Ah.....Berega

When Dr. Masenga told me we were going to Berega Hospital in Morogoro to do obstetric fistula surgery, I looked at the map and was able to find Morogoro: A decent sized city in central Tanzania. I didn't find Berega, 130 km west of Morogoro and 40 kilometers from the nearest electricity pole. The drive was beautiful, but it also acutely illustrated for us the deadly reality of living in remote settings for women in labour.

During the first day of surgery, we paused between the first and second surgery long enough to clean the operating room when a woman came in with obstructed labour. She had been labouring for two days and had been transported 15 kilometers on the back of a bicycle to arrive at Berega hospital. The medical officer in charge and an assistant did the cesarean delivery and the baby was blue and floppy. No breathing, a heart beat of about 60 beats per minute. Dr. Mkambo, , one of our chief residents from KCMC, Dr. Vasquez and I and rushed to the baby to help resuscitate. 20 minutes of Bag mask ventilation, chest compressions and a dose of epinephrine later the baby was pink and crying, a little. Mother was fine. This is what we call a near miss for both mother and baby. Two hours later the baby would have been dead and the mother potentially with greater injury. It was great to see Mkambo, just recently trained in NRP and ALSO, seize the opportunity to do what he knew he could to save the baby.


There are countless women who fall on the other side of that "near miss" line.........Waited for too long to decide to come to the hospital. Family could not afford her to go to the hospital. There was no transportation and it was rainy season and the only bicycle in the village could not make it with a pregnant woman in labour on the back. They reached the hospital, but there was no surgeon there to attend to her or she could not pay for her care and was turned away to another facility 50 kilometers away. She arrived on time to the hospital, but waited in labour for 3 days there before anyone attended to her. These are the stories fistula patients tell.

Berega was beautiful. Mud huts, brick homes, beautiful, friendly people with a connection to the land and themselves. Women collected water from holes they dug in a dried up wash a couple of kilometers from town. Women with babies on their backs who survived intact from their deliveries. It was a good trip.

Update

We've been busy lately and the internet access has been sufficiently unreliable as to discourage an attempt at a long posting. We've accomplished a lot over the last month, especially with emergency obstetrics and neonatal resuscitation teaching. Drs. Mary Hartman and Peter Michelson as well as Janet Fields, nurse midwife, joined us from Nov 3-12 to teach neonatal resuscitation and emergency obstetrics to all of the obstetric providers at KCMC hospital. We have seen the direct impact of this teaching on the lives of women and babies here. One example: We were called a few days ago by one of the residents to an emergency: a woman with antepartum hemorrhage. She had a placenta previa (the placenta is covering the opening of the womb) and had bled profusely at home. We arrived on the scene and the nurses and resident had placed two large bore IV's with fluids running wide open, the patient was in trendelenburg position (head lower than feet, to optimize blood pressure), the operating theatre and blood were being prepared, vitals were being monitored and there was a distinct sense of personal and professional satisfaction amongst her providers that she was receiving the best care possible. Her baby did not make it, but she did. The loss of fetal and neonatal life here is tragically common.

Brandi has prepared emergency kits for the labor ward to deal with postpartum hemorrhage and eclamptic seizures and these are present and available in the ward and have been well received by all of the staff. We have set up refresher courses for all of the providers and plan to assess the level of knowledge and skills retained in this methodology.

We are travelling to Morogoro this weekend for a week long fistula treatment and training camp at Berega hospital and have a similar trip planned to Dodoma in January. We are collaborating with AMREF (http://www.amref.org/) and CCBRT (http://www.ccbrt.or.tz/) with these efforts as well as expanding fistula services at KCMC.

With the help of Vera Mushi, we have identified and travelled to 4 outlying centers to help establish global health rotations for the PA students from Duke. KCMC is a wonderful place to learn medicine, but has many learners and cannot accomodate too many more.

Brandi and Dr. Oneko are meeting with Merck Pharm this evening to discuss potential studies in Cervical Cancer and HPV here in the future. A promising lead.

Looking forward to hearing from you here in Moshi!

JW