or simply needing so much more (anything, love, food, education, care) than they were getting, just about broke me. I kept thinking I could do better. And maybe I couldn’t. But my brain and my uterus kept yelling at me that I could do better and give me those kids and let me take care of them, damn it! 

I was about to break. And then, my 7-month pregnant cousin died of an aneurysm, the baby survived but had to be in the NICU for a few weeks, the family lived far away, and it fell to me, to go see her (the baby) and give her all the love and affection I could, until she could go home. Far away. Far away from me. 

So I did. I took care of this tiny little human, and loved her, and gave her my heart, and then... her dad came and took her (rightfully) away. And I broke. 

I was still rotating through peds. It was almost exams time and I could barely force myself to get out of bed and keep moving. 

But somehow I did. 

I kept going, managed to get honors in peds (I have no idea how!!) and get the house almost finished (with a LOT of financial help from my wonderful mom, who paid for my kitchen, among other things). 

And now, it’s Christmas. I am currently sitting at an airport bar, waiting for a flight to Mexico, a place I’ve already been, so I can turn off my brain and do nothing, but lie on the sand, bake in the sun, drink margaritas and eat tacos. 

Moral of the (very long) story: we are stronger than we think. If you’re going through a rough patch, know it, in your heart and soul, that it will be ok. YOU will be ok. I promise. 

Merry Christmas. 

Neonatal resus, or how not to kill a baby

I haven't written here in quite a while. The 3rd year of med school was really hard, and after my last time in Chad, I was not in a good place emotionally, which made it all even more difficult. At the end of the year, we have an exam that is the equivalent of Step 1 in the US, which allows us to pass on to clinical rotations during 4th year. Here med school is 6 years, 3 basic sciences and 3 of rotations.

It was hard, but I passed, bought a house (no joke!) and went on vacation for 5 weeks through Central America (Mexico, Belize, Costa Rica and Panama) which did wonders for my mental health. I came back rested and feeling better than I had in a while. Ready to start rotations.

However, as luck would have it, my 1st rotation was OB/GYN. And I started to have flashbacks from Chad. From hemorrhaging mothers and ruptured uteruses, and dead babies. More than once, I had to force myself to think of something else, look out the window and distract myself, so as to not start crying. Nobody here, the residents, attendings, fellow students, know that I've been to Chad and have seen more tragic outcomes in 6 weeks than they will see in their entire careers. As an inexperienced med student with no way to process any of it, and in a setting so poor in resources, than even if I had known what to do, I wouldn't have had the materials necessary to do it.

But let's skip over my 4 months in OB/GYN and jump forward to today. I have now started a 3-week rotation in Neonatology, before moving onto Pediatrics. And today we had a class and sim-lab for neonatal resus. I held it together by forcing myself to concentrate and actually learn everything I could, practicing manual ventilation and intubation, and learning all PEEP and PIP parameters.

At the end of the class, I walked out quickly, trying to hold back the tears. I couldn't stop thinking of one baby in particular, in Chad, who was born alive but died while I auscultated his diminishing heartbeats. That moment will be etched in my memory forever. The feeling. The shock. The numbness that followed. The only ambu bag we had was pediatric, which the nurse was trying to use but I don't think our efforts at ventilating were at all successful. The OB/GYN was busy trying to save the mother's life. I had no idea what to do, and there was no one else. I *know* that there was nothing else I could have done. But right now, I feel like I killed that baby. I feel like I should've been better prepared. And I'm fairly certain that, had that baby been born in a hospital with a NICU, or at least a neonatologist and better equipment, that baby would not have died.

THE UNFAIRNESS OF THIS WORLD MAKES ME INCREDIBLY ANGRY AND SAD.
(Sorry for yelling, but I can't help it.)

The world in 2018 is a disaster, and instead of improving, everything is going to hell. Instead of having a better division of resources, we're polarizing more and more. The rich are getting richer, and the poor are struggling to stay alive. The feeling of impotence and the anger at the world, at the leaders, at the greed of the richest and the apathy of...pretty much everyone (myself included) is getting to me. We need to do better. *I* need to do better. 

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).