I was called to assist with a potential neonatal resuscitation. I didn’t know anything about the patient, her pregnancy history, or her labor issues. I barely had time to put on a white coat and gloves. Peeking into the c-section room from the hallway, I could see the mother with her arms outstretched, and two physicians scrubbed and already starting the surgery. I checked to make sure the ambu bag, oxygen tank, the infant warmer, and the suction tubing were all functional. But I didn’t need to- - the midwife was two steps ahead of me diligently checking over everything. The Labor ward was quite calm, different from my U.S. experience where any potential resuscitation would be surrounded by an atmosphere of nervous tension. Or maybe it has always been just MY nervous tension that I have brought to the labor ward.
When I peek again into the c-section room, another physician has scrubbed in, and I wish I had time to find out the mother’s pregnancy and labor history. Three physicians scrubbed in for a c-section is not a good sign (unless they are teaching new residents). The baby is pulled out, but doesn’t make a sound as it is wrapped in a cloth and rushed to the resuscitation room. We open the cloth to find a limp, wet, slightly blue baby who is not breathing. There are suddenly six hands trying to stimulate, warm, dry, cajole, suction and assess the child. We all try to take a different part of the baby- one person is drying, one person is suctioning, one person is getting the ambu bag ready. I realize that I haven’t looked at the newborn resuscitation algorithm in two months, and in that time I have been travelling, writing grant proposals and scheduling courses and so my algorithm retrieval sections of the brain are sluggish. But with six hands that all know something about resuscitating a baby, I’m hopeful that we can get the baby to cry.
When is a cry more desperately needed than in the first few seconds of life? The three of us (two doctors, one nurse) are all working feverishly to get this baby to cry. In most other settings, we try to dampen a baby’s cry (during vaccine injections, ear checks , late night awakenings, long airplane flights).
After the first seconds of stimulation and assessment , the ambu bag is used, the mask is snug on the baby’s face, and someone is giving positive pressure ventilation. Not me, though. I have taken my hands off the baby, and I notice that she is a girl. A beautiful baby girl, perhaps the mother’s first baby. The other doctor doesn’t know the mother’s history either, as he was called at the last minute also. After just twenty seconds, the baby starts to sputter, fight, and get agitated. And then she belts out a huge cry, a howl of indignation.
Yes!
We three adults finally exhale, smile, and start talking. The midwife takes over completely, as she has years more experience in what the newborn baby needs now. But I stand and coo over the crying baby, happy to hear her. I remember that the c-section room is just across the hall, and perhaps the baby’s mother is also hearing her baby cry for the first time. I think about hearing my children’s first cries, and the relief I felt. It is enough to make me cry as well, and I leave the room quickly.
I still hear the baby crying as I leave the labor ward. What a great sound.
Monday, August 3, 2009
Tuesday, June 2, 2009
Rallying for Safer Motherhood
This is the 1st time that I’ve participated in a Safe Motherhood event that featured a clown wearing stilts.
We drove out to Karatu in the Arusha Region more than 3 hours away from Moshi. We went with Mackrine Shao, Regional Coordinator for the White Ribbon Alliance (WRA). The International WRA has gained a lot of positive attention, with celebrity and political endorsements (Sarah Brown, wife of England’s prime minister Gordon Brown, is WRA’s patron, and names associated with WRA events include Melinda Gates, congresspeople and actresses). WRA-Tanzania, I’m proud to say, is quite an energetic national association.
Mrs. Shao is the epitome of a dynamic activist who seems to thrive on the sorts of political and community outreach that takes legwork.
Literally.
One Saturday morning in Karatu we celebrated Safe Motherhood Day. Although Safe Motherhood was celebrated on April 23 in other regions of Tanzania, Mrs. Shao had to postpone this region’s celebration until the District and Regional offices were ready to participate. The initial small group of participants met at the health clinic in high spirits. There were students from a youth band, a dozen NGO volunteers, our family, Mackrine and Kate (a visiting MPH student) who started the approximately 5 km rally through Karatu. By the end, we had about 100 students, 20 townsfolk, the District Medical Officer, the District Assistant Secretary (guest of honor), a theatre group, acrobat troupe, and the man on stilts.
There were a few speeches interspersed between informative entertainment. In a village where maternal and newborn death is a common tragedy, it was interesting to see the topic brought to attention with humor and honesty. Most such events in the U.S., where maternal mortality is rare (11 per 100,000 live births) are filled with powerpoint presentations, earnest lectures, and an aura of sadness.
In Tanzania, the maternal mortality statistics range from 578 deaths per 100,000 live births (Tanzania Demographic and Health Survey) to 950 deaths per 100,000 births (WHO). However, tracking maternal (and newborn) deaths is incredibly difficult- considering that about 53% of women deliver at home, with a traditional birth attendant or a relative, there are many uncounted deaths. If a woman dies on the way to the hospital, her death is not counted by the hospital. The village council is supposed to keep track of deaths and births for each village but it depends on the village, we are told. Frequently, a woman who dies from a postpartum endometritis 2 weeks after delivering is not counted among the maternal deaths.
The KCMC-Duke Women’s Health Collaboration contributed with a demonstration of emergency obstetric techniques. First, Mackrine had to reassure us that we could bring out our anatomically correct demonstration mannequins including a female pelvis and a newborn. We wanted to emphasize to the crowd the importance of delivering with a skilled health worker. Of course, we are just figuring out which health workers are actually skilled in emergency obstetrics- but women still have better odds of getting help with complications if they deliver at a health facility rather than at home. (The argument women give is that the health facilities are so understaffed and undersupplied, they would rather deliver at home knowing that there are no supplies or skilled workers, rather than travel great distances and pay money they can’t afford to deliver in similar circumstances).
To the great delight of the clapping crowd, we safely delivered the baby through the pelvis. Then the women volunteers took the newborn, wrapped in a kanga, and performed a celebratory dance around the stage to the music of the band. The man on stilts disappeared sometime during the presentations, and I don’t’ know if he was from the band, the acrobat troupe or the theatre group. However, he wasn’t needed to keep the crowd interested. After a long morning of speeches, skits, dances, and demonstrations, the rally ended quietly with many thank you’s passed around. By 2 pm, we had packed up our car for the 3 hour drive back to Moshi. Hopefully the rally made an impression on the women watching like it made on us.
I would love to download pictures and video from the day, but I will have to wait until our internet connection is able to handle it.
We drove out to Karatu in the Arusha Region more than 3 hours away from Moshi. We went with Mackrine Shao, Regional Coordinator for the White Ribbon Alliance (WRA). The International WRA has gained a lot of positive attention, with celebrity and political endorsements (Sarah Brown, wife of England’s prime minister Gordon Brown, is WRA’s patron, and names associated with WRA events include Melinda Gates, congresspeople and actresses). WRA-Tanzania, I’m proud to say, is quite an energetic national association.
Mrs. Shao is the epitome of a dynamic activist who seems to thrive on the sorts of political and community outreach that takes legwork.
Literally.
One Saturday morning in Karatu we celebrated Safe Motherhood Day. Although Safe Motherhood was celebrated on April 23 in other regions of Tanzania, Mrs. Shao had to postpone this region’s celebration until the District and Regional offices were ready to participate. The initial small group of participants met at the health clinic in high spirits. There were students from a youth band, a dozen NGO volunteers, our family, Mackrine and Kate (a visiting MPH student) who started the approximately 5 km rally through Karatu. By the end, we had about 100 students, 20 townsfolk, the District Medical Officer, the District Assistant Secretary (guest of honor), a theatre group, acrobat troupe, and the man on stilts.
There were a few speeches interspersed between informative entertainment. In a village where maternal and newborn death is a common tragedy, it was interesting to see the topic brought to attention with humor and honesty. Most such events in the U.S., where maternal mortality is rare (11 per 100,000 live births) are filled with powerpoint presentations, earnest lectures, and an aura of sadness.
In Tanzania, the maternal mortality statistics range from 578 deaths per 100,000 live births (Tanzania Demographic and Health Survey) to 950 deaths per 100,000 births (WHO). However, tracking maternal (and newborn) deaths is incredibly difficult- considering that about 53% of women deliver at home, with a traditional birth attendant or a relative, there are many uncounted deaths. If a woman dies on the way to the hospital, her death is not counted by the hospital. The village council is supposed to keep track of deaths and births for each village but it depends on the village, we are told. Frequently, a woman who dies from a postpartum endometritis 2 weeks after delivering is not counted among the maternal deaths.
The KCMC-Duke Women’s Health Collaboration contributed with a demonstration of emergency obstetric techniques. First, Mackrine had to reassure us that we could bring out our anatomically correct demonstration mannequins including a female pelvis and a newborn. We wanted to emphasize to the crowd the importance of delivering with a skilled health worker. Of course, we are just figuring out which health workers are actually skilled in emergency obstetrics- but women still have better odds of getting help with complications if they deliver at a health facility rather than at home. (The argument women give is that the health facilities are so understaffed and undersupplied, they would rather deliver at home knowing that there are no supplies or skilled workers, rather than travel great distances and pay money they can’t afford to deliver in similar circumstances).
To the great delight of the clapping crowd, we safely delivered the baby through the pelvis. Then the women volunteers took the newborn, wrapped in a kanga, and performed a celebratory dance around the stage to the music of the band. The man on stilts disappeared sometime during the presentations, and I don’t’ know if he was from the band, the acrobat troupe or the theatre group. However, he wasn’t needed to keep the crowd interested. After a long morning of speeches, skits, dances, and demonstrations, the rally ended quietly with many thank you’s passed around. By 2 pm, we had packed up our car for the 3 hour drive back to Moshi. Hopefully the rally made an impression on the women watching like it made on us.
I would love to download pictures and video from the day, but I will have to wait until our internet connection is able to handle it.
Tuesday, May 26, 2009
Sleepless in Moshi
The strangeness of the last 10 months is difficult at times to fully process or appreciate. Sometimes the writer's block is profound. Sometimes the drivel that comes out on the paper is so bad or comes from a place so bleak that it must be summarily squashed and hence one of the many reasons for the long delay in writing on this blog. After working in low resource settings on many short stints over the last 12 years, I thought there would be minimal difference between the way I internalized these short term experiences and those that one accrues over a longer stretch. I was wrong. The summation of many and varied exposures and the continuous exposure is fundamentally different and should be considered carefully ahead of time by those contemplating it; for there is no taking it back. And our situation is tame by most global health standards. We work in a place where there are only dozens of maternal deaths a year. There are many places that are worse. Losing track of time as we develop this or that program and submit this or that grant. The strain on family and relationships. The vagaries of new professional relationships. Concern over the loss of skills and future potential as a physician in the States. Thoughts of reintegration in to that system and moving on.
Few thoughts and recent patients:
1. Humility: I can remember my first exposure to a large number patients with obstetric fistula in Niger . Leaking of urine from a fistula causes fistula dermatitis. This can look exactly like secondary syphillis (condyloma lata) . After I had cancelled a few patients for surgery because of what appeared to be a rampant outbreak of syphillis amongst our fistula patients, I was promptly educated by an older and wiser colleague who told me what this really was. I sheepishly rescheduled the patients and learned a good lesson. We recently took a young woman to the operating room who was dying of something. We knew not what. She was thin and wasting away. Gaunt, tired. She began speaking of her own death. She had an abdomen full of ascites (fluid) and a large pelvic mass. We chose to operate to make a diagnosis in case this was a treatable type of cancer. We made an incision and on opening the abdomen found what looked like cancer everywhere. Her blood count was too low to try to remove all of this and there was only 1 unit of blood available in the blood bank. She likely would have died on the operating table if we tried to remove the tumor. We took a few biopsies and closed her up thinking there would be no hope for her. I was convinced like never before this was some terrible malignancy and hoped at least it would be one that could be treated, because every day she was closer to death. We pleaded for the pathologist (who already has a backlog of 6 months of cases to read) to give us an answer quickly. In 4 days (a miracle) we had our answer. It was Tuberculosis. We were all elated and once again I was humbled by the variety of ways a patient can manifest a disease and my limited exposures in the past. We began treatment and just three weeks later she was on her way home looking 100% better.
2. One of our patients we brought from Berega (see prior blog) is still here at KCMC. She has a rectovaginal fistula and underwent a loop colostomy to divert the flow of feces. She also has such a small bladder after her prior bladder fistula repair that she leaks constantly anyway. She needs surgery that cannot be done here for lack of a few instruments and expertise. She leaks stool now on to her abdomen through the colostomy instead of between her legs. Perhaps the lesser of two evils for her. There is no supply of ostomy bags, so she wraps a kanga around her to compress the stool and hide its odor for a while and then changes it a few times/day. Noone will take her at this point and we've been asking friends and colleagues to come with the appropriate expertise to help. She may be like that forever.
3. We have at least 4 women on the service dying of cervical cancer. A terrible way to go with bleeding and foul smelling necrotic tissue coming from the vagina. Intractable pain from metastases to the bone. No morphine to ease the pain.
4. 3 recent patients with choriocarcinoma which is nearly 100% curable, but we don't have access to the chemotherapy drugs they need. sent a few to Dar Es Salaam recently to the cancer hospital. Have to decide at some point how much is it worth spending to try to save the life of an individual woman in her prime. Is it $200, $300, $500, $10,000? If we spend $2000 in Blue Jean Ball funds on one woman do we deprive 10 women in the future of some local life saving therapy that we can't afford at that time.
5. 16 year old came in two nights ago at 32 weeks pregnancy with a intrauterine demise (stillbirth) and seizures. She had been treated for days at an outside facility and presented too late to do anything. She passes away yesterday morning. She was an orphan herself and no relative or friend was with her at any point in her labor or death.
Many more interesting and devastating stories, but time for bed.
Our team is going to a sugar plantation tomorrow (employs 10,000 people) to teach the ALSO emergency obstetrics course at their hospital.
A recent article by
Denise Grady at the New York Times
http://www.nytimes.com/2009/05/24/health/24birth.html?_r=1&em
Few thoughts and recent patients:
1. Humility: I can remember my first exposure to a large number patients with obstetric fistula in Niger . Leaking of urine from a fistula causes fistula dermatitis. This can look exactly like secondary syphillis (condyloma lata) . After I had cancelled a few patients for surgery because of what appeared to be a rampant outbreak of syphillis amongst our fistula patients, I was promptly educated by an older and wiser colleague who told me what this really was. I sheepishly rescheduled the patients and learned a good lesson. We recently took a young woman to the operating room who was dying of something. We knew not what. She was thin and wasting away. Gaunt, tired. She began speaking of her own death. She had an abdomen full of ascites (fluid) and a large pelvic mass. We chose to operate to make a diagnosis in case this was a treatable type of cancer. We made an incision and on opening the abdomen found what looked like cancer everywhere. Her blood count was too low to try to remove all of this and there was only 1 unit of blood available in the blood bank. She likely would have died on the operating table if we tried to remove the tumor. We took a few biopsies and closed her up thinking there would be no hope for her. I was convinced like never before this was some terrible malignancy and hoped at least it would be one that could be treated, because every day she was closer to death. We pleaded for the pathologist (who already has a backlog of 6 months of cases to read) to give us an answer quickly. In 4 days (a miracle) we had our answer. It was Tuberculosis. We were all elated and once again I was humbled by the variety of ways a patient can manifest a disease and my limited exposures in the past. We began treatment and just three weeks later she was on her way home looking 100% better.
2. One of our patients we brought from Berega (see prior blog) is still here at KCMC. She has a rectovaginal fistula and underwent a loop colostomy to divert the flow of feces. She also has such a small bladder after her prior bladder fistula repair that she leaks constantly anyway. She needs surgery that cannot be done here for lack of a few instruments and expertise. She leaks stool now on to her abdomen through the colostomy instead of between her legs. Perhaps the lesser of two evils for her. There is no supply of ostomy bags, so she wraps a kanga around her to compress the stool and hide its odor for a while and then changes it a few times/day. Noone will take her at this point and we've been asking friends and colleagues to come with the appropriate expertise to help. She may be like that forever.
3. We have at least 4 women on the service dying of cervical cancer. A terrible way to go with bleeding and foul smelling necrotic tissue coming from the vagina. Intractable pain from metastases to the bone. No morphine to ease the pain.
4. 3 recent patients with choriocarcinoma which is nearly 100% curable, but we don't have access to the chemotherapy drugs they need. sent a few to Dar Es Salaam recently to the cancer hospital. Have to decide at some point how much is it worth spending to try to save the life of an individual woman in her prime. Is it $200, $300, $500, $10,000? If we spend $2000 in Blue Jean Ball funds on one woman do we deprive 10 women in the future of some local life saving therapy that we can't afford at that time.
5. 16 year old came in two nights ago at 32 weeks pregnancy with a intrauterine demise (stillbirth) and seizures. She had been treated for days at an outside facility and presented too late to do anything. She passes away yesterday morning. She was an orphan herself and no relative or friend was with her at any point in her labor or death.
Many more interesting and devastating stories, but time for bed.
Our team is going to a sugar plantation tomorrow (employs 10,000 people) to teach the ALSO emergency obstetrics course at their hospital.
A recent article by
Denise Grady at the New York Times
http://www.nytimes.com/2009/05/24/health/24birth.html?_r=1&em
Friday, February 27, 2009
After a Devastating Birth Injury, Hope
This is the title of a New York Times article this week. You can read the full article at:
http://www.nytimes.com/2009/02/24/health/24hospital.html
Denise Grady, a New York Times reporter, accompanied Jeff, Brandi (our wonderful Global Health OBGYN fellow) and Dr. Masenga (OBGYN physician at KCMC and expert fistula surgeon) to Dodoma in central Tanzania. They held an obstetric fistula surgery training camp, sponsored by AMREF and helped with funds from the Blue Jean Ball (http://bluejeanball.mc.duke.edu/index.html). Denise Grady's article describes the problem facing girls/women with fistula quite well.
http://www.nytimes.com/2009/02/24/health/24hospital.html
Denise Grady, a New York Times reporter, accompanied Jeff, Brandi (our wonderful Global Health OBGYN fellow) and Dr. Masenga (OBGYN physician at KCMC and expert fistula surgeon) to Dodoma in central Tanzania. They held an obstetric fistula surgery training camp, sponsored by AMREF and helped with funds from the Blue Jean Ball (http://bluejeanball.mc.duke.edu/index.html). Denise Grady's article describes the problem facing girls/women with fistula quite well.
Saturday, January 10, 2009
“Tangu lini?” we ask the boy child. Since when?
He is 16 years old, but because of HIV, and malnutrition and social factors that we could only guess at due to our limited Swahili, he looks barely 10. His body is skinny, and he weighs less than my 8 year old daughter. The bumps on his face are like little pieces of yellow-red gum that’s been chewed up into small varied globs and stuck there in haphazard fashion. How long have the bumps been there? For 10 months. Looking through his medical chart, we only find one other mention of the face lesions (although the undecipherable handwriting of the physicians makes it difficult to know this for sure). Two months ago, the physician referred the boy to dermatology clinic where he was diagnosed with molluscum contagiosum. This link shows a picture of another child with molluscum: http://www.cehjournal.org/extra/53_05_01.html.
The referral note from the dermatologist didn’t include any treatment options, or the boy’s probability of improving or being cured. We ask the boy if the dermatologists said anything to him about the diagnosis, or prognosis but he shakes his head no.
We flip through the child’s medical records to see what we can offer him. He is obviously very embarrassed about his face lesions. The only question he asks the nurses is whether we can offer him any cure for his facial disfigurement. He doesn’t ask us, the doctors, directly. He only nods respectfully and offers single word responses. He appears shy and modest, and he has no family members with him that we could question. The nurses tell us that he lives in Moshi with his mother, who runs a business and never comes to his clinic appointments. His HIV status was discovered during an admission to the hospital 10 months ago due to sepsis. Actually, his CD4 count has significantly improved, from 350 to 770, in the last 10 months. But this disqualifies him from the only simple treatment for his facial molluscum- antiretroviral (ARV) medications.
Later that morning, we see a 12 year old cachectic boy with HIV, vomiting, and severe ascites (abdominal swelling) with unknown social situation (Are his parents dead or alive? Who are the different people who claim to be his guardians? Has he been given any of his ARV medications since his HIV diagnosis was made 15 months ago?). The next patient is an 8 year old girl living in an orphanage who has had worsening mental status over the last few weeks despite taking her ARV medications, and who can barely stay awake, stand, or control her stools when we visit her. What is causing her to get worse? Who will pay the $80 cost for her CT scan (luckily, one of the doctors)? Once we know the diagnosis, is there anything we can do about it?
So many mysteries, so many unanswered questions. The one certain thing is that prevention is the best cure. Now, in Tanzania, we have the chance to have HIV-free children born to HIV positive mothers thanks to PMTCT (Preventing Mother To Child Transmission) programs. The latest guidelines call for all pregnant to be screened for HIV at their first antenatal clinic visit, no matter what remote part of Tanzania they live in. Those found to be HIV positive are to receive certain ARV medications starting at 28 weeks of pregnancy, with a more intense ARV regimen during labor. If a pregnant woman doesn’t seek care in time, or doesn’t receive this regimen for whatever reason, the newborn baby is to get ARV medications for 28 days. And with this approach, the number of children with HIV related horrible, complicated medical issues will be drastically reduced. It is definitely not an easy task. Most pregnant women in Tanzania are now being screened for HIV during pregnancy, but only a few who qualify are actually receiving guideline-based ARV medications. Either the medications are not available, or the proper combinations aren’t available, or the hospital staff do not know about the changes, or the patient’s condition doesn’t allow for it.
Before PMTCT was initiated, the Ministry of Health in Tanzania estimated that 72,000 babies a year were infected with HIV by through pregnancy, deliver and breastfeeding. That number could be reduced to less than 8,000 by following the latest guidelines. Although the nurses and staff of the HIV clinics and pediatric wards are working hard to improve the lives of children with HIV, the best treatment is prevention.
I don’t know if we will ever be able to clear the 16 year old boy’s face of molluscum. But because of his plight, we will work harder to ensure more pregnant women receive full PMTCT services and medicines so future children are less likely to have to live with such stigma-inducing diseases. I can’t convey such a complex message to the 16 year old, even if I could speak fluent Swahili. I hope the Dermatology clinic has something more to offer him.
He is 16 years old, but because of HIV, and malnutrition and social factors that we could only guess at due to our limited Swahili, he looks barely 10. His body is skinny, and he weighs less than my 8 year old daughter. The bumps on his face are like little pieces of yellow-red gum that’s been chewed up into small varied globs and stuck there in haphazard fashion. How long have the bumps been there? For 10 months. Looking through his medical chart, we only find one other mention of the face lesions (although the undecipherable handwriting of the physicians makes it difficult to know this for sure). Two months ago, the physician referred the boy to dermatology clinic where he was diagnosed with molluscum contagiosum. This link shows a picture of another child with molluscum: http://www.cehjournal.org/extra/53_05_01.html.
The referral note from the dermatologist didn’t include any treatment options, or the boy’s probability of improving or being cured. We ask the boy if the dermatologists said anything to him about the diagnosis, or prognosis but he shakes his head no.
We flip through the child’s medical records to see what we can offer him. He is obviously very embarrassed about his face lesions. The only question he asks the nurses is whether we can offer him any cure for his facial disfigurement. He doesn’t ask us, the doctors, directly. He only nods respectfully and offers single word responses. He appears shy and modest, and he has no family members with him that we could question. The nurses tell us that he lives in Moshi with his mother, who runs a business and never comes to his clinic appointments. His HIV status was discovered during an admission to the hospital 10 months ago due to sepsis. Actually, his CD4 count has significantly improved, from 350 to 770, in the last 10 months. But this disqualifies him from the only simple treatment for his facial molluscum- antiretroviral (ARV) medications.
Later that morning, we see a 12 year old cachectic boy with HIV, vomiting, and severe ascites (abdominal swelling) with unknown social situation (Are his parents dead or alive? Who are the different people who claim to be his guardians? Has he been given any of his ARV medications since his HIV diagnosis was made 15 months ago?). The next patient is an 8 year old girl living in an orphanage who has had worsening mental status over the last few weeks despite taking her ARV medications, and who can barely stay awake, stand, or control her stools when we visit her. What is causing her to get worse? Who will pay the $80 cost for her CT scan (luckily, one of the doctors)? Once we know the diagnosis, is there anything we can do about it?
So many mysteries, so many unanswered questions. The one certain thing is that prevention is the best cure. Now, in Tanzania, we have the chance to have HIV-free children born to HIV positive mothers thanks to PMTCT (Preventing Mother To Child Transmission) programs. The latest guidelines call for all pregnant to be screened for HIV at their first antenatal clinic visit, no matter what remote part of Tanzania they live in. Those found to be HIV positive are to receive certain ARV medications starting at 28 weeks of pregnancy, with a more intense ARV regimen during labor. If a pregnant woman doesn’t seek care in time, or doesn’t receive this regimen for whatever reason, the newborn baby is to get ARV medications for 28 days. And with this approach, the number of children with HIV related horrible, complicated medical issues will be drastically reduced. It is definitely not an easy task. Most pregnant women in Tanzania are now being screened for HIV during pregnancy, but only a few who qualify are actually receiving guideline-based ARV medications. Either the medications are not available, or the proper combinations aren’t available, or the hospital staff do not know about the changes, or the patient’s condition doesn’t allow for it.
Before PMTCT was initiated, the Ministry of Health in Tanzania estimated that 72,000 babies a year were infected with HIV by through pregnancy, deliver and breastfeeding. That number could be reduced to less than 8,000 by following the latest guidelines. Although the nurses and staff of the HIV clinics and pediatric wards are working hard to improve the lives of children with HIV, the best treatment is prevention.
I don’t know if we will ever be able to clear the 16 year old boy’s face of molluscum. But because of his plight, we will work harder to ensure more pregnant women receive full PMTCT services and medicines so future children are less likely to have to live with such stigma-inducing diseases. I can’t convey such a complex message to the 16 year old, even if I could speak fluent Swahili. I hope the Dermatology clinic has something more to offer him.
Wednesday, December 17, 2008
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.
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.
Wednesday, December 3, 2008
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
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
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