Wanderlust

I Use Birth Control

2012-02-10T10:53:00.001-05:00

I don't like the tone of this birth control debate. Conservatives are trying to make it sound like contraception is some fringe practice only for promiscuous people. It's ridiculous.

Contraception shouldn't even be controversial. So let's change the conversation.

I use birth control, and it's awesome.

Women, do you use birth control? Say so, loudly. Men, have you ever used a condom? Then you use birth control, too. Let's tell them. Enough with this crap already.

Ron Paul Is A Jerk

2012-02-07T22:39:00.000-05:00

There are a lot of reasons I think Ron Paul is awful. I won't go into all of them here. However, I do want to comment on this interview with Piers Morgan, in which Morgan challenged Paul on his views on abortion, because what he said was so mind-bogglingly stupid.

Before we start, let's remind ourselves (little as I like to remember this fact) that Ron Paul is an obstetrician-gynecologist. So, in theory, he should know better.

1. Honest Rape

I can't even think about this right now, because my head will explode. I will come back to this.

2. "I would give them a shot of estrogen."

Doctor, in case this wasn't covered in your medical training, the morning-after pill, also known as Plan B or levonorgestrel, is a form of progesterone. There is no estrogen in it, and "a shot of estrogen" is not the treatment for emergency contraception.

So although you seem to have said that in order to sound medical and authoritative, you actually sounded like an ass.

3. "The people who like abortion and endorse abortion..."

No one "likes" or "endorses" abortion. We recognize the right to abortion and the need for abortion, and strive to protect the rights of women to make decisions about their reproductive lives (and, Doctor, if you were truly a libertarian, you would too). All pro-choice people would be thrilled if no one ever needed an abortion again, but that is just not the reality of the world.

You know that, but you are pretending not to, because you want to sound like your position has a shred of legitimacy. But in this interview, you showed how absurd, cruel and unrealistic your anti-abortion platform is.

4. "Does that mean that one minute before birth, you can kill the baby?"

No, it doesn't. No one is arguing that you can. That is a straw man used to distract from the main argument. It is possible to legalize abortion without ever killing a baby one minute before birth. In fact, that is what we have right now. There are currently limits on the gestational age at which abortion is permitted. It's neither hard, nor confusing. If you want to object to abortion, object to what it truly is, not some exaggerated absurdity that you made up in your head.

(Logistically, it's not even possible to do this. One minute before birth, the infant is crowning. How would you "abort"?)

5. "...that individual should go immediately to the emergency room..."

Spoken like someone who has never met anyone who had been raped, who has never had to visualize a rape, and who has never understood what it is to be female. Does he think that being raped is like being mugged? When it's over, you're kind of annoyed and inconvenienced, and then you shrug, dust yourself off and head over to the authorities to report it?

The fact that a presidential candidate in this day and age can differentiate "honest rape" without a massive uproar shows exactly what our society thinks of rape: that it is the fault of the woman, and if she had just been more "honest" (better dressed, demure, careful, sober, obedient, virginal), then she wouldn't have been raped. And that widespread, unquestioned assumption makes it just so easy to go to the emergency room after a rape - to undergo a painful, humiliating rape kit that may never be tested, and then to describe and prove the rape to the doctors and the police.

6. "...there's no chemical, there's no medical and there's no legal evidence of a pregnancy......Life does begin at conception."

I put this here because he sounded so dumb, but I actually don't care about it. Yes, Piers Morgan is catching him in an inherent contradiction, but so what? His opinion on abortion so ridiculous to begin with that I'm not exactly looking for logic or internal consistency. Catching anti-abortion loony tunes in their own convoluted logic doesn't make them see reason; it only makes them cling to their hateful ideology that leaves no room for humanity.

7. Back to "honest rape"

Ron Paul doesn't want to believe that rape happens because he, as a man, doesn't really have to think about it. He doesn't have to worry that it will happen to him. He is probably not the person women are turning to when they are raped, and I cringe to think that any woman had to see him as their gynecologist.

I also find it astounding that he, as a gynecologist, never encountered women who had been raped, because the fact is that it is depressingly, frighteningly common. It leaves me only to think that with his patients, he didn't ask (likely) and they wouldn't tell him (also likely). Because who would want to divulge this traumatic experience to someone who is going to question whether your rape was "honest"?

I can't stand Ron Paul, and have never been moved by his facile, reductive positions, but this interview showed what a callous jerk and bumbling twit he is. As a doctor, he should at least be able to speak on these subjects with some modicum of knowledge, even if his positions are wrong. But he didn't seem to know the first thing about rape, estrogen, progesterone, or abortion, and as an obstetrician-gynecologist, that is pathetic.

Still Angry

2012-02-03T15:25:00.000-05:00

While I'm glad that the Susan G. Komen foundation seems to have reversed its decision, I'm still angry.

It's time to stop demonizing abortion (and Planned Parenthood). Whatever your discomforts, convictions or beliefs about how other people should behave, it is necessary to acknowledge that life is messy, and that sometimes things have to happen that we don't like very much. You don't have to agree with abortion to be opposed to its criminalization. I would love it if no woman ever had an unwanted pregnancy, or a pregnancy complication for that matter, but that's not the world we live in.

It's time to acknowledge how easy it is to get pregnant unintentionally, whether through a momentary lapse, series of bad decisions, or unlucky contraceptive failure. It's also time to acknowledge that bearing a child and rearing a child are both significant challenges, sometimes burdens, that should not be taken lightly.

It's time to concede the grey areas. A first-trimester pregnancy is not the same as a newborn infant, and accordingly our society doesn't treat an early miscarriage the same as it does an infant death. An abortion is sad, but it is the woman's sadness, not ours, and she needs to be respected and trusted to make a decision.

The Komen foundation thought that they could quietly defund Planned Parenthood in part because we, the pro-choice community, have not been vocal enough in showing how strongly we believe in reproductive freedom. Subtly, we allow the implication that abortion is a personal failure, and is shameful. We think that it would never happen to us, until it does.

We allow politicians to yell and scream about "Medicaid funding for abortion" and we don't question them. Well, why shouldn't federal Medicaid fund abortion? It is a legal, safe procedure that affects the health of women. Taxes are not fee-for-service. I don't have a car, and I wish our country had more trains and less highways, but I don't yell and scream that my taxes shouldn't go to repairing and building roads (but maybe I should). Maybe Medicaid shouldn't fund abortions. Maybe there are good arguments to be made against funding it, even if I haven't heard any. But we should stop letting them take it for granted, and actually argue about it.

We quietly simmer while abortion access is severely curtailed through legislation and murderous intimidation. When restrictive laws are passed, we think, "How terrible. I'm glad I don't live there." Or if we do live there, then we think, "How terrible. I'm glad I don't need an abortion." What would be our response if laws restricted access to Pap smears? (After all, cervical cancer is caused by HPV, which is acquired through sex. Should Pap smears be shameful?) As this excellent Guttmacher article argues, we need to stop accepting "the apologetic approach."

Abortion is legal and most of the country is opposed to criminalization, but it is an easy target for conservatives who want to seem moral and religious. What if we yelled back, and told them that they were immoral for trying to shame women? What if we called them out for what their anti-abortion rhetoric really is, which is disrespect and hatred? The pro-choice community was angrier yesterday than I have ever seen it in my lifetime, and I think there is more anger out there. Let's start showing our anger.

Komen Foundation and Planned Parenthood

2012-02-03T10:33:00.000-05:00

Petition against the Susan G. Komen Foundation's decision to stop funding Planned Parenthood's breast cancer screening programs.

What I wrote:

As an obstetrician-gynecologist, I have seen first-hand the devastation of women's cancer, and the importance of screening and early detection and treatment. Your actions are short-sighted, and, at best, cowardly. At worst, they are misogynistic for contributing to the forces that would deny women reproductive freedom. I will never donate another dime to your organization, and I will find other ways to support cancer research, screening, and treatment. Furthermore, I will always support and stand by Planned Parenthood.

Induced Abortion in Uganda

2012-02-03T10:21:00.001-05:00

A research paper by the Guttmacher Institute contains interesting information about abortion in Uganda:

Abortion is permitted only to save a woman's life
The incidence of induced abortion is 54 per 1000 women
One in 5 pregnancies ends in abortion
85, 000 women are treated every year for complications from induced abortion
38% of births in Uganda are unintended, and half of all pregnancies are unintended
Ugandan women have an average of 2 more children than they want
Only 14% of women were using an effective contraceptive method

The Girl Effect

2011-10-26T22:29:00.003-04:00

I had to post this magnificent video here. It's heartbreaking and uplifting and beautiful. I can't stop watching it.

I've written about what life is like for women having giving birth in rural Uganda. If we are going to help women, we need to start with girls. They need freedom, education, empowerment and opportunity. The revolution will be led by a 12-year-old girl. I love this.

Tororo District Hospital Website

2011-08-21T23:38:00.003-04:00

A very generous tech friend has donated his time to help create a website for Tororo District Hospital.
It's still in progress, but I am excited to see it up and running, and looking forward to developing ways to make the website useful for the TDH staff and the Tororo community.

You can see the website here.
There is also a section with information about how to do a clinical rotation at TDH for medical residents interested in global health.

We will be making changes to the site over the next few weeks, so be sure to check back in and see its progress!

Retained Twin

2011-06-30T16:35:00.004-04:00

On my most recent trip to Tororo, I am asked by the midwives to see a patient for “retained second twin.” This means that the patient delivered the first twin (usually at home, on her own) but the second twin did not come out for a long time, prompting her to present to the hospital. In this case, the patient presents with a note from the traditional birth attendant, who sent her in.

The patient delivered about 18 hours ago. She looks calm, and not in pain. There is a single umbilical cord coming down between her legs. The midwives can’t determine the position of the fetus. I palpate the abdomen, and I don’t feel a head in her pelvis, but I can’t tell much of anything. I do a vaginal exam, and find that while the membranes are bulging out into the vagina, tense with amniotic fluid, the presenting fetal part is high up in the uterus, and I cannot palpate it, no matter how high I reach, although the cervix is fully dilated. It is very hard to reach around the bulging membranes. The midwife tells me that there was no fetal heartbeat, but miraculously (normally I am quite unskilled at using the fetoscope), I seem to find one. The midwife agrees.

I bring the ultrasound, and find that the midwives and I were correct – the head is not coming first. It is a difficult scan because the infant’s body is bunched down in the lower abdomen, but as I follow the axis of the spine, it seems that the fetus’ pelvis is lowest in the woman’s uterus. The fetal head appears to be at the uterine fundus, so it is most likely breech.

If the fetus is breech (meaning either feet or pelvis coming first), I can try to deliver vaginally. But if the fetus is transverse (meaning torso, arm or shoulder coming first), there is no way to deliver without performing a version.

If I had been present at the delivery of the first twin, this would be easier. Usually, the second twin is still high up in the uterus, and I can actually reach an entire hand in and turn the fetus to either cephalic (head down) or breech, and then deliver. (It helps if the patient has an epidural, of course). But since the woman has now labored for 18 hours since delivering the first twin, the second twin is stuck in position, and I cannot rotate it successfully, despite my efforts.

I would really like to avoid a cesarean in this woman. This is her fifth delivery – she has four living children other than Twin A. She clearly has a proven pelvis, and it is not clear whether Twin B will even survive at this point. Cesareans are much more morbid here than in the US, and I don’t want to put her through one for a non-viable fetus.

However, I can also see on the ultrasound that this fetus’ heart is beating strongly. This kid is alive. So I have to decide – do I try for a vaginal delivery now, or go straight for cesarean?

The midwives and I both feel that she has a good chance at delivering vaginally. She has pushed 5 babies out, so her pelvis is good, and her only problem seems to be the lack of powerful contractions. We decide that we will hang a slow infusion of oxytocin to get her contractions back, and then I will slowly break the bag of water and see if I can deliver the child breech. I am not 100% sure that he is breech, but I am taking a gamble in the hope of sparing the mother a surgery.

Before I do so, though, I want to make sure that theatre is prepared in case I need an urgent cesarean. If I get a cord prolapse, we won’t be able to wait the usual hour (or more) to get the patient to theatre before the fetus is compromised.

They start the infusion, and I take care of some other patients. When I return, she is grunting heavily and telling the midwives she wants to push. I examine her, and the bag is bulging even more tensely in her vagina. The presenting part is still not palpable. I take a needle and puncture a tiny hole in the bag. As water leaks slowly out and the bag becomes less tense, I am able to palpate what is inside. And what I feel is…..cord.

Crap.

I just lost my gamble. Now what? Will we ever get her to theatre on time? If the baby is breech, should I just try to do a quick extraction instead of taking the risk of theatre?

I palpate the cord. It has pulsation, meaning the baby is still alive. Since the fluid is leaking out only very slowly, it is still buoyed by the fluid in the membranes. I palpate further and feel something as narrow as cord, but much more firm. I follow it up..….fingers.

CRAP.

Transverse presentation. Now I have really lost the gamble. I have already called out to the midwives to prepare for theatre. One is bringing over the stretcher – I am impressed as this is unusually fast. I tell them not to bother having her sign consent, just bring her. (That never happens.)

I dash over to notify the theatre staff, and they start preparing. First, they are out of suture. I look in the suture closet and find only silk and a little nylon. AARGH. Both of those are non-absorbable (permanent) and I loathe using them. What happened to the vicryl and chromic that used to be here?

The theatre nurse informs me that they have been out of stock of most sutures for 2 weeks, and the district has not yet approved the purchase of more. Facepalm. Luckily, the anesthetist has just a little vicryl and catugut stored away in a locked cabinet for just this reason.

A tray is already being prepared with a c-section kit ready to be unwrapped. When I was living here, I had bought sterilizing cloths so that instruments could be packed in sets, and sterilized in advance of surgery (so that we wouldn’t have to wait an hour to sterilize instruments right before the surgery). I am pleased to see that the system has continued.

When I left the labor ward, the midwife was moving the patient onto the stretcher. But where are they now? I feel the minutes ticking by. It always takes forever to move the patient, and is one of the most frustrating things that, no matter what I do, never seems to change. I pace and keep poking my head outside the theatre door, staring anxiously. Just when I am about to run back to the labor ward, the patient appears in the prep area. They had stopped to consent her, hence the delay. Fine, whatever. They tell me that the patient asked very clearly for a tubal ligation. I reconfirm with her and document it.

Kevin, a female anesthetist who has training in spinal anesthesia, appears and asks me if she can do a spinal. In the US, we would do general anesthesia in this situation because we have no time to spare in a cord prolapse – the child could be dead in minutes. But I know that spinal anesthesia is much safer for the mother, and given all the other delays we still have to get through in preparing theatre, I don’t think that putting in the spinal is going to make a difference, so I agree.

Kevin is a rusher – I like that. Things tend to go at a slow pace here, even emergencies. But when Kevin realizes she needs a different needle for the spinal, she runs to the supply room, and runs back. The spinal is in very quickly.

I have invited Katie and Hannah two young American possible pre-meds to observe the c-section. They are quietly observing in a corner. I hope they don’t pass out, but I’ve given them instructions on what to do if they feel woozy. I’ve also warned them that there’s a good chance this baby will die.

We are finally ready after what seemed like much too long. The spinal anesthesia works beautifully. I get in quickly, but once I open the uterus, the first trouble starts. The position is terrible, and I realize I should have made a vertical incision on the uterus. The fetus is folded over itself and squeezed into the lower uterus, and the back is facing me, with the shoulder at the incision. Mentally, I kick myself, because I should have put together my ultrasound findings (spine up) with palpating the hand in the vagina (transverse presentation) to know I needed a vertical incision.

It is impossible to grab anything. I try to bring the feet out, but can’t. I try to bring the head out, but can’t I try to turn the fetus, but can’t. I try to push the arm up from the vagina to flip the baby, but it doesn’t help. Finally, I extend the uterine incision on one side. It’s still difficult, and I repeat my maneuvers. Finally, as I am trying to move the head, I see testicles pop out of the incision, and realize that the pelvis is out. I have to scold the scrub nurse not to yank on the infant’s body as I am delivering – this is the worst thing you can do, because it causes a reflex in the baby that can cause the head to get stuck. I can now gently sweep the legs out, and carefully ease out the body and the head.

The baby is blue, limp…..dead. I try to palpate rapidly for a pulse in the neck or the cord, but feel nothing. I quickly clamp the cord and pass the baby to the midwife. Sometimes, babies who look like this are assumed to be dead, so I give clear commands to resuscitate immediately. I turn back to the mother, but continue to keep one ear on the resuscitation.

The midwives generally do a good job resuscitating, but the one thing they are often complacent about is oxygen. The oxygen concentrator is often not working, or doesn’t have the right connecting tubes, so people tend to give up and not waste time trying to use it.
But I know this kid needs oxygen if he’s going to live, so I keep calling out to use the oxygen.

Katie and Hannah are watching anxiously, itching to help. I tell them to try to hook up the oxygen while the midwife works on the baby, so they jump in. The oxygen can’t connect to the bag/mask, but there is a small nasal catheter that can be placed down the baby’s nose to give oxygen. I tell them to leave the oxygen catheter in and keep bagging if there are no spontaneous breaths. The heart rate improves to almost normal, but still no spontaneous breathing.

Meanwhile, I am suturing a bloody field. My extension of the incision and my aggressive attempts to deliver the fetus have damaged the left uterine artery, which is shooting blood. The uterine artery is not far from the ureter, which connects the kidney to the bladder. It is very easy to damage the ureter, and potentially catastrophic if it happens. I clamp the artery carefully, and then am able to dissect it away from the surrounding tissue and tie it off so it stops bleeding. All the while, I am calling out orders for the resuscitation without actually being able to see how the infant is doing. It’s hard to focus – one of the knots I tie is is useless because I am distracted while tying, and I have to retie. Finally, I control the bleeding. I start to wonder if I operated on this woman and bled her out only to deliver a dead baby, and I kick myself again.

Katie and Hannah are communicating to me how the baby looks so I don’t have to take my eyes off the field. The color is improving, but it is not clear if the infant is breathing. Kevin and the midwife insist that the breathing is fine, while Katie and Hannah say that there are only infrequent gasps. It’s hard for me to tell, but at least the heart rate is staying up. I tell them to keep the oxygen on and count the respirations per minute. There is no clock in the room, so one of them has to count seconds while the other counts respirations. Now that the bleeding is controlled, I can try to get through the rest of the surgery quickly, and then check out the infant. But my first priority always has to be the woman.

It is time to tie the tubes. I generally try to confirm once more before I cut them, and especially in cases where the baby is not doing well. I have the midwife ask the patient in Japadhola, and there is some confusion. First she says yes, then no. They ask her again, and she says not to cut them, because “her husband will quarrel with her.” I have them ask again. She repeats that she has not discussed it with her husband, so I should not cut them. Everyone is disappointed – this woman has been through so much, and is having her sixth child. If only the men came to the births, the women would all get contraception. I leave the tubes alone, and close the abdomen.

I have to argue with the theatre staff again about the skin closure. All of the doctors at TDH use silk (permanent) suture, in which they drive a huge needle straight through the skin on both sides, and pinch the skin together tightly. The silk suture has to be removed (painfully) after 7 days. Often the incision gets infected, and leaves a giant scar with a keloid. The staff (who are not the ones I have operated with in the past) has never seen a subcuticular suture, which is what I do. I take a tiny suture, and I sew just beneath the skin edge, bringing the skin together gently. When I am finished, you can’t see the suture, only a very thin line. The suture absorbs over a few weeks and does not need to be removed. They don’t get infected the way that the other closure does.

The staff is concerned that the suture I am using is too small, but when they see my closure, they stop questioning it. The midwives have seen how nicely my incisions heal, and they love it.

The patient has lost a lot of blood, but seems OK. I check out the infant. He is no longer blue, just pale. His heart rate is normal, and he is finally breathing spontaneously. His muscle tone is weak, and he does not cry. His arm (the one that was in the vagina) is very swollen, but not broken. I try to stimulate him by rubbing his back or flicking the bottom of his foot. At first, he doesn’t respond, but finally he gives a weak objection, and I am pleased. It’s at least some reaction.

I write my operative note while the patient is being moved off the table. When I come back to the infant, he looks even better. His skin is turning light brown, and his whine when stimulated is getting louder, almost a cry. His hand squeezes Katie’s finger, and we are pleased. Now, his biggest problem is warmth. I write for him to be placed in the warmer, and when the mother is ready, kangaroo care.

Hannah and Katie are pretty stunned. We go out for lunch (it’s 3pm, we are all starved) and reflect. I sincerely believe that if they had not been there to assist with the resuscitation, the baby would have died, and I tell them as much. “You saved the baby,” I say, and it’s true. I joke that this might be the first day of their medical careers. Katie announces that she just might go to medical school to go into Ob/Gyn. I try not to beam too much, but I am proud.

The next morning, we all go to see our patients. I am worried that the infant might have died overnight; he was still weak. Will Katie and Hannah be too upset if he died? At least I have dealt with this before and am emotionally prepared, but the first time is really hard. But no, the nurse tells us both twins are alive.

We find the mother lying in bed, but she beams when we arrive. I greet her and her mother, who is holding the infants. They both look great. The first twin, Opio*, is happily sleeping. The second twin, Odongo, is slightly bigger, and looks great. His tone is a little weaker than Opio’s, but much improved. His arm is still swollen but less red, and when I move it and try to unflex his hand, he cries out with angry objection. I am happy to see that forceful cry.

The woman looks great. Despite her blood loss, she looks happy and bright. I remove her bandage, and the incision is beautiful (if I do say so myself). We ask if she wants a photo with her babies, and she does.

The Odongo is on the left, Opio is on the right. The patient, so smiley, immediately puts on a serious face for the photo, as is the custom here. She laughs when we show her the photo. She tells me that I can share her photo, because she is so happy we saved her.

I remind the patient that we did not cut her tubes. “But I signed to cut them,” she says. Sighhhhh. I remind her that she told us not to cut them during the surgery. “Yes,” she says “because I had not informed my husband.”

The nurse lectures her about family planning, and she does not want more children, but is vague about her plans for contraception. She agrees to come back in 2 months for family planning, and I warn her that she could get pregnant after 1 month. The husband is at the window, so we bring him into the discussion. He speaks English.

I tell him what happened at the delivery. He doesn’t realize that the infant nearly died, so I tell him that the situation was very dangerous for both the woman and the second twin, and that the next pregnancy could be complicated as well.

“I was thinking about this yesterday,” he says. “I think that we have enough and we should stop, because my wife was in danger and I don’t want that again.”

We explain that we could not cut her tubes, and we encourage him to make sure she comes back for family planning. Bringing the husband in is essential in getting women to accept contraception here, and it’s unfortunate that most do not come. If he had been around yesterday, we could have cut her tubes. Luckily, we are all in agreement now. We shake hands all around.

Over the next week, I continue to visit the woman every day. Katie comes with me to see the patient every day. I am very impressed with Katie’s passion – I wish more medical students would show this level of commitment. I strongly believe that we should follow up on our patients and take responsibility for them, especially as a surgeon. Seeing patients after you operate on them means that you see the consequences of your actions, and that you don’t put the patient aside once the skin is closed. It also means that you see the pain, the healing, the struggle and the reality.

Many patients are anxious to go home, and often start to ask for discharge when they are healthy enough to get out of bed, but she doesn’t. Her milk is slow to come in, but finally comes in on the third day. But she is emaciated to begin with, her infants are small and the delivery was stressful. I am in no rush to send her home. It turns out that the patient speaks more English than she had initially indicated, and we can communicate a little. I tell her that I want her to eat lots of food, including meat and beans (protein malnutrition is a huge problem here), and that I want her to become “fat” so she can produce plenty of milk. She laughs gleefully when I say that.

I tell her she can stay as long as she wants to rest. I don’t want her chasing after 4 more children and digging in the fields and carrying water anytime soon. I ask her when she wants to go, and she says “Saturday?” That will be around 10 days after delivery. Hey, why not?

Odongo’s arm improves slowly. The swelling decreases, and he cries less and less when it is moved. I palpate carefully, and I don’t feel a bone injury. I have him examined by one of our study’s medical officers who is very knowledgable about Pediatrics, and he agrees that the injury is only soft tissue, and is improving well.

Every day, the patient shakes my hand warmly and proudly displays her babies. Through the nurse, the patient tells me how happy she is. The nurse says “When she goes to bathe, she runs quickly quickly and comes back because she doesn’t want anyone else to touch them. She loves them so much!” She is gazing lovingly at them as this is translated. It is hard to fathom that Odongo was so close to death. With a slightly different twist of fate, all of this love would have been profound grief.

*In Tororo, surnames of children do not match those of the parents. They often relate to the circumstances at birth (eg. born in the morning, or born in the time of the rain, etc.) A first twin is always given the surname Opio (boy) or Apio (girl), and a second twin is Adongo (girl) or Odongo (boy). The first name is not assigned until a chicken is cooked to celebrate the birth.

No Remorse

2011-02-05T03:35:00.008-05:00

On Monday, I am setting up a brand new lab. A visitor from the US with lab expertise has come to help us set it up, and I am running around getting the right materials and equipment together.

In addition, word has gotten out that I am back in Tororo, and various nurses and midwives come asking me to see patients. There is someone in labor ward with no fetal movement and no audible heartbeat – might be a fetal demise. Could I do a scan? There is someone in the Gyn ward who might have an ectopic pregnancy. Could I scan? I want to help, but I also need to make the lab my priority. I promise to come later, once the lab has settled down.

Finally, the lab is going, and I am able to take a few minutes. My phone rings, and it is one of our study counselors.

“There is the woman here who wanted to abort, and she is here for an ultrasound.”

I cringe at the fact that he knows this – did she arrive and tell him that she wanted an abortion? Oy vey.

“Ok, yes, I will scan her. Thank you, I am coming.”

When I walk up to the research clinic, it is bursting at the seams. Three months ago, the waiting room was usually full on Mondays. Now, on this Monday, every seat is taken, women and children are all over the floor, seated anywhere they can find, spilling out of the waiting area. Our studies are at their peak enrollment, and it’s crazy on Mondays.

I go looking for the ultrasound, and I find one of the doctors scanning a woman with decreased fetal movement. I take a few minutes to teach the doctor how to check for adequate amniotic fluid. When she’s finished, I take the ultrasound machine with me. There is not a single space I can find in that clinic to do this scan; there are way too many patients to be seen. I decide to bring my patient to the Labor Ward, where there are available beds. Then I can also scan the woman with no fetal heartbeat at the same time. Two birds, one stone.

When I walk to Labor Ward, I look for the patient with no fetal heartbeat, but I can’t find her. I have my patient wait, and I look for other midwives to tell me where the patient went. On the way, I run into three senior midwives, including the Principal Nursing Officer (PNO), who are overjoyed to see me. I get enormous hugs and it relieves some of the stress I feel from having so much to do. Apparently, the other patient has already been seen and was ok.

I go back to my patient. I feel her abdomen first. The uterus doesn’t feel quite 20 weeks, but more than 14. On scan, there is definitely a live fetus that measures at 16 weeks. The nursing trainees who are in labor ward watch me do the scan, fascinated. I write down my findings on the ultrasound form. No one speaks Japadhola, so I bring the patient back to the clinic for a translator.

The counselor who called me about her earlier can speak Japadhola, but he is with a study patient. I ask him to see my patient afterward and explain that she is, in fact, pregnant at 16 weeks, and there is nothing to be done. She should go for prenatal care. He agrees to tell her, and we have her sit in the waiting room until he is ready to see her.

I dash back over, with the ultrasound, to the Gyn ward. The sun is brutal, and schlepping the heavy ultrasound is my least favorite thing about this job. Whaddayagonnado. I take a shortcut through theatre, where I greet some theatre staff.

In Gyn ward, a woman is limping painfully toward the door – that is the patient with the possible ectopic. She doesn’t look good. The nurse has her lie down again so I can see her. In the bed next to her, a young woman looks very sick, crying and moaning with abdominal pain. She looks awful.

“What is wrong with her?” I ask.

“She was admitted for one week with peritonitis in Mbale. Now she came here. Maybe you can see her too.”

“Why didn’t they operate in Mbale? She looks like appendicitis.”

“I don’t know.”

Probably because she couldn’t bribe anyone, that would be my guess. I am not sure I would be comfortable operating on her. I could probably do an appendectomy, but what if it were something else, like incarcerated or perforated bowel? Luckily, I know Dr. W is around. I will mention her to him.

I start scanning the patient with a possible ectopic, but it’s a confusing scan. She has a lot of stuff in her uterus, but no definite pregnancy. She has a lot of fluid in her abdomen, which could be blood – implying a ruptured ectopic pregnancy. She is tender but not overwhelmingly so. The woman next to her looks much worse. This could be a miscarriage or an ectopic, it’s hard to tell. If I had a transvaginal ultrasound probe, I might be able to get more information. But sometimes ectopics are very hard to diagnose. In the US, we have the option of laparoscopy, which looks inside the abdomen with a camera through a tiny incision, so that if there is no problem, you can close up without doing major surgery. Here, if you want to look inside the abdomen, you have to open it up.

I call Dr. W, who I know is around and had requested that the nurse ask me to scan, and I ask him to come and look at the sono. He agrees with my confusion, and we discuss a plan. I suggest doing a D&C (uterine evacuation) first – then if he sees products of conception, he doesn’t have to do a laparotomy. He could also do a minilaparotomy (through a 2-3cm incision) to see if the fluid in the abdomen is fluid or blood – and if it is fluid, he can close the small incision without worrying. If there is nothing in the uterus, then an ectopic pregnancy is almost certain, and a true laparotomy is warranted.

I wish I could operate with him, but I need to go back to the lab. I realize it’s lunchtime and I need to make sure the visiting lab technician gets something to eat. The sun is burning incredibly hot, and neither of us has an appetite for lunch. We go into town to buy a few items for the lab, and we have a lunch of fruit and soda – it’s all we can think of eating in the heat.

When I get back, I need to have a research meeting, so I leave my visitor in the lab. As I walk to the meeting, I get a phone call.

“Hello, Doctor!” It is the Senior Hospital Administrator, with whom I have a great relationship. He always appreciates all the work I do, and never fails to help me get anything I need to help patients – from generator fuel to supplies and equipment.

“Hello! I haven’t seen you yet, but I am around,” I say.

“I am glad you are back. I had wanted to have a meeting with you.”

That was unusual. I have barely arrived and I hadn’t even seen him yet – what could he need to meet about?

“Absolutely. I am going to a meeting now, and I have to work in the lab. How about tomorrow?”

“Tomorrow?” He sounds hesitant.

“Is today better? I think my meeting will be about 1 hour. Can I come by your office after that meeting?”

I have a lot to do, but this man has been so helpful to me – I have to make him a priority. I figure he wants me to give medical advice to a family member or something.

“That is ok. I will wait for you here,” he says.

My meeting turns out to be really fast, and so I head to his office earlier than I expected. When I arrive, there are three Ugandan men in the room – one is sitting directly in front of the SHA’s desk, and the others are further back in the room. The SHA looks serious, which is not typical for him, and he is questioning the man near him.

“So after you saw the patient, how did she come to find the doctor for an ultrasound?” the SHA asks the man.

I realize that the woman that had been looking for an abortion is also in the room, in the back. She is staring down at the floor, looking humiliated. I’m not sure what’s going on. What’s the big deal? Maybe they don’t realize that I saw her on Saturday and told her to come today for the ultrasound.

The SHA asks the man the same question again, and the man doesn’t really answer.

I try to be helpful: “I saw the woman and Saturday, and I told her to come for the ultrasound.”

The SHA, still looking surprisingly serious, holds up one finger and says “Just a moment, doctor.” That is also unusual for him.

The SHA asks the man a third time: “If the patient came to you on Saturday seeking an abortion, and you changed her mind, then how did she come to find doctor in the hospital?”

Huh?

Then I notice the logo on the man’s polo shirt – it reads “Uganda Life International."

Weird - it is the same organization that E had wanted to refer the patient to. But from the discussion, it sounds like she had already been there. This is incredibly confusing.

Finally the SHA, not getting an answer, turns to me.

“Doctor, in order that we don’t keep you waiting, let me explain what is happening. These men are from Human Life International. I will let them explain what the organization is.”

The man in the polo shirt turns to me. “I am Father O____, but I am not here as a priest today. I am the head officer in charge of our organization, which is called Human Life International. Our organization has the objective of reaching out to the community in order to save the lives that would be killed by abortion.”

Uh huh. I figured. I nod politely and say “I have heard of your organization. It is nice to meet you.” I am unfazed. Who cares? I don’t do abortions in Uganda. I’m not going to tattle on this poor woman, if that’s what they’re after.

He keeps talking but there is no additional information, just continuing to explain their objective. Then, finally, he gets to the point.

“We have been informed that you took this woman to perform an abortion on her.”

Uh. What?

“There must be a misunderstanding. I do know this woman, but I did not perform an abortion on her,” I reply.

A man in the back with a computer in his lap speaks up. “We have an informant that has said that you told this woman to come here today, so that you could do an abortion on her.”

“No, that’s incorrect. Let me clarify my interaction with this woman and you will see. On Saturday, I was leaving the clinic, and I was asked by another doctor to see her. We were not sure of her gestational age – she thought she was two months, and she looked about 5 months. In addition, we were not sure she was actually pregnant. She had never had a pregnancy test, or an ultrasound scan. The appropriate next step in this case is to confirm and measure the pregnancy. Because we do not have access to the ultrasound on the weekend, I told her to come back today. Today, she came back and I did the ultrasound. She is pregnant, and the pregnancy is 16 weeks, but because she speaks Japadhola, I could not tell her. So I brought her to someone in our clinic who speaks Japadhola, and he said he would tell her. I left her there with the ultrasound report, waiting for him. That was the last I saw her.”

The SHA spoke up, looking relieved. “Now, you see, Doctor has explained. She did an ultrasound. Now we are settled, and we can finish this discussion.”

Everyone speaks at once, but the man in polo shirt was loudest. “No, we cannot finish because she has not shown remorse!”

I am taken aback by the virulence of his response. He appears to be almost salivating with excitement to accuse me further. But of what? I know the woman is still pregnant, so no abortion was done. Everything I did makes sense – anyone would (or should) have done an ultrasound for her. Naively, I had thought that by explaining the logical medical thought process, everyone would see reason and we could all shake hands and move on.

Now, it is clear that reason is not relevant here. Something else is going on. As I watch these men shout at us, I realize that they have already convicted me in their minds (of what?), and they will not be dissuaded. They seem perversely pleased.

The SHA tries to continue the line of questioning he was on when I came in the room.

“You are saying you saw this woman on Saturday and you turned her mind,” he starts.

“We saw her, and we turned her mind. After she was saved, we sent her home,” says the priest in the polo shirt.

“So how is it that she then came to find doctor to have the ultrasound?” asked the SHA.

“I don’t know. But we saved her, we turned her mind, and then this doctor said she would do an abortion.”

This is interesting. E had suggested sending the woman to Human Life International, but we didn’t realize she had already been there. Apparently, they didn’t change her mind, although they don’t seem to want to admit that. It seems that she walked out their door, and straight into the hospital. I wonder if some of this has to do with their wounded pride – they were congratulating themselves for their heroism, when in fact the woman merely said what they wanted to hear so she could get away.

“Our objective at Human Life International is to save the innocent lives from people doing abortion.”

He points to the woman. It is unclear to me whether she is his implied “innocent life” or only her fetus.

“We have come to investigate because we were called by someone who reported that YOU were doing an abortion on this woman!”

I feel blindsided by this. What is going on? I try to keep my cool. Since they are clearly ridiculous, and since I get prickly around the subject of reproductive freedom, I am already poised to be annoyed with these men. This loud, irrational yelling doesn’t help. I tell myself not to shout the way they are shouting – so that I am always the calm one – and to keep the discussion strictly on what I did rather than my feelings on abortion and the misogyny of reproductive oppression. I have plenty of time to remind myself of these things while the men grandstand and speechify. I try to say only what is necessary, and to say it calmly but seriously, without showing weakness or fear.

“This woman came here seeking an abortion. You told this woman that you would do an abortion on her! You did the ultrasound in preparation for an abortion! You took this woman to theatre to perform an abortion, where you did the ultrasound scan!”

Responding to this is easy. “This woman has never been to the operating theatre with me. Where did you hear that?” I reply.

“You were seen taking her to theatre to do the abortion!”

“I took her to labor ward, so that she would have a bed to lie down on while I did the ultrasound. That is not theatre.”

They look confused for a minute, but then the man with the computer repeats the accusation. “You told this woman you would do an abortion! Abortion is illegal in Uganda, you may not know that. We are here to save the lives of those who might be victimized by abortion, and we are here to investigate. We have information that you planned to do an abortion. That is a crime and it must be investigated.”

“I am aware that abortion is illegal in Uganda, which is why I don’t do them here. This woman is still pregnant, so no one did an abortion on her. Therefore, no crime has been committed. You are right; I have no remorse, because I did the right thing. I provided adequate medical care, which no one else did for her. What are you accusing, that I provided adequate care?”

The SHA backs me up.

“There has been no crime. I think we can all stop talking of investigation now,” says the SHA, getting annoyed at these men, but still trying to be diplomatic.

The man with the computer says “Although the act has not been done, there is still criminal intent, and criminal intent needs to be investigated!”

I don’t know the Ugandan legal system, which has its roots in the British legal system, but I suspect he’s bluffing. It would be absurd to charge someone for what you accuse them of intending to do, unless they actually attempted to do it. Then again, you never know. Legal systems can be crazy, and even more so in dysfunctional countries.

A brief image enters my head of being arrested - the way that the midwives were last year - while the case gets “investigated.” Another image appears of being on trial for “intention” to do abortion in a court here. Several thoughts rush through: American consulate getting involved, Hillary Clinton, Rwanda, Iran, international politics and diplomacy, and what if the American government couldn’t help? That is all very scary, but I do not allow myself to think that through immediately. I bring my focus back to the discussion.

The SHA has responded to the criminal intent comment. In addressing the man with the computer, the SHA said something about him being a “legal officer.” I’m not sure what he means by that. A lawyer? A lawyer should know that this is preposterous.

The legal officer with the computer speaks up again. “We have evidence. There is something called CIRCUMSTANTIAL EVIDENCE that can make a criminal case.” (More hint that he’s bluffing) “We have information that you told this woman you would do an abortion on her!”

I have had it with this “we have information” nonsense. I challenge that directly.

“Who is this person accusing me? You should tell me who it is, because that person should come to this room and accuse me directly. I have already explained, and I have been clear. None of you were here when I saw this woman, so you cannot say what happened. In fact, we have no information at all beyond this supposed accusation.”

“Are you saying that the person accusing you is lying?” says the computer man.

“Yes, that person is lying. There were only two other people in the room with me when I met this woman on Saturday. One of them works with me and it is definitely not him, and the other one is her attendant. If it is not one of those people, then this person was not there and cannot testify to such things. If it is her attendant, let her come and say it to me, because she will know she is lying. So you tell me who the person is who is claiming these things and I will tell you whether or not they were there.”

“We cannot tell you the name of the accuser, because this is an investigation and it is confidential.”

Bluffing again. The SHA calls him on it.

“This person should come to this room and discuss,” the SHA insists. “Doctor has told us what has happened, and now we have no other information. We shall need to discuss the matter with this person to clarify this investigation. We should end this now until this person can come and speak.”

It is clear that these men have no intention of stopping now. They have not brought any new information to the table, nor have they been able to contradict my story at all. But they behave as if they have cornered their prey, and they are savoring the attack.

“This person has accused, and has testified to knowledge of this doctor’s intent. We will take this matter to the police. We shall even take this matter to the first lady, who is deeply opposed to abortion! We shall prosecute this doctor for committing abortion. We have evidence.”

The first lady? Come on. I want to roll my eyes, but of course I don’t.

“This woman is still pregnant. There has been no crime, and this is truly ridiculous.” I say.

The SHA agrees. “Who is the one accusing? Is the patient herself accusing the doctor?”

“No, it is not the patient,” says the computer legal officer, “it is another person. We cannot divulge the name.”

Then the man by the window, who looks very young, pipes up.

“Doctor, what did this woman tell you was her purpose for coming to you?”

I have heard him try to shout that previously, but I ignored it because he was out-shouted by the other men – and because it was a dumb question. There is no way that I am going to incriminate the woman herself.

“As I have said, I do not speak Japadhola, and this woman does not speak English, so we cannot speak directly to each other. I cannot tell you what her intentions were, because I was never able to speak to her myself. I was only able to speak to her attendant, who is not here.”

In my mind, I note that the attendant is not here. Could she be the “accuser” who called these men? She didn’t seem like it, but who knows. Her English was basic as well – could she have misunderstood what I said to them? That is possible. What if she couldn’t understand that we only wanted to do an ultrasound, and thought that we had agreed to do the abortion? Although we specifically said it’s illegal and told her we can’t, it’s always hard to know how much people understood, especially because people are too polite to tell you they didn’t understand. If they misunderstood us, that could be a problem. Worse yet, what if it was a setup? The attendant’s absence is conspicuous – what if she was in cahoots with them to try to catch and threaten a mzungu?

If they do question the woman, what if she says she thought I was going to do an abortion? These men would go even crazier, and wouldn’t care about the fact that the woman can’t testify to what I said, only to what was reported to her. I don’t even know why she’s in the room in the first place. Why would she have gone back to them after the ultrasound, or even gone to the SHA’s office herself? Wouldn’t she want to leave – either to go back to the village quietly, or to find someone who would do the abortion? From the look on her face, I doubt that she is collaborating with them. She seems just as much their victim as I am.

I realize, also, that no one has even spoken to her yet, after about 20 minutes in this room. I feel so sorry for her. She looks terrified and humiliated, and she seems to be subtly curling herself into a ball in the corner, almost willing herself somewhere else. She doesn’t understand a single word. I want to speak up to protect her, and suggest that she be allowed to leave the room, but this has already gotten too intense, and I need to defend myself first.

Eventually the men realize that they can’t get around the fact that I am the only one among us who was actually present.

“We have not spoken to the victim. Let her speak for herself,” one of them says.

The SHA points out that she only speaks Japadhola, and asks if any of the men do. They all look at each other. No one can speak to her. How interesting. They are accusing me so vehemently, and yet they have never actually questioned the woman herself. Not only that, I am the only one who offered her any medical care. She saw them on Saturday and was “saved”, and yet by the time I saw her, she had had no pregnancy testing whatsoever. For all the lamenting over her soul, they don’t seem particularly interested in her personhood.

The SHA jumps in to defend me again. “This doctor has done so much work at our hospital, and she has not asked for any money, ever.”

He is interrupted by computer legal officer. “Well other people take money to do abortions but maybe she is doing abortions for free.”

I take over. “Why would I do abortions? Are you saying that I am stupid?”

I am interrupted by polo shirt priest, “People who do abortions are not stupid.”

I ignore him. “You are saying I am stupid. Because if I were to do abortions, then I would be risking everything I am doing here. As you have heard, I do a lot of work in the wards here as well. If I did abortions, I would put all of that at risk. I also work with the research group, and I would be putting them at risk. I would never, ever do that. The work I do is too important, and I am not stupid enough to risk that.”

“You told the patient that you would do an abortion. You intended to do an abortion.”

“If I intended to do an abortion, then why is she still pregnant? I did her ultrasound this morning, and now it is 5pm. Why didn’t I do the abortion already?”

“We can’t answer that but you had the intention to do an abortion. That is why you did the ultrasound, in preparation for the abortion.”

“So what are you accusing me of? Are you accusing me of providing adequate medical care to this patient? Because it seems I am the only one who did. And, no, I don’t have any remorse about that. I would do it again tomorrow. Because it doesn’t matter to me what the patient came in for, she deserves respect, and adequate medical care. She needed an ultrasound for her own care, and I did it. None of that has to do with performing an abortion. So is that your accusation? That I provided good care?”

We are going in circles. They keep saying the same things, and we keep pointing out the same holes. As I am repeating the fact that two people were in the room with us, I realize what I need to do.

“There were only two people in the room when I spoke to this patient, and I am going to call one of them right now and tell him to come, and you will see what he has to say.”

I call E. “I need you to come to the Senior Hospital Administrators office immediately. It’s an emergency.”

More arguing as we wait. Two additional men who appear to be from Human Life International silently enter the room and sit down as the discussion goes on. E arrives in less than five minutes. As he walks in, people are still talking. E has no idea what they are saying.

“E_______,” I say. “These men are from Human Life International. The woman that we saw on Saturday is here. They are saying that I told the woman that I would do an abortion on h---“

Immediately, the priest in the polo shirt starts yelling objections. “She is informing him of what we are discussing before he has testfied!”

Oh, for crying out loud. Do these guys think they are a court of law?

“We have been discussing for a long time, and he is not aware what we are talking about. Doesn’t he need to know why we have called him here?” I ask.

The SHA quiets them down, and invites E to sit down. Immediately, E takes over the conversation. He holds out his hand to the priest in the polo shirt.

“Hello, my name is E_________ A___________I am the senior study coordinator of the IDRC research collaboration. And you are?”

The priest relents and shakes E’s hand, and states his name.

“Now, you see,” scolds E. “THAT is a proper introduction. That is how we should introduce ourselves.”

The men are stunned into silence. I am impressed.

“Let me tell you first that I am angry. I am angry because you did not call me. Why didn’t you call me? You are wasting this doctor’s time with this, and if you had called me I wouldn’t even have involved her,” says E.

The men don’t know what to say. The priest in the polo shirt tells me to explain the situation to E.

“You stopped me from telling him. You want me to tell him now?” I ask.

“You tell him what we have discussed so he is aware,” they command.

E doesn’t even let me talk. He starts talking.

“Let me tell you what happened. I called Dr. Veronica to come and see the patient. So, in fact, if you were going to call someone, you should have called me. I asked her to help me because the woman looked more pregnant than she was saying. Dr. Veronica and I thought she looked five months pregnant. We NEVER told her we would do an abortion. In fact, Dr. Veronica specifically told her that is illegal in Uganda. She was very clear. Dr. Veronica said that she might not even be pregnant, since she had no pregnancy test or ultrasound. For that reason, she offered to do an ultrasound. The ultrasound is not available on the weekend, so Dr. Veronica offered to do the ultrasound on Monday. We very clearly told this woman that we could not do an abortion because it is illegal. And you never should have spoken to Dr. Veronica without calling me first because I never would have involved her. These accusations are totally false, and I am very angry.”

His story matches mine exactly, because it is true. Suddenly, the mood changes. The men seem cowed and start to cover themselves. They try, less confidently, to make the same assertions – that I had the intention to do an abortion, that I took the patient to theatre, and so on. But E shuts down every accusation immediately, and powerfully. Suddenly, the men are on the defensive.

They start a new line of discussion.

“Well, I think that maybe we can bring this to a close because we have already saved this soul,” (still unclear which soul they are referring to) “and so we can go from here and conduct an investigation.”

Retreat.

E is having none of it. He is not interested in letting them off easy.

“I am so embarrassed. I don’t know how I am ever going to apologize to this doctor for the trouble you have caused for her. She never should have heard about this, because it is ridiculous. This doctor has done so much for this hospital.”

Computer legal officer speaks up. “We don’t’ know her. Of course we know you, but we don’t know her, so we couldn’t know. We had to investigate the accusation.”

“You may not know her, but everyone here in this hospital knows her, because she has done so much work here.” E is right. If they don’t know me, it’s because they never come to the hospital, because everyone there knows me. “You should have called me, because if you had called me first, I would have told you that everyone knows her, and I wouldn’t have wasted her time.”

E continues lecturing them. He is amazing. They try to interject, backing off and talking about how they had “already saved this soul” and so they could move on, but he doesn’t let them.

As I listen to him talk, I know I don’t have to talk anymore. It gives me time to process all of this. I think about all the work I have done in the hospital. I think about the woman who nearly bled to death on the OR table, the eclamptic 15-year-old, and all of the other people that I have literally saved with my own hands. Thinking about all the death and near-death that goes on in that hospital, I get increasingly emotional at the injustice of these bloodthirsty men. They don’t care about all those people, only about the fetuses of women who want abortions, and only until they are born. I would like to believe that people who do this sort of thing really do want to help the women, and are just misguided. But it is painfully clear in this room that the woman herself is irrelevant to their objectives.

As I look around the room, I realize that the Principal Nursing Officer (PNO) has recently entered the room. She was one of the nurses who had exuberantly hugged me earlier in the day. I am confident that she will be supportive of me, because she likes me so much. But she is also and older, quiet woman, so maybe she will be afraid to support me publicly.

As I think about all of this, a text message comes through on my phone. It is from Dr. W: “1.5 liters hemoperitoneum! Ruptured left fallopian tube.”

The patient I had scanned that Dr. W took to the OR did, in fact, have a ruptured ectopic pregnancy. She is lucky to have survived – there was a lot of blood in her abdomen. Seeing that message, I am briefly stunned. The irony is immediately apparent. I want to show the text message to these men and say “Do you see this? I literally saved this woman. I did the ultrasound, and diagnosed her, and recommended that she go to the OR. If I had not done that ultrasound, she might have waited hours or days before going for surgery. THIS is saving a life. And what are you doing?”

But I can’t say any of that. I realize that I can’t talk again, because I am feeling an increasing urge to burst into tears. I don’t want to show this to them, because I don’t want them to see any weakness, and I don’t want them to know how much they have affected me. I have thus far managed to seem irritated and offended, but not emotional and frightened. The more I think, the harder I need to work to hide the tears below the surface. I twist my lips and look at the ceiling to hide my trembling lip and watery eyes.

I want to tell them to come to the children’s malnutrition ward and raise some money to feed those children. I want to tell them that women need ambulances to get to the hospital when they are dying at home in labor. I want to tell them to build roads for those ambulances. I want to ask how many children could have been fed by the cost of one custom, Human Life International logo-emblazoned polo shirt.

More images from my year in this hospital flash through my mind. The feeling of operating on a woman, and not knowing if she was going to survive, the feeling of trying in vain to rescusitate a dying infant – that visceral feeling returns to me. Waking up in the middle of the night and rushing to the hospital for a malpresenting fetus or obstructed labor. I did all of this good work all year – can it all be washed away by the wild accusations of a this predatory peanut gallery? The hospital staff had always been supportive of me, but would these accusations now cast enough uncertainty over my reputation? I don’t know how much longer I can take without bursting into tears.

E is still going, alternately scolding the men and extolling my virtues. He will not let them off the hook. Then the SHA takes over, emboldened by E’s moxie.

“I know this doctor very well. She has done so much work in this hospital. You have no idea how many patients she has worked on, how many lives she has saved. We owe her a debt. It is NOT only me who owes her a debt, NOT only the Tororo Hospital that owes her a debt, but the ENTIRE TORORO COMMUNITY! The entire community owes her a debt that can never be repaid. She has never asked for any money, and she has saved so many lives…”

At that, I know I am about to lose it. I get up and walk quickly out of the room as he continues talking. I get out of earshot before I burst into tears. I race to the clinic and grab a friend and research study coordinator with whom I have worked closely. Through tears, I tell her what happened. She is furious.

“Those men. Who are they? How can they do that to you? What do they know about you? To accuse you like that! If it had been a Ugandan, they wouldn’t even be here. You know why they are here, because they saw a mzungu, and they thought they could get some money. They thought you would get scared, and offer them a bribe. Ha! They went after the wrong mzungu.”

It is entirely plausible. She is dismissive of the men, and that helps me feel better than nothing will happen. She reassures me that E will send them packing.

It takes me about half an hour to compose myself enough that I can prevent myself from crying again. E is still in there. While I am waiting for him, I place a call to Dr. W, who had operated on the patient with the ectopic pregnancy. I am embarrassed to suddenly start crying as soon as he answers, but I can’t help it. I need his advice. He is seeing patients in his private clinic and offers to stop immediately and meet me. I tell him not to leave his patients, that I will talk to him later.

Finally, E comes to find me and although I am feeling calmer, I am still pretty freaked out, and I need his reflections of what has happened.

He is bluntly dismissive and critical of the men. He tells me that they are just looking to make trouble, but that he won’t allow it. It surprises me to hear a Ugandan, and especially one as mild and diplomatic as E, use such harsh language. Clearly, he is upset by what has just happened. He tells me that he doesn’t know the priest himself, but he does know that one of the men in the room was a police officer. I get nervous when he says this, but he assures me that the man claimed that he was not there acting as a police officer. He also tells me about some negative experiences he has had with that particular police officer in the past.

“Veronica, I feel so bad. I don’t know how I am going to ever apologize to you. I don’t know why they didn’t call me first. OK, I know why. But they should have called me, not you. I would never have even called you. You did the right thing in calling me there. In fact, I told them so much about you that now I have told them that they need to come here and apologize to you.”

“They’re coming here?” I ask. I’m not sure I want to see them. I know I will get angry again, and I am in no mood to accept an apology.

“Well, I don’t think they are going to come, because they are afraid.”

“Afraid of me?”

“I don’t know. I told them so many things. I think they just are afraid now for having falsely accused you. I don’t know if they will come, but I told them they must."

I would prefer never to see those men again. But in the back of my mind, I have visions of what I would do if they did attempt to apologize. Maybe I would lecture them on their own hypocrisy. Maybe I would ask them where they were when I was operating on a patient who nearly bled to death on the OR table. Maybe I would refuse to allow them to say anything, but insist that we all walk over to the children’s malnutrition ward and stand in the middle of it while they apologized to me. I would say ‘What are you doing for these children who are already born? Are you saving their lives too?”

Of course I would never have the guts to do any of those things. But would I accept their apology? It is hard to imagine. I am so angry, so offended, so infuriated at their behavior. An apology is not enough. Maybe I would spit the polo shirt priest’s words back to him “But you are not showing any remorse!”

E and I continue to rehash the situation. He notes that he was naïve about this organization, and that I had pointed out on Saturday that they sounded suspicious. Of course, being American, I already know what any organization with “Life” in the title is and does. But as a Ugandan, it doesn’t have that particular significance.

E tells me that he feels guilty for having brought the patient to me in the first place now because it caused so much trouble, but I disagree. I tell him I am glad he did, because she still needed my medical care, and whatever happened afterward, she still needed an ultrasound and deserved access to care.

He makes a good point that I hadn’t thought of – he is frustrated that the accusations of these men caused us to reveal private health information of this patient. He is right. I hadn’t even thought of that. They had no right to ask me to justify my actions, because they are between me and the patient. It is even more of an injustice that they think they have the right to intervene, and violate her privacy. I feel like a jerk for telling them anything. But I can imagine how much more fierce their attack would have been if I had refused to tell them anything.

I ask E for one more favor before we leave. I ask him to call Dr. K, the Ugandan head of our research collaboration. He is a wise and influential man, and he has always appreciated the fact that I do clinical work. In case this problem goes any further, I want to be sure he is aware of the situation. I know he will be supportive. E assures me that he will call.

I am still pretty stunned about what happened. I usually work later, but I can’t focus on work anymore. I am still processing everything, running through it in my head over and over in shock. How did I go from doing an ultrasound on someone to this? In fact, I am lucky that this particular patient was introduced to me by E. But this easily could have been any random patient in the wards. People here know that I will even stop people who are wandering around the hospital grounds if they look particularly sick, to make sure that they are getting care, and if they aren’t, then I see them myself. What if this had happened with a patient I had randomly met? These men would have said I was wandering around talking women into having abortions, and then doing them, and I would have no one to backup my story.

I apologize to the visiting lab technician, who has now been waiting for me for a couple of hours, without knowing why I disappeared from the lab. She is very accommodating, and I drive her back to our house, then come back to the hospital to meet some people for dinner. When I drive up, I see Dr. W, the PNO, and Rose standing outside talking. They all turn to me as I drive up, and from their faces, I know what they are talking about.

Dr. W walks up to me immediately and takes my hand.

“Veronica, I am so sorry. That is terrible what you went through --“

He can’t finish his thought, because the PNO bursts forward, edging him aside. There are tears streaming down her face and she wraps her arms around me. She starts sobbing and then I am crying, too.

“I am so sorry, I am so sorry,” she says. “That was so terrible. What those men said to you. I can’t believe it."

All three of them express their support and sympathy. They are outraged. I very much appreciate their support. I had been slightly worried that people might partially believe the accusation, but I can tell that there is no doubt in anyone’s mind that it was not only false but preposterous. In fact, it IS preposterous. Every single person on that hospital grounds knows what I do. I blend in about as well as Joe Pesci in rural Alabama. There is no way I could ever do an abortion without people knowing.

Later, I call the SHA to thank him for his kind words. Before I can say anything to him he starts apologizing extensively for getting me involved.

“These men were bothering me all day before I called you. In fact, I spent two hours ignoring them in the morning, because I knew what they wanted was nonsense. Then I went for lunch, and they were waiting for me. I told them ‘I am a very busy man, I have to do many things for this hospital I can’t only be with you.’ But finally in the afternoon, I had to see them, and I could not avoid it any longer. I didn’t want to call you but they would not leave my office. I wanted to throw them out, but I am a public official, I can’t. “

“Of course you had to call me,” I reassure him. “Those men were after blood and you had no choice. But I want to thank you for the things that you said. You said such nice things about me, and you couldn’t have been better. I know how hard you were trying to defend me from them, and I really appreciated. When I heard you talking, I knew I had support.”

“You always have my support, doctor. I meant everything I said. Those men don’t understand how much you have done for Tororo. But also the things which you said were very good, very good.”

“Thank you. I was trying to stay calm, but I was very angry with them.”

“You were very calm. You said the right things.”

I can tell he is as shaken by the encounter as I am.

That night, I sleep poorly. I wake up thinking about the situation. I still haven’t quite processed my feelings. I’m not as angry as I thought I would be, and I am unnerved and saddened.

The men don’t return to the hospital after that incident. It seems E really did his job in making them feel ashamed of their accusation. When I first arrive at work the next day, I am a little on edge. Then I run into Sister P a senior midwife I know well. She walks right up to me.

“I am so sorry for what happened, doctor. I heard from Sister. It is terrible!”

“Thank you. It was terrible. Those men were vicious.”

“They are terrible! Doctor, I hope you will not stop your work here.”

“Of course not. I would never stop. And if the same case happens tomorrow, I will do the same thing.”

“I am relieved. We were discussing and we were worried, maybe you would be afraid and you would stop your work from what happened.”

“Never. I wouldn’t stop, because we can’t let them win.”

“That’s right! They can’t win."

That is how it goes all day. I run into midwives or nurses or anesthetists I know, and each one shakes my hand and apologizes deeply for what happened. Every single person expresses their support and gratitude toward me. It is pretty overwhelming. The first thing everyone does, is apologize profusely for the trouble. The second thing they say is that they hope I will not stop seeing patients. Not one person has any doubt about my innocence.

E tells me that he spoke with Dr. K, who seemed to understand immediately what had happened, as if he has seen it before. After expressing his sympathy and support, E tells me, his first comment was “I hope she will not stop seeing patients.”

For several days, people ask how I am doing, whether I am still upset. After about 2 days, the shock passes. I realize that this episode showed me that I was completely incorrect in my concerns that the accusations would taint my reputation at TDH. On the contrary, rather than being in danger of false accusations, I have an incredible network of support from people who know and respect my work. I have a community here, one that was unafraid to come to my defense. The thought kind of blows me away.

People who know that I work here often give me kudos. I am polite, but I don’t think I deserve them. I don’t think that what I do here is particularly brave or heroic because it’s not something that requires moxie. It’s not running into a fire, or fighting a war or standing up to an unjust institution or staring down police dogs and fire hoses or protesting an oppressive regime. It’s incredibly fun and satisfying and amazing. It’s working with really pleasant people and feeling like I did something good with my time. But I do think that what the people in this community did to support me was very brave.

I have had difficult situations in the past, and have found that the people you most expect to defend you often fail to do so. I used to be devastated when these things happened, but as I got older I realized that true loyalty is rare. So to find that the people in this small town - most of whom of are a different culture, religion, background, socioeconomic status than I am, and who are just as vulnerable to being attacked by these men – didn’t blink before defending me to these potentially powerful and vindictive people is astounding. I am no longer angered by the attack. I am profoundly grateful for the community I am a part of here.

Oddly, what made me a target for these men also protected me from them. Being a mzungu, I stood out, and I was a tempting takedown for men who either had something to prove, or wanted money. But also being a mzungu, I stand out in a good way. My presence is noted, my work is appreciated, and I have the ability and resources to come here and do this work without charging money. Of course I am angry at these men for their viciousness and their bullying. But I can’t be indignant about being accused when I know that these men and people like them have probably gone around hunting others, and those others were probably Ugandan. I doubt that a Ugandan would have as much protection as I did, and I am afraid for those people. I think of the people around the world who are doing abortions illegally – many of them are unsafe, but some also know what they are doing and do them well but risk persecution. As a woman, as an American, as a doctor, I am a very lucky person.

A Salty, Prickly Gift

2011-01-29T10:36:00.003-05:00

I return to Uganda in January, and my reception is sweet. The clinic staff is happy to see me, and I get exuberant hugs from the midwives.
Even some of the grouchier nurses, who were hard to win over originally, receive me warmly. One In-Charge nurse, Sister A, a sometimes intense and surly individual, stops by the clinic to talk to someone, and she doesn’t notice me seated in front of her. I’m not sure how she can miss my glaring white skin. Finally, I joke, “You don’t want to greet me?”
She finally looks at me and jumps in surprise, then lunges toward me and punches me hard in the arm, turning it into a hug. Then she laughs and shakes my hand.

I walk around the hospital grounds looking for the other nurses and midwives I know so they will know I am back. I can’t find anyone on the female surgical ward, though. Later, I run into one of the nurses from female surgical.

“You know, your friend, she lost a daughter.”

“Which friend?” I ask.

“The one you operated on, I don’t know what it was, for something?”

I remember who she is talking about. It was a woman she had introduced to me as her "sister". The woman was around 50 years old, had HIV that was well-controlled, but she also had severe uterine prolapse. I did a vaginal hysterectomy on her.

“Your sister?” I ask.

“Well, I say my sister but she is not my sister, she is my cousin. She is the daughter of my father’s brother. My sister-cousin.”

This is usually how it goes here. Relationships are fluid – people will say “my auntie” or “my sister” even when the person is a distant relative, or even just a friend. It denotes a close relationship, especially when they want you to help the person. I don’t mind.
I remember the woman well. I liked her a lot. She was very educated, spoke excellent English, and had sent all of her children to university, including the girls. She was very proud of her children’s accomplishments, and she was meticulous about her HIV care. It is rare to find someone that educated and that empowered in this rural area.

“Yes, how is she?” I ask.

“Well, she is ok, but she is not very ok. She lost a daughter,” the nurse tells me.

“That’s terrible,” I sympathize. “From what?”

“Well, the girl was a university student, and she got pregnant, and she didn’t tell anyone. And she went and had it removed, and she died. Imagine! In University! She didn’t tell anyone.”

A few days later, I am at the clinic late, finishing up some work. I realize that it is almost 7pm, and I need to rush home before the sun sets at 7. I drive a motorbike that is old and decrepit, and the electrical system doesn’t work, so it has no headlight. It’s good for me because it forces me to go home before dark. I really shouldn’t be riding such a thing at night anyway. On my way out, I poke my head in the window of the office of E, a Ugandan colleague. He has a leadership role within our research clinic, and I respect him a lot. There are two local women in his office, which is unusual. He doesn’t see patients often, and they are not employees.

“Is everything ok?” I ask, noting their presence.

“Not really. Can you come in for just a quick second?”

I walk around to the door and enter, shaking both women’s hands in greeting.

He asks me, “How far along do you think her pregnancy is?

I look at the belly of the woman he is pointing at. It is small enough that I wouldn’t assume she is pregnant, and yet there is a certain bulge there.
“20 weeks?” I guess, still wondering what this is about. Does she want to enroll in our study for pregnant women? Is she supposed to be further along? If so, it could be growth restricted.

He asks the women to guess how many months that translates to. They can’t. He explains that it is about 4 months.

“She thinks she is about 2 months,” he says.

The pregnant woman has her eyes cast downward the whole time. She is wearing a 3-inch crucifix around her neck, the kind that has a miniature Christ carved into it. The other woman, who speaks some English, looks confused.

Finally, he turns to me and says, “They want an abortion.”

Oh. I see.

This is a really hard situation. At home, this would be easy. But here, abortion is illegal. At home, I would do it. At home, even if it were criminalized in my lifetime, I would probably still do it. It’s not really a question for me, and I don’t struggle with it. But I am not willing to do it here – I am not that brave. A Ugandan jail does not sound appealing. But more than that, it is the laws of a country I am a guest in, not my own laws. I feel that, as a foreigner, it is not my place to decide to violate the laws of this country. Even more than that, I wouldn’t want to risk compromising all the other work I’m doing here. It would be deeply unfair to the research collaboration and all its employees to risk associating them with illegal abortions. It would also stop me from seeing all the other patients I have been able to help.
Maybe it is cowardly, maybe a part of me would like to be able to throw caution to the wind and say “I am brave enough.” And maybe others would be brave enough, but I am not.

As a foreigner, would I be more at risk or less at risk than the Ugandans who do illegal abortions? I know that they are being done, everywhere. I have seen so many women bleeding and infected and nearly dying as a result. And for each one of those, there are maybe 100 who had no complications.
I know my position on this – I already had to turn down an even more compelling case, and even that one still haunts me. The women who see abortions in Uganda are desperate. I want to be able to send them somewhere safe, where I know that they will receive adequate counseling and a safe procedure if that is ultimately the woman’s decision. Ugandans are so stoic, so I can only imagine the shame and desperation they must be feeling to approach us and ask for this. I want her to know that I do not judge her for wanting an abortion, so she doesn’t have to feel ashamed with me.

“In my country, in US, abortion is legal, so I don’t mind that you are asking.”

The attendant nods but looks confused. “Tomorrow?”
She is not getting me. E tries.

“Do you know where doctor is from?”

She can’t guess: “Far.”

“You are right, she is from far,” says E.

I try to hint, so I say “Obama.”

“Do you know which country Obama is president of?” asks E.

“Kenya?” she says. She can tell from our reaction that she’s not correct. “America?”

“That’s right, America. Doctor is from America. In America, women can have abortions,” he says.

“Yes,” I say, “so for me, I don’t mind. But in Uganda, it is illegal. We cannot do an abortion here.”
The attendant understands.

E and I discuss what to do. At 20 weeks, it is unlikely that anyone would be able to do an abortion safely, as the equipment wouldn’t be available here. But I feel her abdomen and realize that her uterus is not palpable – she might be early still.
She is 30 years old, and has 5 children. She keeps her eyes downcast, and only looks at me when I address her, although she knows no English.

“When was her last menstrual period?” I ask.

“She doesn’t know. She was on injection family planning, so she didn’t get one for months,” E tells me.

“How does she know she is pregnant?”

“She went somewhere, and they told her she is pregnant,” her attendant tells us.

“Did they take her urine?” I ask.

The attendant translates, and the patient shakes her head no.

“Did they do an ultrasound scan?”

Again, no.

“So how can they know she is pregnant?”

No answer.

E suggests sending her to a woman he knows who is doing some kind of research study on why women want to have abortions, and how much they know about it. I haven’t heard of this person, but it could be an interesting study. I once saw a study presented on pre- and post-abortion counseling from Uruguay that was quite revolutionary. But I doubted this was the same thing.
In addition, why send this woman to a study when what she wants is care? He says that the woman doing the study can do appropriate counseling. Maybe, but who can counsel someone truly objectively unless they are actually capable of performing an abortion? If it’s not legal here, then how can this person provide that counseling?
Finally, he tells me that she is funded by some organization called something like “Human Life International.”
That sounds incredibly suspicious. And like a bad idea.
To me, it is unethical to send these women to someone who might berate them, or lie to them, or worse, get them in trouble for seeking an abortion. I don’t trust anyone.

I realize that if she is 20 weeks, no one will be able to do anything. And at this point, how do we even know she is pregnant? Maybe she thinks she is pregnant because she has not had a period, and maybe she’s wrong. Maybe she is third trimester with growth restriction. Maybe she has an ectopic pregnancy. Who knows? What if she goes to this “Human Life International” group asking for an abortion, and gets arrested when she is not even pregnant? Before we send her anywhere, I should at least do an ultrasound to check for pregnancy and for gestational age.
I don’t have access to the ultrasound on the weekend, so we instruct her to come back on Monday. We also tell her about the dangers she might encounter if she does try to get an illegal abortion, especially if the pregnancy is as far along as we think.

As I ride my motorbike home, I think of the words of an American friend who struggled with the decision of whether to keep an unplanned pregnancy. Aware of how lucky we are to live in a country where we have the choice, she spent weeks crying and talking and deliberating. Later, reflecting on her ordeal, she wrote to me in an email: “Choice is a salty prickly gift if you’ve got a conscience.”

In the United States, people who believe abortion should be illegal call themselves pro-life. People who believe it should be legal call their opposition anti-choice. Neither term is particularly accurate. Abortion is far more common in places where it is illegal than where it is legal, so criminalization doesn’t “save” any lives. But making abortion illegal doesn’t take away a woman’s choice, either. It changes that choice. When abortion is legal, the choice is between bearing (and usually raising) a child, and undergoing a safe, minor procedure. When abortion is illegal, the choice is between bearing (and usually raising) a child, and undergoing a procedure with the risk of death or imprisonment. Apparently, for many women, that is still a risk worth taking. Perhaps the appropriate term would be pro-criminalization. I doubt that terminology makes a difference in something as polarizing as induced abortion, but I also wonder if most people who think abortion should be illegal understand what that really looks like. Then again, that doesn’t seem to be the part of the equation that individuals in favor of criminalization are interested in.

Those who oppose abortion use the term “abortion on demand” to make it sound as easy as watching a pay-per-view movie. Anyone who knows a woman who has considered an abortion knows that this is far from accurate. What stops a woman from getting an abortion is her own conflicted emotion about the pregnancy growing inside her. Some think that showing women an ultrasound of their pregnancy will create guilt that will deter them. That guilt is a drop in the bucket compared to what these women already feel. Women are not children; they think long and hard about their decisions, and often do what they know is best with a heavy heart – whether that is continuing the pregnancy or terminating it. The idea that these decisions are taken lightly is disrespectful.

Trust women.
Wanting to criminalize abortion is a legitimate position, even though I disagree with it. But disregarding the torment that most women go through in making the decision is unacceptable.

I don’t know what will happen to this woman if she is pregnant. I will do her ultrasound, and try to explain why illegal abortion can be so unsafe. I want her to think about the consequences to her five living children if she were to die from an unsafe abortion. But I also know that if she made such a huge effort to come from the village and wander around the hospital asking for what she knows is an illegal procedure, then she is unlikely to be dissuaded from her search. I hope, at least, she will know enough to ask questions about safety. I don’t know what her emotional state is, since I can’t speak to her, but I imagine this was a wrenching, bitter choice for her.

Oral Board Exam

2010-12-09T17:42:00.001-05:00

Back in the United States, I am about to take the Obstetrics & Gynecology Oral Board Examination. It is an exam that all Ob/Gyns fear and dread. We discuss it endlessly in training: “When you take the boards, make sure you say xxxxx.” Everyone who has taken it has their story about what questions they asked, or how scary and poker-faced the examiners were. Even older physicians who are decades out from their oral exam betray a very visceral retelling of their experience. And here I am, about to complete this monumental event. It’s like an Ob/Gyn bat mitzvah.

Part of the exam requires that you collect cases that you then submit the list to ABOG (the American Board of Obstetrics and Gynecology) for approval. These cases are in three different categories – obstetrics, gynecology and office practice. The obstetrics cases are either cesarean deliveries or complicated obstetrical inpatients. The gynecology cases are either gynecologic surgeries or inpatient gynecologic cases (such as pelvic inflammatory disease). The office practice cases are patients seen and managed as outpatients. Within the three different categories, there are many subcategories of which you need to fulfill a certain number, to demonstrate the diversity of your practice.

I collected all of my cases in Uganda. This was a daunting task. I didn’t know anyone who had previously taken their boards by collecting cases from a developing country. Would ABOG let me do this? Would I be penalized because my diagnostics and management resources would be limited? Was it crazy?

But then again, what is obstetrics and gynecology if not applicable to the entire world? What kind of message is that sending if ABOG only allows cases from developed countries? Does it mean we can’t provide adequate obstetric and gynecologic care without abundant resources? In truth, obstetrics and gynecology are very bare-bones specialties. They require a history, a physical exam, a pelvic exam, a scalpel, and a suture. Pregnancy testing, ultrasound, and some basic medicines (oral contraceptives, oxytocin, antibiotics) help a lot, too. We have added very valuable resources into our practice, such as epidural anesthesia, electronic fetal monitoring, CT scans and serology, but you can do a lot without those things.

Nothing in ABOG’s regulations precludes entering cases from other countries. I wrote to ABOG, and they were remarkably supportive. They made some modifications to their procedures to make it easier for me to submit the required documentation from Uganda, which I very much appreciated. I took this as a good sign.

As I collected my cases, I tried to fit them into the predetermined subcategories. This was difficult. For example, “Hyperlipidemia” – I can’t check cholesterol in Uganda, nor does it really matter. Life expectancy isn’t long enough for most people in Tororo to worry too much about cholesterol levels. (Besides, what would someone do if they had high cholesterol? Take a statin? Change their diet? Most people are lucky to get the food they can.) There were other subcategories that required laboratory testing or pathology diagnosis to meet the criteria, and I had to ignore those. That left me fewer categories to work with, but I made it fit.

When I got back to San Francisco, I started showing people my list for editing advice. Everyone said the same thing “Your list is crazy.” It is? I couldn’t see it myself. I knew that it was a little different from the others, but this was my life for a year, and I suppose it had come to seem normal. I guess most lists don’t have seven ruptured ectopic pregnancies, but really, was it that different? People on my list had abnormal bleeding, infertility, preeclampsia, fetal distress, cervical cancer, pelvic organ prolapse, pelvic inflammatory disease, HIV. Was this really so different from everyone else? Maybe because I trained in the Bronx, I’m used to seeing a high level of abnormal (and “rare”) pathology. But even my Ob/Gyn friends in the Bronx thought my list was crazy.

I started to get nervous. Once I had submitted my list, ABOG could still reject it. I had paid about $1300 to take this exam already. If they rejected the list, I would lose all that money, and have to spend another year collecting cases. As it got closer and closer to the date on which I was supposed to hear from them, I got increasingly anxious. Had I missed the letter? Had they rejected my list? I started paranoiacally checking their website (which is stuck in 1997, apparently) and calling them – to which I got no response.

Finally, exactly one month to the day before I was supposed to take my exam, the letter came. My list had been accepted, and my date was set for December 8, 2010.

Relief hit me. Then paranoia again. Wasn’t that Pearl Harbor Day? Crash and burn! Kamikaze! Is that a bad omen? Noooooo! Then my superego stepped in and calmed me down. I was being superstitious, and besides, Pearl Harbor Day is December 7. Sheesh.

I spent the next month studying assiduously. I practiced answering questions, and solicited advice from anyone I could find.

And now, here I am, on the plane on the way to the boards. The captain asks us to turn off our electronic devices, so I pull out some good old-fashioned paper reading. I decide to review my case lists, which I have printed out in preparation for tomorrow.

As I look through my cases, I remember these patients. The woman with ovarian torsion who was basically saved by the nurse, who was so concerned about the patient’s severe pain that she called me in urgently. (Sadly, this is not to be taken for granted.) The patient tried to give me a chicken after the surgery to show her gratitude. The woman with pelvic inflammatory disease two months after a delivery who stayed for much longer than she needed to because her IV antibiotic doses kept getting missed by the nurses for days at a time. I finally gave her oral medication and figured she could be more adherent taking that at home. The woman with a tubo-ovarian abscess whose pelvis was so scarred that I couldn’t do anything at all in the surgery – I washed with some sterile saline and closed her back up, feeling guilty. Somehow, that resolved her symptoms, and she came to visit me in the clinic, convinced I had saved her life and forever grateful.

As I think about these patients, my anxiety level reduces. I have such affection for them, and as I read their cases on my list, I wish I could show the examiners a photo of each woman, to describe the three-dimensional person behind the case. I also remember the feeling of being in Uganda, and how much I loved it. I remember the frustration of trying to track down an anesthetist, or schlepping the ultrasound back and forth to the ward, or sweating as I try to evaluate the patients who need me as the afternoon rainclouds close in and threaten with a dense humidity. That frustration was very real, but never once did it compare to the enormous satisfaction I got from doing the work. Shaking hands with a patient who was grateful to be cured, or just grateful that I was giving her any medical attention at all. Seeing a healthy mother and healthy baby after a cesarean in which I wasn’t sure that either was going to survive. Laughing as I speak in English and a patient speaks in Japadhola or Ateso, but we both wave our arms frantically and somehow manage to communicate something. Seeing a patient whom I had treated for an ectopic, proudly exposing to me her lovely pfannenstiel (“bikini cut”) scar and thrilled with how it has healed painlessly and almost invisibly. Whipping out my practiced Ugandan English accent, and seeing the patients’ sheepish, shocked and relieved smiles that they can actually understand me, despite all that glaring white skin. Walking with the midwives to the police station to support the arrested midwives, singing “We Shall Overcome” and a Ugandan civil rights song to entertain ourselves, and feeling indescribable pride to hear the midwives say “Dr. Veronica, you are really with us.”

No, I couldn’t have had a better year if I had planned it.

I love this job so much that sometimes I am surprised - that it all worked out in the end. Surprised that I had no clue what I was getting into when I chose premed, but that apparently I chose right. Surprised that the lazy memorizer and multiple-choice-overthinker turned out to be a mild workaholic with a pretty good memory for the stuff that counts.

When I go into the exam tomorrow, I am going to carry these memories with me, because they are the ones that motivate me to work my hardest, and to know that I know what I am doing, and I can practice obstetrics and gynecology competently. I want to walk into that exam room not as if I am going to walk into a barrage of esoteric questions, but a room full of Tororo patients, whom I have to evaluate and treat in a logical and safe way to the best of my ability. I can do that.

Excision

2010-10-04T14:42:00.003-04:00

On my first day back in Tororo, I spread the word about a couple of patients that I would like to see again. I have no contact information for them, but Tororo is a small community, and someone who knows someone will eventually tell the people I am looking for that the mzungu doctor is back at the malaria clinic and wants to see them.

One of these patients is a 17-year-old girl whom I have been treating for a few months. She first came to my attention when she was 35 weeks pregnant and admitted on the antenatal ward and was being treated for “vaginal discharge.” The Ugandan medical student had mentioned her to me, because he noted that she had been given several different antibiotics, but from having seen other patients with me, he suspected that this was, in fact, a yeast infection.

I was very happy when I heard him say that. I have found that patients (in Uganda and in the US) are often over-treated for vague vaginal symptoms – especially discharge – without an adequate assessment. These cases are often called “cervicitis” or “bacterial vaginosis” – which are real infections, but have strict diagnostic criteria that are frequently not met, or even attempted. I find that around half the time, the women in question actually have a yeast infection – either that was their presenting complaint, or the antibiotics they were given caused it.

So I was glad that this student had learned to second-guess the knee-jerk prescribing of antibiotics for vaginal discharge that occurs so often.

I asked him to tell me more about the patient, and I discovered that there was more going on than just discharge. She had HIV (at 17….sigh), and some strange lesions around the vagina.

We went to her bedside. She spoke only Japadhola, so someone translated for me. I could tell she was not forthcoming with her responses. Most of her answers were one or two words. She looked sad, nervous and alone. She didn’t look me (or anyone) in the eyes.

She said that the lesions had been there at least a year, and were growing. I asked to look at them, and I was given gloves.

On exam, the problem was glaringly obvious. She had massive genital warts covering her entire labia on both sides. The introitus (vaginal opening) was barely visible, although it was still there. There was a thick white discharge coming from inside, which was most likely yeast given her HIV infection and recent antibiotic treatment.

The genital warts were truly terrible. I couldn’t imagine how she could walk or urinate normally. She was probably constantly aware of these lesions, every moment of the day. It must have been awful to live with, especially not knowing what it was.

I wanted to be sensitive about asking about HIV, since we were in the antenatal ward with lots of patients just outside the thin curtain. I quietly asked when her first intercourse was. It was at 14. I imagine she probably got HIV and HPV around that time as well. And in all likelihood, that sexual experience was not consensual. I didn’t ask.

Managing her warts was a difficult problem. It was clear I had to do something about them, but what, and when? I didn’t want to risk doing something complicated while she was still pregnant. I consulted a lot of people about her – including people in San Francisco and people in Kampala, and all were very helpful.

The midwives were concerned that she would require a cesarean. Can the baby even come through that opening? And would it acquire the warts? In truth, she could, and should, deliver vaginally. The vaginal opening would still stretch to accommodate the baby’s head, and the risk of passing warts to the infant was extremely low. The risk to the mother of complications from cesarean was much higher, especially given her HIV, and her likelihood of many future pregnancies. I made sure I told as many midwives as possible, as well as the medical student and the patient herself that she should be allowed to labor as normal. I also wrote it very clearly in her antenatal card.

What to do about the warts themselves? There is an effective medical treatment, called podophyllin, that I am familiar with. But I was reluctant to use it before delivery, and anyway, would it even work with such extensive warts? I contacted a colleague of mine who has expertise in HPV (the virus that causes genital warts as well as cervical cancer, although different strains cause each disease). She had seen such cases in Kenya, and told me that podophyllin would be complicated in this case – it would cause too much necrosis (dying of tissue) and would likely lead to infection. A better option in severe cases was surgical management; namely, cutting off all the warts. I would have to do it after the postpartum period.

Was there anything I could do in the meantime? I thought about HIV medications. I sent for a CD4 count through the hospital system, although it takes a long time. If her CD4 was low enough, she could qualify for antiretrovirals (ARVs) under the Ugandan Ministry of Health Guidelines. But ARVs might improve her immune system, and might help reduce the size of the lesions as a result. If I waited for the CD4 results, she would only be on the ARVs a short time before delivering. I consulted a physician in Kampala who was more familiar with the guidelines, and she said that severe genital warts would qualify the patient to start ARVs, regardless of CD4. That was good news for the baby, too, because it would reduce the likelihood of HIV transmission. I started her on triple therapy.

The patient was in and out a few times before she delivered. I saw her sometimes in clinic, and sometimes in labor ward. I treated her for yeast infections a couple of times, and she did improve after treatment. The warts stayed about the same.

I wasn’t aware when she was delivering. I heard later that she had delivered vaginally without complication. My instructions had worked – no cesarean was needed.

When I saw her postpartum, the baby looked OK, and the warts were still there. I discussed with her the options for management of the warts, and explained what the surgery would be like. The conversation was difficult, and I had S, a physician who speaks Japadhola, with me translating everything. I had to be very honest about the surgery – it would affect her entire external genital area, and there would be a lot of pain. I would give her pain medicine , but she would have a hard time walking at first, and would probably require a catheter to urinate for a few days to reduce the pain.

I remember this conversation well. This girl, unlike most Ugandans, never smiled. Her face never betrayed any emotion. When she was overwhelmed, tears would suddenly roll down from her eyes, over her expressionless face. It was heartbreaking. I couldn’t imagine what kind of suffering she had been through in her 17 years that had caused her to turn so far inward. Whenever I saw her, I wanted to hug her, to mother her. But she didn’t ask for mothering, and seemed not to notice my touch, or my sympathy. She kept coming back, so she must have realized I would help her, but there was no sign of it on her face, only silence.

During this conversation, her tears flowed. Periodically, she picked up the bottom of her not-very-clean T-shirt and wiped her face, and stared down at her lap again. After gentle but extensive discussion with S, she told us that she wanted the surgery, but she had no one to come and care for her. She was alone in the world. S prodded her – it is rare for Ugandans to be completely alone. There is usually someone in their extended family or community that they can depend on. She admitted that she lives with her grandmother, but her grandmother is poor and old, and can’t come to care for her.

I knew this surgery would be too difficult for her to be alone postoperatively. She had to care not only for herself, but also for the child. We emphasized to her that anyone who cared for her would not have to worry about catching HIV. If that were a concern, we said by way of explanation, then we would also have to worry about me as the doctor. I would be doing the surgery itself, and that was the most risk. If I was not afraid about catching HIV from caring for her, then no one else would have to be.

After more silent, stony tears, she agreed to go and try to find someone. She has sisters and sisters-in-law, but none of them want to help her. We gave her a sense of urgency – I would be leaving Uganda in only a few weeks, and I didn’t want to do the surgery in my last week here, because I also wanted to be there while she was healing and make sure that there were no complications.

The next week, to my surprise, she returned with a young woman, who had her own baby on her back. She was the second wife of the patient’s uncle. She was willing to care for the patient after the surgery. We went through the discussion again – how it would be difficult, there would be pain, and it would take at least 1-2 weeks to recover. Would she be able to care for the patient, the patient’s baby, and her own baby? She said she would leave her own baby at home, and she would be able. The patient had already told us that the woman knew about her HIV. We asked the attendant if she had any fears about catching HIV. She admitted that she was worried about it. We explained to her that we would provide gloves for handling any fluids, and that she could not get HIV by touching or caring for the patient or her baby. We explained how HIV is transmitted. She said she was OK with that, and she no longer feared that she would contract HIV.

We set a date for the surgery, and told them to come back.

The surgery itself was a first for me. I had done surgeries for genital warts before, but never so extensive. I talked to my colleague at length about the procedure, and what to expect. I had a smart medical student with me, who showed impressive intiative and a strong stomach. I will spare the details here, but needless to say, it was an extensive excision.

I tried my best to ensure that my patient received adequate pain control postoperatively. I gave repeated instructions to administer both morphine and anti-inflammatory painkillers. It is common for health workers here to overlook suffering because it is so common, but this situation was extreme, and I couldn’t bear the thought of my young, downtrodden, helpless patient – already traumatized by the shame of HIV and huge genital warts – having to endure this postoperative pain unmedicated.

I had her on antenatal ward instead of Gyn ward because the midwives knew her well, and because she had a newborn infant. I reminded every shift of midwives to give her pain medication as needed. To my surprise, it worked. She still had pain, but at least she had some measure of relief.

I also changed her bandage daily, and was surprised to find the healing relatively rapid and infection-free. Eventually, her attendant got the hang of changing the dressing, and I no longer needed to.

She didn’t get out of bed much, which was disappointing, although not surprising. The same was true of my other young, traumatized patient. Both were withdrawn in the same way, and I suppose that the only way for them to handle both the emotional trauma and the pain was to curl up and close their eyes. They were not engaged with the world.

After a few days, the wound was improving, but the patient was still in bed. There were multiple attendants at her bedside – or at least several women there to visit the attendant. They were sweet and grateful, and respected the patient’s privacy when I closed the curtain to examine the wound.

Soon after that, I came to the ward to find her bed empty. According to the midwife, she had just left on her own, without being discharged. That happened often, so it wasn’t too surprising, but I was still nervous about her. The wound was healing well and I wasn’t too concerned about infection anymore. But pain, difficult urination, limited mobility and poor hygiene could still be a problem.

A few days later, she came to find me in the clinic. S helped to translate. She told me she had left the hospital because the midwives had stopped giving her pain medication, and so she and her attendant didn’t see why they needed to stay anymore. It was a good point. I hadn’t realize that had happened, and I was disappointed, but not surprised.

I apologized to her for that. I knew that I had stopped nagging the midwives, hoping that the pain medication had become routine, but I was wrong. I should have kept nagging. I was so sorry that she had suffered. She told me there was still some pain, but it had reduced by a lot. I asked to examine the wound.

I found good healing, and just needed some improvement in hygiene. I explained this to her, with S translating. Using a male translator is a little awkward, but I don’t have any female options for translation. Besides, I like how S speaks to patients. He has a gentle and respectful manner, and he expresses things beautifully.

I told her that I wanted to see her every 2 days for now, just to make sure she was doing OK. If she had been a different patient, I might have said it was ok to see her once a week. But I knew she was alone, fragile and had few resources. I didn’t want anything to go wrong, and I wanted to be her safety net for now. I asked her if she could come that frequently, and she said she could.

She didn’t come back again. I left Uganda 2 weeks later. I left word with S to look for her and email me if she returned. He agreed, but doubted she would be back.

Upon my return to Uganda, she is one of the first people I look for. The midwives tell me they know people who live near her, they can pass the message to her.

Two days later, she appears in the clinic. She has the same poker face, and her chubby, adorable baby on her hip. I show that I am happy to see her. She doesn’t show any recognition or emotion, but she follows me dutifully into an examination room. S graciously delays his lunch hour to come and translate for me.

She had gotten my message from people in her community – that’s how she knew I was back. She is not having any pain, but does have discharge and itching. She has not seen any new warts since the wound healed.

I look at her as S translates. Unlike many Ugandans, even the poorest, she often looks bedraggled; her clothes are usually intact, but show signs of brown around the edges. I imagine she has very little clothing and can’t wash them very frequently. Her hair is shorn close as many women’s hair is here. But her baby is wearing a cute baby outfit and swaddled in a bright, clean blanket. He has chubby cheeks and large eyes. He stares intently and smiles and laughs in response to eye contact. He starts to cry at one point while we are talking, and she tries to soothe him while maintaining our difficult conversation. Eventually, he is insistent, and she allows him to breastfeed. He seems well cared-for.

I ask how she gets money to feed herself and the baby. She says that if people need work in their fields, she does digging and they pay her. It is hard work, and even harder with a newborn infant.

I ask about her HIV meds. After she delivered, no one gave her any more meds. It is always hard for me to figure out why this happens. Sometimes patients just stop showing up; sometimes they try to get meds, but they are refused at the health care facility. When I try to investigate, no one is ever forthcoming about what happened or why.

Her CD4 had come back before I left Uganda – it was above 500, which means she would not be eligible for ARVs under current Ugandan guidelines. It’s unfortunate, especially since she is breastfeeding and her risk of transmission to the infant is high. Nonetheless, she needs to be enrolled in some HIV clinic – to get Septrin (an antibiotic that prevents opportunistic infection), to have follow-up, and to eventually get ARVs when she does qualify.

I start to bring this up, and S conducts the discussion in Japadhola. I like how he expresses things, so I don’t force myself into the conversation. Eventually, he always translates for me what he has said to the patient. We would prefer for her to go to TASO (The AIDS Support Organization), which has a clinic nearby. TASO is the oldest AIDS care organization in Uganda – before ARVs, it provided supportive care. It is a fully Ugandan organization, and it is well organized, with standardized procedures and organizational cohesiveness. Patients get not only medication, but social support, nutritional supplementation and counseling. Because it is more comprehensive, reliable and organized than the hospital’s HIV clinic, I prefer to send people there.

I don’t speak Japadhola, but I can tell that there is some kind of confusion in the conversation. S tells me that the patient is telling him that she knows where TASO is, but she can’t go there because it is too far. TASO is across the street from our clinic. He stands up and points across the street to TASO, which is visible from the window. She still insists that it is too far.

“I am telling her, ‘We are your friends. We want to help you. You can tell us the truth. If you don’t want to go to TASO, it is ok, but tell us why. Because it is very close to here, and you can come here.’”

Finally, she explains her reluctance. Her neighbor works at TASO, and she is afraid that if she goes, the neighbor will see her and know that she has HIV. The stigma of HIV is still a very real problem, and a major limitation in access to care.

It is unclear what the neighbor’s job is at TASO. If she is a care provider, then she is mandated by her profession to maintain confidentiality. The patient thinks that she might be a cook, but she is not sure.

We then start to discuss the option of going to the TDH HIV clinic. She won’t get the social support and comprehensive care, and she will be more likely to fall through the cracks, but it’s better than nothing. She claims that she was going to the TDH clinic, but no one gave her any medication.

S sees the inconsistency in this, and begins to explore it in Japadhola. It doesn’t make sense. Even if she wasn’t given ARVs, she would be given Septrin – anyone with HIV gets Septrin. He asks details about where she went and whom she saw, and she has no details. He guesses, correctly, that she has never actually been to the clinic. He tells her again not to fear us, that we are her friends and we won’t be angry, we only want to help. She finally admits that she had never gone, although she says that there is no reason why. This is actually possible. Disadvantaged, ignored and helpless – it is entirely plausible that she wouldn’t have known that it would be very good for her to attend the clinic, or why. It would just have been a big effort for no specific reason.

We discuss the TDH clinic with her, and she sounds willing to go. We would really prefer to send her to TASO, and we mention it one more time, but I don’t want to risk alienating her, so we drop it quickly. I am a little afraid that she will get lost in the process at TDH. Will she actually show up? And if she does, will she be able to express why she was there, what were the different medical circumstances she had? Would they know she had a CD4 done? Would she, by chance, encounter someone unsympathetic or overworked or lazy who would turn her away? If she did, would she have the fortitude to insist that she belongs in that clinic? I can’t imagine that she would.

I can only do my best. I write a note describing her antenatal ARVs, and the genital warts excision, and I tell her to bring it to that clinic. Her child, who tested negative for HIV at 6 weeks (although is still breastfeeding) may be eligible for one of our pediatric studies, so I connect her with the coordinators of that study and the study counselor. I hope that at least if her child is in the study, she will have access to our clinic, and someone might ask after her own condition, and maybe even she will run into me once in a while, and I can check up on her.

Coming Back

2010-09-22T03:23:00.007-04:00

I am back in Tororo for a brief visit. Only 2 weeks - much too short, but it's all I could fit in on this trip.

I am delayed by a day in Kampala due to car troubles, and when I finally arrive the next day, there are many hugs to be had. The midwives tell me they were excitedly waiting for me all day yesterday. It is wonderful to see them.

In the afternoon on the day I arrive, I am dashing out of the clinic to a meeting, and I see a woman sitting in the waiting area looking directly at me. When the patients who have come to see me (non-research patients) can't find me, they sit there, sometimes for hours, until they see me walking in or out. She is looking at me so intently that I know she must be there for me.

She approaches. She looks familiar, and I know I treated her for something, but I can't remember what. Maybe infertility? Pelvic pain?

"Are you looking for me?" I ask.

"Yes, for you," she says. "I have come many times for you, but they told me you are away."

"Yes, I am sorry, I have been away. What is your name?"

"P_____." I still can't remember what I saw her for, but it wasn't obstetric.

"Do you want to see me?" She nods. I can't see her now because of my meeting. I know that the next two days will be a blur of meetings because all of the investigators are coming to discuss all of the research that is going on. It should be calmer by Friday.

"Come and see me on Friday," I tell her. I give her my phone number and tell her to call before she comes, because I know that whenever I make plans like this, something comes up. I also tell her to bring any notes that I wrote, so that I can remind myself why I saw her and what I did.

The next morning, I find out that I need to go to Kampala for an urgent meeting on Friday. I feel guilty that I will miss P.'s visit, and I don't have any way to reach her. I hope she calls first. Just in case, I tell some of the study clinic nurses about her, and tell them that she should come back Monday.

While I am at work that day, I get a phone call from an unrecognized number. It is a different patient.

"Hello, Dr. Veronica! This is O______! The midwife told me you were here."

I recognize her name, because it is an uncommon name in Uganda. She is a college girl whom I treated after her illegal abortion went awry, and she had continuous heavy bleeding. I gave her misoprostol and the bleeding stopped. She was very grateful at the time and came to see me twice more to thank me before I left in July.
(The anxiety surrounding illegal abortion makes a mild complication feel life-threatening. The patients I treat after illegal abortion are often convinced I saved their lives, whether or not they were particularly ill.)

"Hello, O. How are you?"

"I am very OK, Doctor."

Now I am wondering why she is calling. Am I remembering the wrong person? Does she have an ongoing problem that I need to continue treating? There is an awkward pause. Finally, I ask.

"Are you calling me because you have a problem, or to say hello?"

"No, Doctor, there is no problem. I am only calling you to say hello and to thank you for helping me. I am very grateful. I am very happy."

The next day, I travel to Kampala. While I am on the road, I get a phone call from P. She asks if she should come on Friday and I tell her to come instead on Monday, but to call first. She agrees.

Half an hour later, I get a text from the same number: "Am so grateful thank you very much for the drug you wrote for me am happy and pregnant. God bless u. P_____."

It's good to be back.

On Monday, P. comes to see me, and I review my notes. She has HIV that is well-controlled on meds, and I had seen her for pelvic pain, infertility, and secondary amenorrhea (disappearance of menstrual periods). In order to try to determine the root cause of her amenorrhea, I started her on oral contraceptives for 1 month. When she started the placebo week of pills, she should have seen a period due to progesterone withdrawal. From my notes, it appears that she did not bleed after the 1 month of pills, so instead I gave her a 5-day course of progesterone, which is the same idea. Once the progresterone is stopped, she should see bleeding.

There are no more notes from me after I gave her the progesterone. She didn't come back.

She tells me that after the progesterone pills, she didn't see any bleeding, but about 2 months after that, she took a pregnancy test and it was positive. She is thrilled.

She had a history of two miscarriages, and had been unable to get pregnant for about 5 years. Her boyfriend (who also has HIV) left her because she couldn't produce a child. From my notes, I see that she had a hysterosalpingogram to see if her tubes are open, and she was told they are blocked. I surmise that I was reluctant to give her any ovulation-inducing agents in light of this information (no point in ovulating if the eggs can't get through the tubes), so instead I decided to focus on bringing back her menstrual cycle. As it turns out, somehow, unexpectedly (and without a period), she got pregnant.

I don't know if it was the medication I gave her that did it. I wouldn't have expected it, since she didn't have a period after either treatment. But she got pregnant soon afterward. Maybe the pills helped kick her regular cycle back into action, or maybe her pregnancy is just a coincidence. I don't know. Either way, we are both happy.

I confirm that she is still on her HIV meds and attending antenatal care. Her boyfriend is supporting her now that she is pregnant, although he is still in Kampala. Because she had no period, I decide to do an ultrasound to determine her gestational age. I'll admit that part of me is worried that the pregnancy is somehow abnormal or that it was a false-positive pregnancy test.

When I do the ultrasound, I see a healthy baby boy at 25 weeks. I turn on the doppler so she can hear the heartbeat. She glows.

As it turns out, her due date is in early January, and I just may be back by the time she delivers. I tell her to look for me when she goes into labor.

Sub-Optimal

2010-07-12T14:56:00.002-04:00

I stop by the Labor Ward to ask the midwives to prepare two women who need cesareans. They are not urgent – both repeat cesareans. When I walk onto the Labor Ward, I call out my usual greeting: “Hello! How are you?”

Two midwives are there. One of them says “We are not very fine, doctor. We have this lady with APH [Antepartum Hemorrhage] and…..it must be….abruptio placenta?”

Abruptio placenta (placental abruption) is when the placenta partially or completely comes off the uterus while the fetus is still inside. It can be fatal for the fetus, and even sometimes for the pregnant women if the blood loss is severe enough.

She hands me the patient’s file, and I see the results of an ultrasound that was done today. It shows a placenta previa. The scans aren’t very reliable here, but I would tend to believe this type of finding. I am wondering if I should re-scan, when I walk over to look at the patient. There is a pool of blood with clots about 3 feet from the bed. She is lying on her side. There is old blood covering her legs, down to the bottom of her feet. Her pink skirt is not pink – it’s white, but covered in blood.

When I see the skirt, I realize she needs a cesarean NOW. She doesn’t have time for me to go and get the ultrasound and start dilly-dallying. At home we would be doing a crash c-section, which means that we would load her onto a stretcher and literally run the stretcher into the OR. We would have all hands on deck. There would be people available to move the patient, set up the OR, arrange for blood to be available, notify pediatrics, help anesthesia, and do the crash. It would be organized but effective chaos. It works.

Here, there is no such thing as a crash c-section. I go to the midwife who told me about the patient and tell her that I agree – the patient needs a cesarean urgently. I ask her to prepare the patient immediately, including consent and an IV. She agrees, then walks over to another patient, looking very unhurried. Another midwife arrives, and I tell her as well. She agrees too, but doesn’t really take action either.

I know that they will do it eventually – they always do. But there is no sense of urgency here. I have had so many situations already where I have seen that even the most urgent situations can take 1-2 hours to get into the OR. At home, I would do it myself. But here, I can’t consent the patient because I don’t speak Japadhola. I can’t put in the IV because I can’t access the supplies.

I see a third midwife who has just come from theatre, from another cesarean. She still needs to bring her patient back to the ward. I tell her about the bleeding previa. She is distracted because she is thinking about her other patient.

I come back to the clinic because there are people waiting to be seen by me that I want to manage before I go to theatre. When I get back to my office, I know I need to push more to get this patient to theatre. I call the third midwife because I know she is effective (and I have her phone number) and I re-emphasize the need to move this patient to theatre immediately. I can tell she gets the urgency this time.

In the clinic, I treat a patient who is still having bleeding after an illegal abortion. Just as I am finishing, another midwife comes by to show me the lab result of the bleeding patient. Her hemoglobin is 8.8, which is actually not that bad (for here). However, we don’t trust it very much. The lab is sometimes unreliable and what’s more, the patient is still actively bleeding, so by the time we are getting her to theatre, she will be lower.

She tells me that they have moved the patient to theatre. I walk over, and find the anesthetist preparing the materials for the cesarean. The patient is there. The anesthetist speaks basic Japadhola. As a formality, I ask him to ask her if she wants a tubal ligation. I ask almost as a reflex – because most of the time when I am doing a cesarean, the women have had a lot of children already. She says she wants one, but when I look at her chart, I realize that she is only 23 years old. She had given birth to 2 children, but only 1 is alive. I try to counsel her through the anesthetist, but his Japadhola is limited. She keeps insisting she wants me to cut the tubes, even if this baby dies.

Even in the US, this would give me pause. I would seriously try to discourage a 23-year-old from a tubal ligation. There is the problem of regret – she has at least 20 more years of potential fertility ahead of her, and she may change her mind in that time. Or she might end up with a different partner, and decide she wants children with that person. Or she might just want the option of fertility, even if she doesn’t ever have another child.

But here, it’s even more concerning. Fertility is paramount. A woman who can’t/doesn’t produce many children is considered inferior. Of course, maybe she doesn’t care. Maybe she genuinely doesn’t want more children, and I can’t blame her for that. But what if her husband leaves her for that reason, or beats her, or takes another wife? Can she support herself?

I tell the anesthetist to ask her husband. In my opinion, I don’t need his permission to do it, but I am thinking that if they discuss it together, maybe he will get her to realize what she is asking for. The husband answers that he doesn’t want her to have a tubal ligation. As I am trying to get the anesthetist to have the husband discuss it with the patient, the patient again calls out that she definitely wants the tubal ligation. The husband changes his mind. “Do what she wants,” he tells the anesthetist.

Aargh. Even more confusing. Does that mean he’s just scared right now, but later he’ll leave her when she can’t have any more children? Or does he really agree?

The anesthetist encourages me to do it. His argument is that in the next pregnancy, she could have another antepartum hemorrhage, but she will be in the village and will not be able to get a cesarean, and she will die. Infertile is better than dead.

The scrub tech agrees, although he is more timid about his opinion.

I open the sutures I will need for a tubal ligation. I am feeling really nervous about this. Should I do it? Should I not?

We move the patient onto the operating table from the stretcher. I realize that perhaps I can convince her to accept an IUD – I can even put one in during the c-section. I know that there is cultural resistance to IUDs, though, and convincing someone to accept one takes good translation and good counseling, neither of which I can give her right now. I tell the scrub tech, who can also speak Japadhola, to offer an IUD. She answers tersely. “She wants you to cut her tubes,” he translates.

Sigh. What to do?

A midwife arrives. I tell her the situation. She immediately offers her opinion.

“Don’t cut her tubes! In Africa, we women must have children. She has only one, if she can’t have more, he will leave her. She is just saying that now because she is in pain, but she doesn’t know what she wants. If you do it, then she will wake up, and she will realize she didn’t want it. She is just scared now. Don’t do it.”

Oh nooooo, what do I do? The anesthetist makes his point again. The midwife makes her point again. Both, I have to admit, are good points.

The worst part about this, for me, is that either way is completely paternalistic. In medical school and residency, there is a huge effort to emphasize patient autonomy. Patients should always be aware of and agree to the course of action. If a patient is making a bad decision, you sit down and discuss it with them. Of course you can decline to do things that are medically unsound (for example, I would decline to do a elective cesarean section with no medical basis, but I would refer the patient to someone who was willing if she wanted.)

Even in a situation like this, with a 23 year old wanting a tubal ligation, I would probably refuse to do it (except under very special circumstances), but I would have a long discussion with the patient. I would explain my concerns. I would explain the risk of regret, the risks of the procedure, the fact that there are alternatives that are just as effective and that are reversible. I would never, ever just make a decision and not explain it to the patient as much as possible beforehand.

But here I have no choice. I don’t have adequate translation. I don’t have people who understand how to counsel for contraception. I don’t even have an emotional connection with the patient – she won’t make eye contact with me. I am cursing myself for even offering a stupid tubal ligation. Why didn’t I look at her chart first?

I try to get the midwife to talk the patient into an IUD, but the midwife doesn’t speak Japadhola. The midwife encourages me to just do the IUD. She goes over to the family planning clinic to get one. The scrub tech tries to convince her again.

While he is talking, I look at the blood pressure monitor and realize that her blood pressure is 60/40. Holy shit. I’m here hemming and hawing over contraception, and she’s bleeding to death. What am I doing?

I race over to the sink to scrub. Just as the anesthetist has put her to sleep, the midwife arrives with the IUD. I tell her to open it.

“It is the right thing, doctor,” the midwife encourages me. “She can remove it later if she wants.”

I’m still not sure, but I can’t think about it right now because I’m thinking about her bleeding previa and how it took us an hour and a half to get her to the OR.

When I reach her uterus, it is small (she is 36 weeks pregnant), but there is enough space between her uterine arteries to make the normal, horizontal incision on the uterus. Because of the placenta previa, I consider for one second doing a classical (vertical) incision, but I decide that there is no indication. I can deliver the infant through the horizontal incision, and if she ever gets pregnant again, it will be safer for her.

I cut, and luckily where I make my incision is just above the placenta. I can see it filling the lower uterine segment, still intact. The infant is breech, as expected. I need to pull out both legs to bring the hips out. I can reach the left leg, but I can’t find the right. The hips are oriented strangely, the baby is curled up on itself in an odd position. I decide to bring the hips out first, but they won’t move. The placenta has taken up a lot of space within the uterus, and it is really hard to move the baby around.

I try all of the maneuvers I learned in residency – I try to pull one foot out, hoping the second will come. It doesn’t. I try to move the hips toward the incision. They are stuck. I reach my hand way in, and try to turn the baby so that I can deliver the head-first. It won’t move. I try to extend my uterine incision. The scissors are dull and it’s difficult, but it doesn’t help anyway.

At this point, I start to curse. It helps me focus. I kept trying the maneuvers, but it becomes clear that they are not going to work. It has now been several minutes. Given the severe hemorrhage from the placenta previa, this baby might have already been compromised. It won’t tolerate much longer inside the uterus like this.

I know what I need to do, but I am really unhappy that I need to do it. I decide to T the incision. That means that rather than extending the sides horizontally (which runs the risk of cutting into the uterine arteries), I will cut upward from the center of the incision into the thick muscular uterine tissue. It forms an upside-down T on the uterus.

This is never good. Making a T-incision means that the point where the 2 lines meet will always be a weak point. Because of that weak point, and because a vertical incision on the uterus is much weaker than a horizontal one, the patient can never try to labor in the future because the risk of uterine rupture is too high. We always have to counsel such patients strongly that they must not try to labor, and they will require a planned cesarean delivery before going into labor.

The problem is that this is a poor patient who lives in some village somewhere. Will she be able to make it to a planned cesarean in advance of labor? If she does go into labor, will she be able to come emergently from her village to the hospital? Will she be able to communicate to her providers then that she requires a cesarean, and why? Will she even make it for antenatal care at all in the next pregnancy?

Well, I can’t worry about that now because her baby is going to die if I don’t get it out soon. I grab the dull scissors, protect the baby’s body, and cut vertically.

Finally, I can grab the right leg and pull it out. I deliver the infant breech. The baby is alive, but very weak. I pass her to the midwife, and turn back to the patient.

The uterus looks terrible. The T-incision is never pretty, but the horizontal portion has extended due to my multiple attempts to deliver the baby, and it looks almost as if the uterus is partially amputated from the cervix, with only the posterior portion attached. Miraculously, the uterine vessels are intact. This is going to be a difficult repair. I briefly consider doing a cesarean hysterectomy, but that seems crazy since I just spent so much energy trying not to have to tie her tubes.

I look at the blood pressure monitor. Her blood pressure, which had improved to 70/40 with some fluid before the surgery, is now 58/28. Good grief. I tell the anesthetist, but he is helping the midwife resuscitate the infant, who is also looking crappy.

I can’t decide if I should insist that he attend to the patient immediately, or keep helping the infant.

Just then, the power goes out. Fan*$%@#tastic.

I have no choice, I have to sew now or she will bleed to death. I can see just enough from the natural light coming in through the windows. It will have to do. I stitch as fast as possible, but I have to be careful to avoid the engorged blood vessels nearby, and to re-approximate the extensive uterine incision. I have to close the vertical portion and the horizontal portion separately. All the while, I am looking at the patient’s blood pressure.

I ask the anesthetist to check the patient’s heart rate. He puts a finger on her wrist and tells me “The pulse is there.” I wasn’t asking to see if she was alive, although the thought that we even need to is rather frightening.

I ask the anesthetist to put in a second IV in order to run in more fluid while we call for blood. Fluid resuscitation can maintain her temporarily, although she will need the blood to survive.

It is difficult to put in a second IV. We can’t put it in her other arm because that is where the blood pressure cuff is attached. There is lots of wandering around and delay without putting in the IV, and I am focused on stopping the bleeding and getting the patient’s abdomen closed, so I don’t notice for a while. General anesthesia could also be artificially lowering her blood pressure, so the sooner I can get her finished and out from under anesthesia, the better.

Once I am suturing the skin, I can stop and ask again. I can see that no second IV has been placed. “There are no giving sets,” I am told. Without the IV tubing to attach fluid, there is no point in putting in the IV needle. Sigh. I ask them to run the fluid as fast as possible, and recheck the blood pressure. I will put in the second IV after I finish.

When we are finally done with the surgery, I write the operative note, change out of my scrubs, and head to the Labor Ward to discuss this patient with the midwife in person. It is now evening, and the evening midwife is usually on alone, which means that she doesn’t have time for the delivered patients because she has to worry more about the laboring ones. But this one needs urgent attention.

When I reach the Labor Ward, I am happy to see one of my favorite midwives, H, who is very hardworking and always greets me with a broad smile. She is already with my patient, receiving her on the postnatal ward. I tell her about the antepartum hemorrhage, the surgery, about the T-incision, the low blood pressure. I see that the blood is already hanging – the anesthetist must have drawn the blood for crossmatching and requested the blood while we were in theatre. But it seems that the giving set is faulty, and we cannot see whether the blood is running into the tubing or not. The midwife and I try to adjust it, but it doesn’t work. If it is not running, it could sit there all night and the patient will get no blood. She dashes off to find fresh IV tubing somewhere. I am glad this midwife is on – she gets things done.

The patient’s husband is there, kneeling at her bedside and holding her hand as if he is holding onto her life. Her mother is on the other side of the bed, holding the patient’s other hand. They are both staring intently at her as if something might happen. They are terrified. I try to reassure them, but I know that this is not the time to talk about details like IUDs and T-incisions. I tell them to watch the blood carefully and make sure it all goes in tonight.

The next day, I go to see the patient. I am relieved to see her alive, but she still look weak and sick. I take her pulse, and it is elevated. (The baby, luckily, looks fine.) I look at the patient’s conjunctivae – the inside of her lower eyelid – to check for anemia. If someone is not anemic, the conjunctivae are pink and have visible tiny red blood vessels coursing through. Someone who is slightly anemic might have conjunctivae that are a lighter shade of pink. If someone is extremely anemic, the conjunctivae are deathly white. This patient’s conjunctivae are very, very white.

Not all patients need a transfusion at the same hemoglobin level. The most important factor in whether or not to transfuse is how she is feeling. This patient is weak and has a high heart rate, which means she is not tolerating the anemia well. Just to make sure that these symptoms are, in fact, from anemia and not infection, I ask the midwife to draw a sample of blood to check the hemoglobin level.

In the US, the minimum level of hemoglobin that we generally tolerate without recommending transfusion (regardless of symptoms) is around 7. Americans are not typically very anemic, because our nutrition is so much better. Even patients who are considered to have “severe” anemia in the US are pretty much average here. Depending on the circumstances, someone with a hemoglobin of 5 may or may not require transfusion, and the level needs to get to 4 or lower to be really compelling.

My patient’s hemoglobin, after the single unit that was transfused postoperatively, was 3.2. A level that low would kill most Americans. I can only imagine what it was during the surgery. I go back to the ward to ask the midwife to crossmatch her for more blood and transfuse another unit. The midwife I encounter is not the most motivated person, and she doesn’t really move when I tell her. It is mid-afternoon and the evening person will be arriving in an hour or so. This midwife tends to slow down around this time and let the evening person take care of it. I have the feeling it won’t get done, so I make a mental note to come back.

When I return in late afternoon, the same evening midwife is on, who had transfused the blood the day before. Before I say anything, I see she is already heading toward the patient with a syringe and needle to draw blood for crossmatching.

An hour later, I run into her on the hospital grounds. “Doctor,” she says, “the lab has refused to give the blood. They have said that the hemoglobin level is 5.3, and it is too high for transfusion.”

You have got to be kidding me. This woman just bled out 90% of her blood volume and underwent surgery yesterday. Not needed?? Obtaining accurate hemoglobin levels is difficult because the tube that the blood is collected in has an anticoagulant, which can sometimes affect the hemoglobin reading. So it’s hard to know whether our lab was correct or theirs was. But regardless, the patient is clearly symptomatic and nees blood. Unfortunately, it is now 6pm and the blood bank is closed for the night. The patient will have to make it through the night. I instruct the midwife to give more fluid as needed and to watch her closely.

The next day, I am relieved to see her looking better. The blood bank won’t budge on giving the blood, but her heart rate is improving, and she looks less weak. I encourage her to start eating food and sitting up.

Her recovery is slower than most, but she progressively improves each day, and is out of bed relatively rapidly. One day I come to her bedside to find her sitting up and smiling. Every time I operate on a patient here, I know they have turned the corner when the smile reappears.

Now I need to explain to her about the T-incision and the IUD. I had already briefly mentioned to the husband before that I didn’t cut the tubes, and he looked stricken and said “But I told you to cut them.” The patient was still weak at the time, so I felt it would be better to talk about it once she had improved.

Now I need a translator in order to talk to her. The midwife comes over to translate, but she doesn’t speak Japadhola. The midwife brings over another patient from a neighboring bed who does speak the language. I speak to the midwife in English, who translates into Luganda, and then the neighbor-patient translates into Japadhola. Yes, these are optimal circumstances under which to discuss life-threatening hemorrhage and family planning options.

I start to explain, and, as usual, there is a lot of back-and-forth before anything is translated back into English for me. At this point, I have realized that when people translate for me here, they are not just language translators, but cultural translators as well. If they were to translate what I say word-for-word, it would still be an awkward and highly unnatural conversation because the way that I think and express myself is so foreign. As long as the translator knows what needs to be communicated, I give them leeway.

I get enough translated to understand that the patient still feels that she does not want more children, especially because she almost died this time. That’s good. Now I need to explain the IUD. I need to tell her that it is as effective as cutting the tubes, and that if she doesn’t want more children, she can leave it in place. But because I put it in without asking her, I feel that I need to express to her that she has every right to have it removed, and I will do it myself if she wants. The midwife responds to me (before translating) that the patient should leave it in so she doesn’t get pregnant. I tell the midwife that I agree, but I want the patient to have options, because I didn’t give her any when I did the surgery.

The midwife understands and explains this to the patient. It sounds like it is going well, when a patient from another bed (who I did a cesarean on the day before this patient) chimes in. She seems to be giving strong words of advice to the patient in Japadhola. Then other people in the ward also shout in comments. I ask the midwife what they are saying. She explains that they are all advising her to keep the IUD in, and they are telling her their own life-threatening birth experiences and how dangerous it is, and how she should accept the family planning so she doesn’t die.

I chuckle a little because this situation is the opposite of what I had been taught to do. No privacy, people shouting random advice about their own experience, a telephone-game of translation, and a sullen patient. But then, she seems to be coming around to the advice, and she finally agrees that she will keep the IUD in for now, and that if they ever decide to have another child, she knows she can remove it later. I am still uncomfortable about the lack of privacy, but who am I to say that my culture’s counseling methods should be imposed here? Sometimes I just need to go with the flow and hope it all works out for the better.

The patient steadily recovers, and the baby does well. The husband seems content, and finally she is ready to go home. This patient was the closest I have come to having someone die under my care in Uganda, and she survived by a hair. I hope she keeps that IUD in.

Too Late

2010-07-08T16:53:00.000-04:00

My phone rings, waking me up. I stare at the blurry phone – the time is 6:30am. The call is from the Labor Ward.

The midwife tells me that there is a patient who has had 1 previous cesarean delivery. She had been laboring well, and was expected to deliver vaginally. Now she is fully dilated, but the baby is not coming down. The midwives suspect she needs a cesarean, and they want me to come and assess.

I ask some questions to get more details about the urgency. How is the fetal heart rate? Is there meconium? How long has she been fully dilated? It is a struggle to get information because this midwife has a hard time understanding my American accent over the phone. It might be urgent, but maybe not.

I try to get up and out of the house quickly, but because it is early morning, and because this is Uganda and everything takes a long time, it takes longer than I would like. I ride my motorbike over to the hospital, and head to Labor Ward when I arrive. The night midwives are still there, and the point me toward the patient.

She doesn’t speak English, and I don’t have enough time to search for the chart to figure out details; the exam is more important. I listen for the fetal heart, but the mother is very uncomfortable and keeps moving. We don’t have electronic fetal monitoring here, only a fetoscope, which is a cone-shaped tool that is pressed to the mother’s abdomen, and the midwife presses her ear against the other end to hear a faint ticking sound, which is the fetal heartbeat. I can’t hear the heartbeat with the patient moving like that. I ask the midwife to help me (they are so much better at it than I am), and she finds it. I hear it, but it sounds really fast. Also, it could be the mother’s heartbeat. When the mother herself is sick or stressed, her heart rate can be high and can be mistaken for the fetus’. I make a mental note to check her pulse, but first I want to do the vaginal exam to see what is going on with the delivery.

I put gloves on and examine her. There is thick, green meconium spilling from the perineum. Meconium can be a normal sign – a full term fetus can pass meconium in labor. But it can also be a sign of trouble, and it’s hard to differentiate when it is an ominous sign. We try to differentiate the thickness of the meconium, assuming that thicker is worse, but it is still a weak predictive tool. Nonetheless, it makes all obstetricians nervous.

I palpate the presenting part. What I feel is very soft and bulging, almost like amniotic membrane. Are her membranes intact? I ask the midwife, and she agrees that it feels like membrane. But that doesn’t make sense, because meconium in in the amniotic fluid – the membranes have to be ruptured for the meconium to be visible.

I palpate further, hoping to feel a firm, hairy head beyond the membranes, but all I feel is mushiness and a strange contour. Suddenly I realize what I am feeling: the baby’s butt. The baby is breech.

I tell the midwife, and she is shocked. At the same time, she immediately realizes I am right – that is what they were feeling all along. It could also explain the slow descent of the baby, as breech infants are slower to deliver.

But what should we do now? The baby’s butt is extremely low in the woman’s pelvis. It almost feels like I could pull it out. If she were earlier in her labor, we just would have taken her for cesarean. But now the baby is close to being out. Moving her to theatre always takes at least an hour. If this baby is as stressed as it seems, it might not have an hour. Maybe I can get this baby out if I can help her push effectively.

I encourage her to push with the next contraction. I ask her to put her chin to her chest, curl around her baby, and lift her legs. She pushes better in that position. I have observed that the midwives often blame the patient for poor pushing when the presenting part doesn’t move (part of the culture here, it seems), but sometimes it isn’t the woman’s fault, it’s just the mechanics of the situation. I can see she is really pushing hard.

We try pushing through three contractions. At first it seems like we are making progress. The midwife notes that this is much more effective than before. But after 3 pushes, it is clear we are not getting anywhere. I don’t want to give up, but I don’t want to let this baby die, either. I call the cesarean.

It is not an easy call. Doing a second cesarean on a patient dooms her to a cesarean for life. And in Uganda, that means either 6 or more cesareans, or limiting her childbearing – which will damage her social standing with her husband and her husband’s family, and sometimes provides a reason for the husband to take on additional wives. Furthermore, what if she can’t get to a hospital for that third cesarean? That could be fatal. If only she could push the baby just a little further it would be out.

But I can feel that the hips are not oriented perfectly straight within her pelvis. They are tilted ever so slightly to one side, which could be what is limiting the descent. The longer I wait, the more chance that this baby will not survive.

I ask the midwife her opinion. “Doctor, that is for you to decide. I have tried and failed, and now I am asking you.” That settles it. They have tried, and I have tried. I ask them to prepare the patient.

Getting the patient to theatre always takes a while. There is no such thing as an emergency (or “crash” cesarean). It’s more like as soon as possible…..which is never very soon.

There are several reasons for this. The midwives are usually very few taking care of many patients. In order to prepare a patient for theatre, they need to have her sign the consent, they need to put in an IV, and they need to put in a urinary catheter.

In order to sign the consent, they need to find a midwife who speaks the patient’s language. With up to 5 local languages, this isn’t always easy. To put in an IV, they need to track down an IV needle, a “giving set” (what we call “IV tubing”) and a bottle of normal saline. None of these are guaranteed to be available. If they are, they are never all in the same place, usually stored in a different building. The midwives have to search several different places to see if there are any items hidden anywhere unexpected. If any item is not available, then the family member needs to be sent to town to buy it. To put in a urinary catheter, the midwives need to find that too, and if not, they need to send the family to town.

After that, the midwife needs to find the stretcher – a narrow, poorly rolling tray-on-wheels, both of whose guardrails are broken and hang limply. They drag the stretcher next to the patient, have her move onto the stretcher, and then they wheel her on the jagged, uneven concrete walkways to the theatre.

In order to cover the patient after the cesarean and to wrap the baby, the patient needs to have brought many sheets (usually large pieces of colorful cloth). If she didn’t, there are no sheets available, and this is another delay while the family buys them from town or finds a street seller who walks around the hospital selling cloth and plastic basins.

On top of all this inefficiency, the midwives are caring for many patients at once. Others may be delivering at the same time, so they need to shift their attention back and forth.

Lastly, there is little sense of urgency here. In the US, when there is a true emergency on the labor floor, every nurse, doctor, scrub tech and other staff member feels as if the action they take every single second could decide whether the baby lives or dies. People spring into action, nurses covering other patients come over to help start IVs, get medications, catheterize, whatever. Residents jump in – one consents the patient, another talks to the father of the baby, another prepares to move the stretcher, and another starts scrubbing. We know our actions will make a difference.

Here, that sense of empowerment is weak. The sense that 10 seconds can be life-or-death is not there. People see stillbirths all the time – it is thought of as nature: unpredictable, unchangeable. Although they know that their actions are important, the urgency is more of a broad feeling than a moment-to-moment tension. People sometimes do things right away, but never at a running pace. Seconds add up.

As usual, it takes about an hour to get to theatre. I find that whether or not I hover around the Labor Ward and anxiously implore people to move faster has no effect on how quickly the patient gets moved; it only makes me more anxious. I try to do other things while I am waiting, in order to distract myself and avoid frustration. But it is a difficult balance, because when I do this, I also feel a little bit like I am abandoning the patient.

When we get to theatre, we move the patient onto the operating table. That is when I remember that I didn’t check the patients pulse and compare it to the fetal heart rate I am hearing. There is a small but real chance that the heartbeat I heard could have been the mother’s, and the baby’s could be low, or the baby could even be dead. Nonetheless, would it change my current management? Not really. She has not been able to push out the breech fetus, and she has a previous scar on her abdomen, so even if the fetus was dead, I would probably have to do the cesarean anyway in order to avoid the very real risk of uterine rupture. If I were to wait for the midwife to go back to Labor Ward to get a fetoscope and bring it back, that would delay the cesarean even further. I decide to proceed.

The patient’s previous scar is a vertical scar on her abdomen. I prefer to use a low horizontal incision, called a pfannenstiel incision, because it has less postoperative pain and better wound healing. But when someone already has a previous scar, we usually use the old scar to avoid creating a T-scar on the abdomen, which would be ugly and heal poorly. I make the incision between her umbilicus and her pubic symphysis, following her old scar. When I get to the uterus, I find a cystic, bubble-like structure blocking my view to the rest of the abdomen. It is attached to the anterior lower surface of the uterus. It must be the bladder attachment – not the bladder itself (which I can see is lower down) but the filmy tissue that attaches the bladder to the peritoneum. It is hard to know when that tissue actually becomes the bladder, especially since it is completely stuck to the uterus. It bubble-like quality is also very strange; I wonder why it is bulging out like that. It could be that the pressure from the very low descended fetus is causing some compression and edema of the lower uterus and anything around it. That bubble might be part of the bladder, I can’t tell, and I can’t cut it, just to be safe.

The problem is that it is blocking the entire area I want to operate on. We usually make a horizontal incision in the lower uterine segment – a thinner, less muscular part of the uterus that heals well. But the lower uterine segment is blocked by this bubble. I have no choice but to do a classical incision – a vertical incision higher up on the uterus, through the thick muscular portion of the uterus. This tends to bleed more, take longer to repair, and have a higher risk of rupture with later deliveries, but at the moment I have no choice. I have to get this baby out, and fast.

I cut through the uterus, careful to avoid the bubble. The baby is easy to pull out. I can see that the baby is blue and not moving. This is not good, although a lot of the babies come out sedated and weak because the anesthetists here use general anesthesia (rather than spinal anesthesia, in which they are not trained) and this sedates the baby as well. They all look weak at first; it’s hard to know which ones will be ok right when I pull them out.

I hand the baby off to the midwife and start sewing. The classical incision bleeds heavy and fast. What’s more, after all this long labor, the uterus might easily be infected, and this also causes a lot of bleeding. I never think about the baby at this point. I need to focus completely on the mother, because she can bleed out in a matter of minutes. Once the bleeding is controlled, I can ask how the baby is, but not before.

It takes a while to close the uterus because of the vertical incision through thick tissue. It requires two layers. As I am finishing the second layer, I hear the anesthetist ask how the baby is.

The midwife says “Still not very good. Still no heartbeat.”

“Not very good” is a bit of an understatement – this is also known as dead.

The resuscitation skills of the midwives, while not exactly textbook, are pretty good. They do what they can. The big thing they usually miss is giving oxygen, and this is because the concentrator is usually unavailable or broken. But in this case it could truly be lifesaving. I ask the midwife whether she gave oxygen. Only then I find out that the oxygen concentrator is not in theatre. It was lent to some ward and no one knows which, and there is no oxygen for the baby. The baby might have been saved through aggressive intervention. Then again, it’s also possible that the baby has been dead since I first saw the patient. I don’t know.

I am sad for this mother. I have just done her second caesar, which dooms her to caesar forever. She will have to recover from this painful operation while grieving for her dead baby. The classical incision puts her at higher risk of complication in the next pregnancy.

If her breech presentation had been recognized earlier in labor and her cesarean performed, would the baby have survived? Probably. If I had been faster in getting to the hospital from home? Maybe. If she had been moved more efficiently from the Labor Ward to theatre? Possibly. If we had had oxygen in theatre? Hard to say – the baby was pretty bad, and might have required more aggressive intervention than we can give. Would her baby have survived if she had been pregnant and delivered in the US? Undoubtedly.

Stick

2010-07-01T09:24:00.001-04:00

I stop by Labor Ward to drop off an operative note I had written on a patient earlier that day. The midwife tells me “There are patients for you.” I tease her that she is drumming up too much business for me. Then I ask her the details.

There are 3 women who need D&Cs (uterine evacuation). One is a person I had seen yesterday who had an early pregnancy that failed. The plan is to do a D&C but she ate lunch, which means she can’t undergo anesthesia today. I write a prescription for misoprostol in the hope that she can avoid a D&C altogether, but at USH 3000 ($1.50) per pill and needing 4 pills, I highly doubt she can afford it.

The other two women are lying in beds on labor ward. Instinctively, one seems sicker than the other, so I start with the sick-looking one. The nurse tells me that she was “BBA” and she has “retained products”. BBA means birth before arrival, which implies a third trimester pregnancy in which the patient delivered at home (or on the way) but came in after delivery, usually for a complication. However, “retained products” implies that the patient had a first trimester miscarriage, but not all of the products of conception came out of the uterus at the time of the miscarriage, and she still has pain, bleeding and possibly infection.

It doesn’t make sense for the patient to be BBA and have retained products – but then I think that maybe the midwife means that part of the placenta is still inside. I try to ask the details, but it seems that the patient has been referred from elsewhere, and it wasn’t the midwives at TDH who diagnosed the “retained products.”

I find that often these terms are thrown around at random, and often the actual complaint has nothing to do with the supposed presenting description. I can’t count how many times I have been sent patients with “cervical prolapse” who actually turn out to have abdominal pain (and no prolapse at all).

So I always start from the beginning, by interviewing the patient. I walk up to the patient and greet her.

ME: Do you speak English?

PATIENT: (blank stare)

Often when the patients don’t speak English, they don’t recognize the word “English.” The word for English in the local languages is “Luzungu.” The prefix Lu- implies language, so the Baganda people speak Luganda. And –zungu comes from mzungu, the word for foreigner. So Luzungu is literally the language of mzungus (actually the prefix Wa- is for plurals, so more than one mzungu becomes wazungu).

ME: Do you speak Luzungu?

PATIENT: I speak.

(Which means she speaks English).

ME: So what happened?

PATIENT: (blank stare)

MIDWIFE: You tell doctor what happened!

PATIENT: (blank stare)

MIDWIFE: Did you have a baby?

PATIENT: Yes

MIDWIFE: Boy or girl?

PATIENT: Boy.

ME: Then what happened?

PATIENT: (blank stare)

MIDWIFE: You talk to doctor! Did the placenta come out?

PATIENT: No.

MIDWIFE: Who removed it?

PATIENT: Nurse.

ME: Then what happened?

PATIENT: (blank stare)

MIDWIFE: What happened after that. Why were you sent here?

PATIENT: (blank stare)

OK, we are not getting anywhere. The patient won’t give us any narrative at all, and I haven’t been able to discern why the other health center suspected retained products if the placenta was removed. Was it removed in pieces? Is she still bleeding?

I decide to examine her. I realize that if I need to remove products of conception from both patients, I will need 2 speculums.

ME: Are there speculums?

MIDWIFE: Yes. I sterilized.

ME: How many?

MIDWIFE: One.

Well, hopefully only one will need a speculum. The midwife brings me gloves to do a vaginal exam and see if the cervical os is open. Immediately, I feel that there is a large chunk of products hanging out of the os, which is open about 2-3 cm. The patient is uncomfortable, but I encourage her to bear the discomfort. If I can yank out this piece, this might be all she needs to stop bleeding and get her cervix to close. I might not even need a speculum. I pull it out, and see that it is a chunk of placenta.

I reach in again to palpate inside the cervix to see if there is any more placenta left inside. The cervix is so dilated I can actually reach inside the uterus. My finger touches something surprisingly hard inside the uterus. What is that? Is it bone? That doesn’t make sense – she said she delivered a live infant. Where would bone come from?

I reach further in and the patient struggles against me. The midwife admonishes her.

MIDWIFE: You bear! Doctor is helping you!

I manage to hook my finger around the hard thing and pull it out. It’s a stick. I stare at it in shock. The two midwives watching me both shriek with surprise.

MIDWIFE: It is criminal abortion!

I don’t like that term at all. I suppose in actual meaning it is no different from “illegal” abortion, but it sounds much more judgmental. It also reminds me of a quote I heard at FIGO: “The discussion is not ‘is the fetus a life from the time of conception and has moral value?’ The discussion is ‘should women who have abortions be criminalized?’” No law has ever stopped abortion; law has only made it illegal.

But at that moment I am too shocked to react to the term. I know that people use sticks to induce abortions. I have heard horror stories of patients coming in with holes in the uterus, sometimes with the sticks still poking through. But I have never seen it myself. I can’t stop staring at the stick. It is about 4cm long, such a hard, vulgar piece of plastic. I can’t believe I just pulled it out of this poor girl’s uterus.

Suddenly I realize that the midwives are talking loudly, chastising the patient, and public discussing the patient’s “criminal abortion” with the family member of the patient in the next bed. All three are shaking their heads and publicly bemoaning the discovery. I feel badly for this patient, who is probably terrified on several levels, and who was so desperate to abort this pregnancy that she let someone do this to her.

One of the midwives is telling the patient she could have died. I’ll admit: this is true. I get chills thinking about how easily that stick could have punctured her uterus. (In fact, it still might have, I need to evaluate her more thoroughly). The midwife tells her that last year, there was a woman who died after coming in with sticks in her uterus like that. The patient maintains her blank stare, which I suppose is an effective protective mechanism.

I try to get the midwives to stop loudly chastising the girl, and try to offer comments about how she must have been desperate, and how we should be sympathetic, but I am ignored. I decide to just move on to the next patient and hope they settle down.

But while I am trying to speak to her, I can’t even hear what she is saying because there is so much loud bemoaning. Finally I call for quiet, and they realize and stop.

Both patients need ultrasound. I go back to the clinic to get the machine. I am still pretty stunned from finding that stick in the uterus.

I scan the first patient, and find that her uterus is still thick with blood and probably some products, and she needs a D&C. A D&C is probably optimal because it will allow me to clear the rest of the uterine contents, and also to make sure there are no more sticks inside. There is no free fluid in her abdomen and she has no signs of uterine perforation, which is good. The second patient is fine and I send her home.

The D&C is uncomplicated, and I find no more sticks, only blood and some small amount of membrane. It could have been so much worse.

Sickler

2010-06-24T15:35:00.001-04:00

One of the nurses on Female Ward wants me to see a friend of hers, who is having bleeding after delivering a baby recently. It sounds normal to me, but I tell her to send the woman to my clinic to see what is going on.

Later that day, the woman arrives in my clinic. She explains that she gave birth in March, and then in April, she had bleeding for about a week and a half, along with some right-sided abdominal pain. She was given antibiotics (as usual – they are given for everything here) and the bleeding stopped. She did not see bleeding again until just over a week ago, when she had bleeding for 1 week, which stopped on its own. The right-sided pain had never gone away; it was not associated with bleeding but did seem to be worse when she was bending over or lifting something.

It sounds to me like the woman is getting her period. I tell her this. She is surprised. She is breastfeeding, so she expected not to see her period. I tell her that she can have bleeding sometimes, even though she may not be ovulating and that, in fact, the bleeding can last longer than a usual period because the body doesn’t have its normal hormonal pattern, and so it doesn’t really tell the uterus when to stop bleeding.

As I am telling her this, I can feel the tension from the elephant in the room. The nurse who referred the woman had told me that the woman kept having babies with sickle cell disease. The woman looks profoundly sad – the kind of sad that is not just today, but that accumulates over years, until the person doesn’t even realize she is sad, because it feels normal.

I ask her about the sickle cell problem. She tells me that her three previous children were all born with sickle cell disease, but she has not yet tested the infant. Of the three, one died at age 6 – and before dying, that child had a major stroke, and then a second stroke with seizures that caused the death. Of the living children, her oldest, a 9-year-old girl, had a stroke a few years ago, and now can walk but has difficulty with speech, and her entire left side, including face, arm, hand and leg, are partially paralyzed. As she talks, I can see the weight of this burden emerging on her face. Her eyes become teary, but she keeps talking.

Finally, we get around to doing the physical exam. Although the bleeding sounds normal to me, I do an ultrasound to make sure there are no fibroids or other sources of abnormal bleeding. It is normal, and there is nothing on the right side where she notes her abdominal pain. I do a vaginal exam to make sure there is no palpable cervical cancer, but it is normal too. I explain that the bleeding is just her menses. The pain is in an odd location – far from the pelvis but not really near any specific organ, at the level of her umbilicus but far to the right. It is not tender. To check for a hernia, I have her sit up with her belly exposed. There is no hernia, but there is a large diastasis. During pregnancy, the abdomnal rectus muscles (in the front of the abdomen) can become very weak and separate to accommodate the enlarged uterus. After delivery, they remain weak and as a woman sits up, there is a visible bulge in the center of her abdomen where the muscles have separated.

My guess is that her pain (which she notes is worst when she is trying to use her abdominal muscles) is probably because she is compensating for the lack of midline abdominal strength by using her side abdominal muscles, and preferentially her right side. I can’t be sure that this is the case, but it is my best guess. I recommend a daily routine of increasing repetitions of sit-ups. I teach her how to do them. She can’t even do one without using her hands.

This leads us back to a discussion of her children. She tells me that caring for her disabled and ill children is very time-consuming and takes all of her energy. I can see it. “You look tired,” I say. She has no help other than a young housekeeper (a “house girl”). I tell her that she needs to take 15 minutes for herself every day to do these exercises so that her pain and strength will improve. In truth, the exercises are not life or death, but I sense that this woman needs 15 minutes to herself once a day. She gives the other 23 hours and 45 minutes to her children.

I ask her how many more children she wants. She doesn’t have an answer. I tell her about the statistics of sickle disease – that if both parents are carriers (and clearly she and her husband are), the chances are 1 in 4 that any one child will be born with sickle cell disease. She is very unlucky, having had at least 3 with the disease. I tell her that she needs to think about how big she wants her family to be. There is no way to predict whether her current infant, or future children, will have the disease, but that she should assume that any further children will also have it – because she has to be prepared for the burden that might come if they do.

She starts to tell me more detail about the sickle cell disease that afflicts her children. She tells me at what age each of them started having symptoms, and she tells me about the events that led to the death of the one child. She tells me about the difficulties of caring for the 9-year-old, who cannot attend school and probably will never care for herself. As she talks, tears start to roll down her face. She dabs at them with a handkerchief.

“What about your husband?” I ask.

“He is a teacher,” she says.

“Does he want more children?”

“We have not discussed it,” she admits.

“You need to discuss it. He needs to understand what it is like for you. Maybe he does understand, I don’t know. Because for a father it is also hard. But for a mother, it is even harder to see your children suffer. If your child suffers, the mother suffers 100 times.”

She nods and sobs. “You understand what it is like for mothers, doctor.”

Well, I can’t say that I understand from personal experience, but I have known enough suffering mothers that at least I can make that observation. But that’s all she wants from me – validation and understanding. I can give both.

I encourage her again to consider family planning. “You love your children, but I can see that you are tired. You need to take care of the ones you have, and you are a human, you can’t take care of 10 children when you already have ones who are very sick.”

She shakes her head and shudders at the thought of having 7 more children to take care of.

She promises me that she will discuss it with her husband. She agrees with me that she is too tired, and the burden is heavy. I have nothing to offer her in terms of help – no social services, no referrals, no therapy. I offer sympathy.

She wipes her tears, which have not finished coming. We both express our hope that her newborn infant does not have sickle cell disease. I tell her to come and find me if she needs anything else.

“You know where I stay now,” I tell her.

“Should I call through my friend, or I can come and disturb you?”

“I am here. You can disturb me anytime.”

After she leaves, I can’t get her out of my head - the sadness that emanated from her face. I hope I have helped by reassuring her that her bleeding is normal, but I couldn’t do anything about her real problem.

Know Your Limits

2010-06-15T10:00:00.000-04:00

One of the most important things any resident learns is to know their limits. Some people don’t learn that lesson, and they are scary. But most of us learn it.

First and foremost, we are taught that in an emergency, you need help. You can’t do it alone. Even if you know what you are doing, you need another pair of hands there, just in case. It is the first thing taught in CPR classes, and it is the first thing every intern should learn.

When I was an intern and working with a team I liked, my chief resident and attending challenged me with a hypothetical scenario one night on call. “Your attending and both senior residents are upstairs in the main OR, and you are on the labor floor alone. You are watching the fetal heart rate tracings, and you see a deceleration. You call us, but can’t each us. The deceleration goes on and on. You try to resuscitate but it doesn’t work. The baby is going to die. What do you do?”

I thought about it, slightly panicked, both over the hypothetical scary situation, and the desire to get the right answer in front of my chief resident and my attending.

As I thought it through, they pushed me more: “Do you go ahead and do the c-section? You have nurses here.”

Could I actually do that? I had only done a few c-sections, I really didn’t feel comfortable. I cringed and answered honestly: “No?” Were they going to laugh at me?

Both of them smiled. “Right. You don’t do it. Because you could kill the mother. That baby might die, but you have to keep trying to get us, even if you have to run upstairs to the main OR and drag us down.”

Later, when I was a chief resident, I designed a lecture for the incoming interns on how to handle obstetric emergencies. In order to help them remember what do to, I created the three C’s: Call for help, Call for help, Call for help. They laughed as we reviewed it on the powerpoint slide, but it stuck with them. (Laughter is the best mnemonic.) Later, when working with one of the interns, I was pimping her on the maneuvers to relieve a shoulder dystocia. “What’s the first thing you do?” I asked. I was looking for “Put the patient in McRobert’s position.” Instead, she smiled and said “Call for help, call for help, call for help.” (Excellent!)

Many times in Uganda I have been faced with situations in which I almost had to decide whether I would do something I am not comfortable with or experienced enough to do.

I have often written here about things I have done here that I had “never” done before – but in reality, they are variations on things I have done before. The cornual ectopic, the abdominal pregnancy – those are situations that I haven’t actually seen, but had been well-prepared for in my training. In fact, I had never even operated on an ectopic pregnancy through a laparotomy – only laparoscopically. But I had done ectopics, and I had done laparotomies, so it isn’t a far stretch to put those two things together into one surgery.

But then there were situations that were less clear. On occasion, I have suspected a patient might have appendicitis. Would I be able to do an appendectomy? I have done quite a number of appendectomies in patients with cancer and it was actually remarkably simple – but their appendices were normal. Would I be able to do the same in an infected, inflamed appendix? I don’t know. Fortunately, none of the patients ever turned out to have appendicitis.

One day, I walk into clinic and see a wheelchair in the hallway (those are rare around here), and a hospital nurse inside one of the patient rooms. There is a young boy lying on the exam table, and an anxious-looking man sitting on a chair – the boy’s father. P, one of the study doctors, is examining the young boy, and asks for my help.

He tells me the situation. The boy is 12 years old. Two days ago, he fell off a bicycle, and the pedal punctured his abdomen, and his intestines came out. He was taken to a Level 3 Health Center, where they pushed the intestines back in, and stitched the hole closed. Since then, he has not passed stool or flatus, and he has severe abdominal pain and fever.

On exam, the boy looks terrible. He looks weak and dry, his eyes are sunken and he is clearly in pain. On the left side of his abdomen, the skin over the injury had been bunched up and stitched with silk suture – which needs to be removed at some point. When I palpate his abdomen, it is obvious that he is extremely tender everywhere, although too weak to make a lot of noise despite excruciating pain. There is also the distinct crackling sound of crepitus when I press on his abdomen. I try to do an ultrasound, but I can’t see anything and it causes him even more pain.

P and I consider the situation. When an abdominal injury causes the bowel to come outside the body, it is called an evisceration. In that case, not only the skin has to be sewn closed, but the fascia (the firm white internal sheath that holds in the intestines and abdominal contents) also needs to be closed. Did they close the fascia? We don’t know. In addition, once the intestines are exposed to the outside, there is a high risk of infection. He is on antibiotics, but the coverage is insufficient (which is ironic, because usually they give extremely broad coverage for every non-bacterial ailment here).

P and I agree that the boy needs an exploratory laparotomy. But who is going to do it? Neither of us is comfortable with extensive bowel surgery. It is hard to know exactly what we will find once the abdomen is open. There is a strong chance that the boy might need part of his bowel resected and re-anastomosed (reattached), or even a colostomy.

At home, I would call general surgery to see the patient immediately. Even if I didn’t expect to find a bowel injury before operating, I could call an intraoperative general surgery consult, and they would be there within minutes.

There is a regional hospital an hour away in Mbale that is much better staffed and equipped, and even has specialists. But if we send him there, will he make it? He would have to go in a matatu – I cringe just thinking about this poor kid suffering through a matatu ride in his condition. I can barely tolerate them when healthy. In addition, if he makes it to Mbale, will they treat him, or will they ask for a bribe first? His father looks extremely poor. Will referring him there be a death sentence?

P and I discuss the options. It’s possible that one of the two doctors here is comfortable with bowel surgery; they have seen it all. I try to call both, but their phones are off.

Plan B: There is an orthopedic surgery camp taking place in the theatre all week. Some consultant orthopedic surgeons came from Mulago Hospital in Kampala to work on children with orthopedic deformities. Possibly one of them might be able to assist with bowel, even if we open up the abdomen first.

I dash over to theatre to ask them. They are very nice about it, and agree that the boy needs a laparotomy. Still they are vague about their exact comfort level, and how much they would be able to help. They tell me to bring the boy. I’m not sure about this, but it might be his only hope. I don’t know.

I head back to the clinic and tell P what they said. “Dr. Veronica, I am not in,” he says.

He is right. We have no sense of whether the orthopedists would be able to help us, we have no other backup, and none of us are comfortable doing this. If we open his abdomen, we could kill him.

On to Plan C: Transfer to Mbale. I know that the hospital has an ambulance, and there might even be fuel in it. If we can transfer the boy in the ambulance, that might increase his chances of making it there, and of getting treated. I call the Senior Hospital Administrator, but his phone is off. I walk to the administrative offices of the hospital to find him, but every door is closed. What’s going on? It’s a Wednesday. Then I realize that it’s a national holiday, and everyone is gone.

As a last resort, I call the Junior Hospital Administrator, a young man who has always been friendly and helpful. He answers. He is around the hospital grounds. I tell him that I need his help with an emergency. “I can be there in 20 minutes. Is it OK?” It will have to be.

10 minutes later, I go to check in on the boy, but the bed is empty. Where has he gone? I find P, and he tells me that Dr. W, one of the hospital doctors, showed up on the ward, so they took him back to the ward to be evaluated by Dr. W, and possibly operated on. I am greatly relieved. I like Dr. W very much, and if he is able to operate on the boy, then he will be OK. I try to call Dr. W’s phone, but it is still off.

The Junior Hospital Administrator finds me a few minutes later. I explain the situation and tell him that things are probably OK, but that if the boy needs to be transferred, I will call him again. He explains that the ambulance is available and has a driver, but no fuel. If we can provide the fuel, then we can send the boy.

Sigh. The usual. I know that if the boy needs transfer, we will find the money for fuel. Maybe we will use money from the poor patient fund, or my own money, or whatever, but I will not let this boy die for lack of fuel. I thank the JHA and tell him I will contact him if the boy needs to be transferred. I don’t hear anything that day, so I assume that Dr. W was able to operate on him.

The next day, I decide to find out what happened to the boy. Dr. W’s phone is still off. Since the boy is 12, he would not be in the pediatric ward. There are so many patients admitted aged 5 and under that the huge pediatric ward is filled with them alone. Children over 5 years are admitted to the adult wards (if they are still quite young, then they are admitted to the female ward with their mothers). He must be in male ward.

I go to male ward, and scrutinize every patient there. It isn’t very hard, because there are no young boys. I walk through the entire ward, but I don’t see him. I find two nurses and ask them for help. I explain the situation. One of them goes out to the ward to announce the type of patient we are looking for (which would have been kind of funny if I had not been really worried about this kid), while the other one helps me search each bed.

The boy is not there. Both nurses agree that they have never heard of such a child, but there is nowhere else he could have been admitted. Disappointment.

I go back to our clinic and mention this to P. He tells me that the boy is in Mbale. Apparently, one of the other study doctors has an aunt who is sick and admitted in Mbale, and he went to visit her there. While there, he happened to see the boy, who was waiting to go into surgery just then.

I am relieved to hear that he made it to Mbale. I know that we did the right thing – if we had operated, we could have killed him. In my desire to save the boy, I considered it briefly, but it would not have been the best thing for him. The study doctor who saw the boy knows the surgeon who was going to operate, and promised me that he would find out what happened. It was hard to let go of a patient not knowing whether someone else would be there to help him. I will feel much better once I know the outcome.

Fusion

2010-06-10T07:25:00.002-04:00

I had stopped by the operating theatre to try and schedule a case. When I was there, the anesthetist asked me to see a patient he had in the waiting area.

The patient was a 9 month old baby girl, the daughter of a clinical officer at TDH. Both parents were there looking concerned. The problem, they reported, was that the baby's genitalia were abnormal.

They removed the baby's clothes so that I could look, and immediately I saw the problem. There was no vaginal opening. I could see the urethra (where the urine comes out) and the rectum was normal, but the labia were sealed shut, almost as if she had had a female circumcision.

It was unlikely. There is only 1 tribe in Uganda that does female circumcision, and although they are not far from Tororo, they would not do it in a child this young. I ask the parents, but they are not from that tribe, and they did not have any circumcision done to the child. They don't know how long the labia have been that way.

I am perplexed. I was expecting something more like ambiguous genitalia. But this is clearly a girl - there is no penis. Maybe it isn't a girl? Should I do an ultrasound and confirm the presence of a uterus and ovaries? Would I even be able to see them at this age? I can't think of anything else to do.

It could also be an imperforate hymen or a vaginal septum. But this appears to be the labia. An imperforate hymen would be inside the labia, and normal labia would still be visible. A vaginal septum would be even more internal.

Well, I don't know what it is, but would I need to do anything about it? The girl isn't going to menstruate for another 10-13 years or so, and operating on a small infant is more difficult than operating on a child or adolescent. The urethra appeared normal, so she can urinate without a problem.

The parents do report that the girl cries every time she urinates for the last 2 months or so. It's possible that this closure is causing some partial blockage of the uretral meatus, preventing the urine from exiting efficiently and allowing infection to build. If that is the case, she might then need surgical correction.

I decide to do some research and have them come back. I tell them to get a urinalysis to look for infection, and to return to me next Wednesday when I normally hold my clinic. They are grateful, and very worried that their little girl might need surgery - or worse, might have a permanent abnormality.

In the meantime, I call a trusted obstetrician in Kampala, Dr. O. I have enormous respect for this man. He is well-known in the field of global Obstetrics & Gynecology, and has made great efforts to reduce maternal mortality in Uganda. He is one of the investigators on my research projects. He is also an extraordinary clinician, a firm but patient teacher and unfailingly professional and polite, even when juggling multiple acute responsibilities. I have called him with questions many times, and he never fails to help me. When he comes to visit the study site, he is able to briefly tour the faciluty and then present a list of ideas for improvement and progress that are always perfectly on point.

When I reach him, I tell him about the problem.

"Oh yes," he says, "I have seen this before. The parents are not washing the baby properly. They are failing to wash the labia, and the baby develops a mild infection and inflamation of the skin, and the labia fuse together."

I am stunned. "Really? That's it? You have seen this before?"

"I have seen this many times. I have even had babies referred to me by urologists."

"What should I do?" I ask.

"It is very easy to manage. You just take a piece of gauze, and you pry open the labia manually. They will come open easily."

I am skeptical. "The labia looked really fused together. Do you really think it will come open, just like that? I am worried about hurting the child."

"You will be surprised, he says. "You will not hurt her. She will cry. You will have to have someone hold her down, and maybe have the parents wait outside the room because they will become upset. But you will not be hurting her very much, and she will stop crying when you are finished. I have done this many times, it is always fine."

I trust this man, but I am pretty nervous about this. "Ok, I will try it. Just in case, if I can't open it, can I take a photo and send it to you?"

"You can send me a photo if you need," he says. He sounds like he knows I won't need to.

The parents return and find me in the clinic. S, another clinic doctor who shares my office, is present. The little girl is as cute as ever. The parents report that the urine result was negative, and the symptoms have gone away.

I tell them what Dr. O has told me. I explain what I am going to do. I ask if they want to be in the room when I do it to hold her, or if they want to wait outside.

The husband turns to his wife. "Do you want to hold her?"

She looks unperturbed. "I can hold her."

"Ok," I say, "women are strong. They can push, and they can hold the crying baby. Men, they cry and they faint." We all laugh. Everyone here likes African-women-are-strong jokes.

I ask S to help me with this, just in case I need a hand. We take the baby into the other room. The mother undresses her. She leaves on the string of beads tied around the baby's waist. Many girls and women wear these beads. They have some kind of cultural significance that I'm not sure about, but they are very pretty. I almost want some.

We lie the baby on the bed and she is already crying. The mother bravely holds her legs. We look at the perineum. The labia look totally fused. There is a line of fusion, but it really doesn't look like it is going to come apart. I am nervous.

Gently, I take a piece of cotton and use light pressure to try to spread the labia. The baby is crying but the mother is holding her well. As I apply pressure, a small depression appears along the fusion line. S is surprised, as am I. He helps me to continue applying gentle pressure. Magically, the labia appear. There is a normal vaginal introitus. The labia have a tiny bit of blood on either side, but otherwise are fine. I can't believe it.

It takes me a few seconds of staring to realize that it actually worked. We instruct the mother on proper cleaning of the labia so that it does not happen again.

The baby is crying, but as soon as the mother picks her up, she stops. She even looks content. Amazing.

The mother is very grateful. I reinforce the cleaning procedure, and she leaves.

S and I are still quite surprised that it actually worked. Now I am even more in awe of Dr. O. Maybe this is something that pediatricians see all the time - I don't know - but I have never seen or even heard of it. S remarks to me that he knows of a 13-year-old girl who has to go for surgery soon to have the same thing fixed, but he didn't realize that a simple hygiene lapse was the cause of it. If the labia had stayed fused for years, this baby would later have required surgery because the fusion would have been too severe for manual separation.

Ten minutes later, my phone rings. Her husband is calling.

"Doctor, I am very grateful! I had to go back to work, so I have not seen her, but my wife has passed the message that she is fine and you have cured her. Thank you so much! I am very relieved and very grateful."

Attack

2010-06-09T06:24:00.004-04:00

This week I have been alone in the house with Agnes, our cook/housekeeper. All of my roommates are away in Kampala taking exams for a masters degree program they are enrolled in. Our next-door neighbor, Beth, is also in Kampala for the weekend and her askari (guard), Fred, is taking care of her house. (Every house has to have a night guard. Fred is unarmed, as is our askari, Lazaro).

At 4am on Saturday morning, my phone is ringing. I see that it is Agnes calling me. She would never call me at that hour unless it was urgent.

ME: Hi Agnes. What’s wrong?

AGNES: Doctor Veronica, I am here with Fred. He is crying.

ME: What? Crying?

AGNES: These people, they came to Beth’s house to steal and Fred, he stopped them but they cut him.

ME: WHAT?? What happened? Robbers? Where are they?

AGNES: They have gone. Doctor Veronica, there is blood.

ME: He’s bleeding? Where is he injured?

AGNES: Blood is pouring. BLOOD.

ME: I’m coming.

I jump out of bed in a daze. I look around, grab my headlamp and put on shoes. What the hell is going on? Where is Fred injured? What if they cut open his abdomen or something? Can I repair that? He doesn’t even have a uterus. OK, stop thinking about that. What do I need? I have no idea. OK, go.

I get outside and Agnes is waiting for me. We approach the fence that separates our yard from Beth’s and call to Fred. When he comes to the fence, he is leaning forward. Blood is covering his shirt, his face, his head. What the hell?? Where is he injured?

I realize that the majority of the blood is on his forehead, and then I see a 4cm horizontal laceration on his frontal scalp that is actively bleeding. I tell him we need to go to the hospital now to stitch it, but he refuses to leave. He says we will go in the morning.

I try to ask what happened. Fred normally has a moderate stutter, but now he is completely shaken up and can barely get a word out. I decipher that they hit him with a panga (machete), but that’s all I can get. I decide to let him calm down – we can find out later. He shows me that during his fight with the robbers, he managed to get the guy’s shirt, his shoes, his keys and his panga (which is really a large knife rather than an actual panga). Pretty impressive.
(We have the same knife in our house. It barely cuts anything, lucky for Fred.)

I encourage him to clean off the blood and put some pressure with a cloth to stop the bleeding. The scalp can bleed profusely, even life-threateningly. He repeatedly refuses to leave his post to go to the hospital. The bleeding seems to improve over 15 minutes. I instruct him to have Agnes wake me up if the bleeding returns.

Agnes tells me that she originally woke up because she heard Fred yelling for Lazaro, our askari. She and I go looking for Lazaro but we can’t find him anywhere. He is supposed to sit in front of the house and guard all night. His bicycle is there, but he isn’t. We walk all over the yard calling his name, but he doesn’t answer.

Fabulous. Eventually, I go back to bed, but sleep isn’t an option. I am wide awake and full of adrenaline. Our guard is MIA, and the neighbor’s guard has just been attacked. What if the robbers had tried to come to our house? No one would have stopped them. The house is locked, but should I lock my bedroom door? What about Agnes, who stays in a separate little house?

I lie awake for a couple of hours and eventually doze off. Agnes wakes me at 7:30 from outside my window.

AGNES: Doctor Veronica!

ME: Yes?

AGNES: Those people, they have returned. Fred has caught them.

ME: What?? They came back?

AGNES: They have come back, and Fred has caught one. He has him there.

ME: I’m coming.

I get outside, and Agnes calls Fred to the fence again. He comes, and he has a cloth wrapped around his head to cover the laceration. He drags over the robber he has captured, and I realize it’s just a kid. He looks about 16, terrified and miserable.

What am I supposed to do now? I call people from work to try to get someone who can go to the police station and send the police here. I finally reach someone and we sit and wait. Interestingly, the kid doesn’t make any attempt to run away, even when Fred dashes off and leaves him alone for a while. Fred brings a mzee (old man) who knows everyone in town, thinking the mzee will know this kid. As they are talking, I turn to Agnes.

ME: So what happened before? How did Fred get cut?

AGNES: When those people came, Fred saw the first one, and he started to beat him. He was really beating him, and he was crying out “Stop beating me! I am going to die!” Then the second one came, and he had the knife and he cut Fred on his head with the knife.

ME: Does Fred recognize this boy? Was he one of them?

AGNES: Maybe.

ME: Did he see the robbers?

AGNES: The first one, he saw. He saw him very well, because he was beating him with the torch [flashlight].

I can’t help but laugh at this.

ME: So this isn’t the first one?

AGNES: No. But maybe he’s the one with the knife, I don’t know. Fred did not see that one.

I call my coworker, Jesse, to see where he is with the police.

JESSE: I am here with the police. But they want money for transport.

ME: They want money?? For transport?? But they’re the police.

JESSE: Yes, the police. They want money.

ME: ………

JESSE: How many suspects are there? Are they many?

ME: Just one.

JESSE: Just one? They thought there were many, and they didn’t have fuel for a vehicle. I think we can come on bodaboda.

The police finally arrive with Jesse. They inspect the yard, and Fred shows them what happened and where. The Detective introduces himself, gives me his phone number and tells me to call him directly if we ever have trouble again. I am relieved. They take the suspect and Fred to the police station. I tell Fred to come and get me once he is finished making a statement. I give a small amount of money to Jesse to pay for the bodabodas (whaddayagonnado).

When Fred gets back, I am starting to feel my lack of sleep. I have had 2 cups of coffee already, but they are fading. Fred has covered his wound with a cloth and a baseball cap. We take a bodaboda to the hospital.

At the hospital, I need to call for the anesthetist to help me open up the supplies I need to close the laceration. The last time I repaired a scalp was in medical school (Interestingly, that person had been whacked with a machete, too. Ah, Brooklyn.) The only thing guiding me is the fact that a year ago, a friend of mine split his head open in a Harry-Potter-style laceration in a Frisbee-induced collision with someone else’s face. I took him to the ER and had extensive discussions with the ER physician and an acquaintance who is a plastic surgeon regarding the proper technique for repair. That incident was not very lucky for my friend, but is quite lucky for Fred, because now I have some slight idea of what to do.

I put together everything I need, and get started. Immediately, I am cursing myself. It is really hard to inject lidocaine into the scalp, and Fred is not getting much pain relief in some areas. The needle I have on the suture is not ideal – it’s too big. The more I manipulate the scalp, the more it bleeds, which makes it difficult to see. For crying out loud, I’m a gynecologist, why am I stitching up someone’s head?

Because there is no one else, that’s why. Fred is really brave about the whole thing. I can see him cringe occasionally, but he tries not to complain. I tell him to complain because then I know where he needs more lidocaine.

The laceration is not very deep. I suture one layer closed, but the superficial part needs better closure. The other needle I have is even bigger, and hurts Fred way too much. I hunt down someone to open a smaller suture for me, and I find a nice tiny suture with a tiny needle. It doesn’t hurt Fred at all. I close the superficial part in interrupted sutures. By the time I am finished, it actually looks pretty good. Not bad for a vagina doctor. I hope it heals ok.

I am so impressed with Fred. All day, I am showering him with praise over how brave he is. He is so sweet and modest, he just smiles sheepishly. He reminds me that he needs a tetanus shot, and that is another herculean task.

It turns out that the tetanus vaccine is only kept in Antenatal Clinic, which is closed on weekends. I go to Labor Ward, where I start a phone chain of calling people to try and get the key for the clinic. I have Fred waiting there, and I imagine he must be hungry, so I buy him a mandazi (Ugandan doughnut).

After more than an hour, a nurse finally arrives to give him a tetanus shot. I make arrangements for Fred to go home by motorcycle. By 3pm, I am completely exhausted and ready for a nap. After buying groceries, I head home, and Agnes and I recount the night, laughing at the insanity of it all.

Raising Money for TDH

2010-06-07T03:20:00.000-04:00

Tororo District Hospital is missing a lot of things. I can't hire more staff or create a reliable supply of medicine, but I can try to help by purchasing essential, lifesaving equipment.

Blair Thedinger, a family medicine resident from Oakland, CA, spent a month here. Blair and I decided to link up with a non-profit organization called World Altering Medicine that raises money for hospitals in developing countries to buy lifesaving equipment for hospitals.

Michelle Montandon, another family medicine resident from the same program, used our site to raise money before her recent trip to Tororo. Through generous donations, Michelle was able to bring $3000 when she came here.

Michelle bought some of the supplies when she first arrived in Uganda, but the oxygen concentrator wasn't available then. So Michelle and I took a trip to Kampala recently to buy the supplies.

First, we went whitewater rafting in Jinja. This was taken just after we survived the final rapid, appropriately named The Bad Place. We are exhausted and glad to be alive.

Then we headed to Joint Medical Store in Kampala to buy supplies. Supplies are subsidized there, and are often cheaper than bringing them all the way from the US.

Michelle is receiving the box of small supplies we bought, marked for Tororo.

I am waiting in the "Picking Area" - the man behind me is carrying our oxygen concentrator.

In order to get these 2 boxes to Tororo, we brought everything with us on a matatu. We had to pay for extra seats in order to fit the boxes. It was a ridiculously long and occasionally harrowing journey, and we were happy to get to Tororo safely and with all items intact.

We were able to buy a lot of great supplies with the money.

The midwives don't have adequate protective equipment for when they deliver patients. We bought gumboots and aprons.

The midwives modeled their aprons:

Hadija is demonstrating proper use of the gumboots while taking blood pressure:

Here, midwives don't have an electronic fetal monitor to listen to the fetus' heartbeat. They use a fetoscope, which is a cone-shaped metal instrument. It's quite hard to use and took me a few months to really learn. We didn't buy any fetoscopes, but Hadija really wanted me to take a photo of her using one:

We also didn't buy the weighing scale either, but Hadija was getting really into the photo shoot, and we were having fun:

The one blood pressure cuff on maternity ward was broken - the velcro is weak and so the cuff always falls off the arm while you are taking the blood pressure, and the patient has to hold it on. The accuracy of the readins is questionable. So we bought a new blood pressure cuff, which is more portable than the old one (the one Hadija was using) and doesn't have mercury.

Patricia was very happy with the blood pressure cuff.

We also bought some operating theatre equipment. Some of it seems small, but it can lead to a big improvement in efficiency.

Previously, instruments would be sterilized in one big tray, left inside the autoclave all the time, and pulled out one by one for any surgery when they are needed.

We bought autoclave cloths and autoclave tape. The instruments can then be wrapped and autoclaved, and then stored inside the cloth to maintain sterility until needed. The tape has temperature-sensitive stripes that turn black when autoclaved.

The instruments can be packaged together in sets for a particular surgery, like a D&C or a cesarean section. This allows the theatre staff to pull out an entire set all at once, which means it is much faster to get a patient to surgery. Below is a laparotomy set.

The sets or individually wrapped instruments can be placed in metal autoclave containers and sterilized within the container and left there until needed.

The operating theatre staff started using the autoclave almost immediately after we brought it. Wesonga, the anesthetist, demonstrates some autoclaved sets within a container.

Lastly, we unveiled the oxygen concentrator we had dragged all the way from Kampala. Wesonga (the anesthetist) and I were excited to open up the box with the oxygen concentrator.

Dr. Wabomba, one of the hospital doctors (left), turned up and was also excited about the oxygen concentrator.

Michelle and I were thrilled that we were able to buy it.

The hospital, prior to this, had only two oxygen concentrators. One was in maternity, and the other was in the operating theatre. Both are very old, and often broken. We brought this one to theatre, and are hoping to fix the old one and bring it to Pediatric ward, which currently has no oxygen at all. When a child in Pediatric ward needs oxygen, the nurses need to schlep the concentrator over from maternity. It is bulky and heavy, and by the time they actually get it moved, sometimes it is no longer needed.

There are more things I would like to buy for the hospital:
1. More oxygen concentrators
Optimally, I would like each ward to have an oxygen concentrator - there is plenty of need for it, and it is absurd for someone to die of respiratory distress for lack of oxygen.
2. More protective equipment for the midwives
We were only able to buy a few aprons and gumboots for the midwives, and I would like to buy more, especially so that they are protected when they deliver HIV-infected patients. They do so many deliveries every day that the few we bought will be destroyed quickly.
3. Autoclave containers
Especially one for the labor ward, where they have a very small autoclave but never bother to use it, so there are never any sterile instruments. When a woman needs a vaginal tear sewn, the midwives hold the needle in their gloved hands without an instrument. If I can buy a small container that would fit in the autoclave, they could sterilize instruments in advance and store them in the containers.
4. Speculums
When a woman has vaginal bleeding, she can't be examined because there are no speculums. So I would also like to buy some speculums that can be wrapped up, autoclaved and stored for use when needed.
5. Poor patient fund
I would like to have a flexible fund to pay for necessary tests and/or medicines for patients who absolutely can't afford it. I have been doing that casually at the moment, and it would be great to have a system in place.

As I come back and forth over the next couple of years, I hope to buy more supplies on each trip. I prefer not to buy anything that will be used up, like medicine or disposable things, but more permanent and reusable equipment that can have a big impact for a lot of patients.

I will be reporting on our future purchases here on my blog, and if you let me know that you donated, I will email you individually and let you know exactly what your donation paid for.

So, therefore, dear readers, friends, family and compassionate strangers, I ask for your donations in order to help me help TDH. You would be surprised how far a small amount of money goes - even $5 would buy an apron for a midwife.

The link to our Tororo page through WAM is here.
The donation page of the website is here.
I will also put a link on the sidebar of my blog so you can donate any time you feel so moved.

There are 3 ways to donate:
1. Paypal - This will deduct 3% from the total donation for Paypal fees. You can't specify which program you want to donate to, so if you use Paypal, you should email both me and to WAM to let us know that you want to donate to the Tororo project.

2. Network for Good - This will also deduct 3%, but you have the option of adding the 3% to your total so that the full amount will go to the project. You can designate the Tororo project. Network for Good also accepts credit cards.

3. Personal check - You can mail a personal check to the address on the website. The total amount will then go toward the project.

Vacation Over

2010-06-05T15:29:00.003-04:00

Remember how in Peter Pan, every time a person says “I don’t believe in fairies,” a fairy dies? I have a similar power. Every time I say “I think I’ll go home early today,” someone in Tororo immediately starts hemorrhaging.

I go to Nairobi for a long weekend, and getting back to Tororo requires an epic journey. My flight is cancelled without my being notified and I am forced to stick around another night (not a terrible development, as I get to spend more time with friends). I use 6 different forms of transportation (taxi, plane, matatu, walking, bicycle bodaboda and motorcycle bodaboda). I have to politely reject a man trying to hit on me in a matatu, then use the same man to protect myself from a drunk bodaboda driver yelling “MZUNGU LET ME TAKE YOU TO THE BORDER!” I cramp my legs trying to fit in the oddly shaped matatu, feeling whiny and wimpy as none of the Kenyans and Ugandans on the same matatu seem at all uncomfortable or fidgety.

By the time I make it to Tororo, I am sticky and dusty and exhausted, and my hair resembles a bird’s nest. Still, it’s only 1pm, so I head straight to the hospital to get some work done. I'm exhausted, but I figure I can just round on a few patients, check my email and go home around 3 or 4.

Soon after arriving, I get a phone call from a nurse on the Female Surgical ward. She asks me to come and see patients. There were some patients I knew were waiting for me from last week, needing ultrasounds. I grab the scanner and head over.

The ones I know about are in Beds 2, 5 and 7. I had taken notes on them before, and I am ready to scan them. There is also someone I had scheduled for a hysterectomy in Bed 9, who is admitted in preparation for surgery. Then the nurse points out that she would also like me to see Bed 6, Bed 8 and Bed 12. A clinical officer asks me to see a patient he admitted in Bed 10. As I start to see people, the nurse says “You know, there are also 2 people here who I was going to send home. I think they have cysts or something. Let me send them away, you have too many to see.” I stop her and promise to see them too. They are in Bed 3 and Bed 4. So I need to see Beds 2-10 and Bed 12.

I start scanning. Bed 5 has some kind of huge abdominopelvic mass. It looks most likely ovarian, but I can’t tell exactly. It’s more than 15cm. I am thinking ovarian cancer, but it’s hard to be sure. She will need it removed. I tell the nurse we will schedule her for surgery. When she translates, the patient reaches out for me as I am about to walk away. She grabs my hand and gives me the triple handshake, smiling and thanking me in Japadhola. “She is very happy. She is tired of that mass paining her,” translates the nurse.

Bed 6 is easy – she had a miscarriage earlier today, her bleeding is better, and her uterus is empty on ultrasound. Done, sent home.

Bed 7 has been in menopause for 20 years, but has been bleeding for 1 year now. Highly suspicious for uterine cancer. Another doctor attempted a D&C but her cervix was too stenotic. I scan the uterus – it has a large mass in it that looks like a fibroid, but she shouldn’t have a bleeding fibroid at her age. I contemplate my options – should I give her misoprostol to soften her cervix and repeat her D&C, or just go ahead and do a hysterectomy? I would prefer to do the D&C to check for cancer, but will I find a pathologist to give me an answer? I am still waiting on another patient’s path from 2 months ago. And if they do read it, will I still be here to do her hysterectomy? I am leaving in a month. Lastly, will it change my management? I am not a Gynecologic Oncologist, at most I can remove her pelvic organs, bu I can’t do node dissections, nor would it be useful without a pathologist to examine the nodes (and chemo/radiation). I can’t decide – I will think about it later and get back to the patient with my plan.

Beds 8, 9, 10 and 12 are still waiting for me. Bed 12 needs a pregnancy test, but the hospital doesn’t have any test strips right now. Bed 9 is for surgery tomorrow, and looks ok. Bed 10 is a young girl with a right-sided pelvic mass – probably a dermoid cyst (although she has gotten loads and loads of unnecessary antibiotics already). But first, I turn my attention to Beds 3 and 4, who are looking more urgent.

We start with Bed 4. She is visibly in pain, she looks like she is having episodes of cramping pain. She complains of heavy vaginal bleeding. Her last period was 6 months ago. I scan her and find a lot in her uterus. Looks like liquid plus some solid. I think it is probably an old pregnancy that died a while ago, and is just now coming out. The liquid is probably blood. I can’t see an actual fetus shape, but maybe it has degenerated. I decide to do a vaginal exam to see if she is dilated – and that changes my diagnosis. When I feel her cervix, it is rock hard, bulky and immobile – especially inside the canal. My guess is cervical cancer. The stuff in her uterus is not a pregnancy, but probably liquid and clotted blood. Her cervix has closed off from the tumor, and blood is collecting inside. She will need an exam under anesthesia, biopsies and a D&C to confirm.

Then we reach Bed 3, who supposedly has ovarian cysts. She insists she is not pregnant, although she last took Depo Provera over 1 year ago. She looks pretty good, not in visible pain. That changes when I touch her abdomen – she cringes and recoils. Hmmm. I do an ultrasound. Immediately, I see a small live fetus inside her uterus, measuring 9 weeks and 5 days. It has a visible heartbeat. It’s inside her uterus, so this is not an ectopic pregnancy. I notice that the fetus is in the upper part of her uterus (fundus) and she seems to have a round structure, maybe a fibroid, in the lower part of the uterus. Maybe her pain is from a degenerating fibroid? The pain seems excessive for just a fibroid, though.

Then I look outside her uterus. Behind it, there is a lot of black, representing fluid. What is all that fluid doing in her abdomen? And there also appears to be something more solid floating in the fluid. Is it a clot? What is going on? Did she rupture an ovarian cyst that is now bleeding? I can’t even find her ovaries. She has an intrauterine pregnancy. Could she have a heterotopic pregnancy, where one twin is inside the uterus and the second is in the tube? That is exceedingly rare – I have already seen it once in my life and don’t expect to see it again. I ask if she has a history of twins, but she doesn’t. She has 6 children, all born singletons.

As I am trying to figure out what is going on, I realize that she is becoming increasingly uncomfortable as I press on her abdomen for the scan. I ask the nurse to get her some pain medicine. As soon as I do, the woman suddenly closes her eyes and seems to lose consciousness. The nurse immediately goes to get an IV to insert and hang fluid. The woman looks pale and sweaty. I take her pulse – it is normal. What is going on? I notice her move her arms toward her face with purposeful movements; she is not unconscious. Is she just being melodramatic about the pain, or is the pain just incredibly severe and she can’t help but close her eyes? She opens her eyes again and the nurse gives morphine. A second nurse puts in the IV.

I need to figure this out fast. I know that scanning is creating pain, but if that is really blood in her abdomen, then I need to take her to the OR immediately. I review the chart. As it turns out, the woman just had an ultrasound at the TDH department. It is not a great report, and the person seems as confused as I am. Eventually, the sonographer concludes, the patient should be admitted and “we should reevaluate with a clear mind.”

What? No idea what that means. Then I realize what I am looking at. I re-scan the pregnancy. It is not exactly in the uterus, but along the upper border. What if it is a cornual ectopic –located in the corner of the uterus, which is a thin wall, and bursting through the wall? It would explain why the pregnancy is bigger than a normal ectopic (in the tube they tend to rupture around 7 weeks, this is almost 10). Still, cornual ectopics are rare, and a tubal pregnancy is statistically much more likely in this case.

Regardless, she needs to go to the OR now. It’s almost 5pm. Will I be able to get an anesthetist and theatre nurse at this hour? This is life or death.

“And I was going to send them away!” marvels the nurse. One has a probably ruptured ectopic, and one has probable cervical cancer. Good thing she didn’t.

I call the anesthetist, and to my great relief, he agrees to come immediately. I write notes on the other patients while I wait for him to come. When he arrives, we move the patient quickly to the OR.

I open her abdomen urgently. As soon as I open the peritoneum, blood comes pouring out. Blood, blood, blood, more blood. Liquid, rapid, bright red blood. It is everywhere. I scoop it out with my hands (there is no suction). The anesthetist puts a big plastic garbage pail at the end of the table, and the blood runs down off the drape, between the patient’s legs, into the pail. It also pours all over our feet as we operate, soaks the drapes and the patient’s abdomen.

I can’t see anything because of all the blood, but it seems like the bleeding is still active. I stick my hand in to see if I can feel what is going on, and maybe pull the aberrant ruptured tube (or whatever) out of the incision. I pull out clots, and reach back in. I feel something different, mushy and textured. I pull out an intact placenta and fetus in a sac. Holy moly. Where the hell did that come from?

I scoop out more blood, and sop it up with mops (large squares of gauzy cloth). I pull up the right tube, and it is intact. I pull up the left, tube, and it is intact. Finally, I find the uterus. More mopping, and I realize that there is a 2cm hole, about 3cm deep, in the right corner of the uterus. It really is a ruptured cornual ectopic.

And it is still bleeding like stink. I need to close the defect. I have never actually operated on a cornual ectopic before. I heard about other people doing them in residency, listened intently to other residents’ accounts of them in case I ever encountered one, but I never saw one. They are relatively rare.

But here I am, and she is bleeding. I figure the best thing to do is pretend it’s a myomectomy. This defect is similar to the hole that is left after you remove a small fibroid. I close the defect in layers, with tight locking sutures to stop the bleeding. After 2 layers, it has improved, and after the 3rd layer, it is hemostatic. Phew. Meanwhile, more blood has collected and I need to mop it out. There is so much that I worry that something else is bleeding. My kingdom for a suction.

I finally get all the blood cleaned up, inspect the pelvis carefully, and discover that everything else is intact. There is no bleeding. I close the abdomen.

When I step away from the table, I realize it looks like the scene of a massacre. There is blood everywhere, and the pail has a scary amount of blood in it. I have no idea what her blood level is – the lab can’t do that test right now. She was extremely pale before the surgery, but most of the blood loss was already in her abdomen before we started. Still, she might need a transfusion.

At 7pm, as the dark is falling and the last bodaboda is available at the hospital gate, I finally head home. I look in the mirror, and something is crusted on my forehead – is it dirt from my long journey or blood from my crazy surgery? I take a shower, and when I wash my hair, the white conditioner turns brown from all the dirt in my hair. Finally clean, I lie down on my bed, exhausted. Tomorrow, I will go and see all the patients I didn’t see after I discovered the ruptured ectopic.

The Strength of Rose

2010-05-20T10:09:00.004-04:00

Rose has read this post and has given me permission to share it, and to use the real names of her and her sister.

My primary reason for being in Uganda is to conduct research related to malaria and HIV in pregnancy. One of the studies I am involved in is a clinical trial trying to prevent malaria in HIV-infected pregnant women. Women enrolled in the study receive full antiretroviral therapy (ART).

Being enrolled in the study means the women will get much more intensive and individualized care than they would normally get in a government clinic or hospital. Rather than taking 1 or 2 antiretroviral medications (ARVs) to partially prevent transmission, they will receive full ART with 3 drugs, which will suppress the HIV, improve their CD4 counts, and nearly eliminate transmission. They will also have access to a large team of doctors with specialist support, personalized counseling from trained HIV counselors, and transport reimbursement for clinic visits. When they miss visits, we go and find them.

Because of all of these advantages, getting into our study could be lifesaving, and many of the women know it. Women have to fit certain enrollment criteria to be included in the study. Sometimes, the study coordinators have told me, women who have been excluded from the study leave our clinic crying. It is a big deal to be able to enroll.

One of our study nurses, Rose, is a midwife, and she is outstanding. She is a hard worker, very sympathetic, and also has training as an HIV counselor. She used to be a TDH midwife, so sometimes after her work at the clinic is finished, she goes to the TDH Labor Ward to visit and help them out when they are busy.

One day, Rose shows up with her own sister, wanting her to be enrolled. The sister, Safila, has HIV, and it is unclear what her gestational age is, but she appears to be in late second trimester. Rose had to practically drag her sister from the village to Tororo town to be screened for the study. Rose used the promise of the study to convince her sister to come stay with her in town, and knows that the requirements of clinic attendance involved in the study might just be enough to keep her sister there and save her life, and the baby’s.

As we do the ultrasound, Rose stays in the room and watches anxiously. When we announce that Safila is 26 weeks pregnant, Rose sighs with relief – patients can be enrolled up to 28 weeks. Safila is quite stoic, and it’s unclear whether she understands (she speaks some English but Rose often translates for her), but Rose looks like she is going to cry with happiness.

We send off some blood work to make sure all of her levels are ok for enrollment, and tell her to come back in a week. Three days later, the labs come back. Her platelets are extremely low – normal is 150 or greater, and they are 35. For enrollment, they must be 50 or greater. She cannot enroll. In addition, her CD4 count – a marker of the severity of her HIV disease – returns and is extremely low – it is 40. She has AIDS.

I worry about how Rose is going to take the news, but she immediately understands and accepts this. I assure her that, although Safila cannot not enroll in the study, I will continue to follow her personally with support from the specialists in Kampala and San Francisco.

Safila does qualify for ART because of her low CD4 count. Because of the platelets, we are reluctant to put her on the first-line medications, which would include AZT. Options are limited here, and many patients would get Stavudine, a drug that is no longer used in the US (for the most part) because of bad toxicities like permanent nerve damage. Through some serious legwork, I manage to discover that the hospital has a supply of Truvada, which is a newer combination regimen that we do use in the US, and is very good with few toxicities. I am taking the risk that they will run out of Truvada later, but I decide I will deal with that if/when it happens.

I start Safila on Truvada and get updates from Rose on how she is doing. We discuss the bouts of vomiting, and other complaints. We don’t find evidence of any underlying opportunistic infections in our workup. At first, I see Safila weekly to monitor her reaction to the ART. She seems to do well, so we space out the visits to every 2 weeks.

After some time, Rose mentions to me that recently Safila has been feeling worse. She has been vomiting daily for weeks now, and has bouts of diarrhea that come and go. It just so happens that G, an Infectious Disease fellow from UCSF, is visiting, and I take advantage of his presence to get help with management. I have support from my mentors in San Francisco, but it is nice to have someone who can lay hands on the patient.

He gets a more thorough history from Safila and from Rose. We discuss the possible causes of her symptoms. With limited diagnostic tools, we are unable to do a satisfactory evaluation the way we would at home (or even in Kampala). We decide to treat her for both a parasitic gastrointestinal infection and a bacterial one. We prescribe mebendazole and metronidazole.

It is at this visit that I look more closely at both Rose and Safila. They are sisters, but until now I didn’t realize how alike they look. They have the same full lips that appear pursed at rest. They have heart-shaped faces and prominent cheekbones. They have similar skin color, but Rose’s is shiny and healthy, while Safila’s is mottled and dull. Still, after a few weeks of therapy, Safila is starting to perk up. The most dramatic difference between Rose and Safila is that Safila is profoundly emaciated. Her skin clings to her bones, and emphasizes her cheekbones and the angle of her chin. If Safila were healthy, she would look a lot like Rose.

After taking the medications that G prescribed, Rose reports that Safila is feeling better. The vomiting still occurs but is less frequent, and the diarrhea has resolved. However, there is a new problem. Rose suspects that Safila is not taking her medications, at least not every day. Safila consistently refuses to be observed while taking them. She insists on taking tea or eating a specific food with her meds, something that will delay until after Rose needs to leave for work. Safila then ran out of one medication but not the other, and when Rose counted the ARV pills, the wrong number of pills was in the bottle – which could indicate “pill dumping” – when a patient doesn’t take her medicines but then dumps a bunch of pills at once to make it look like she has been taking them.

Rose has tried to discuss this with Safila multiple times, and is feeling worn down. Safila reacts badly to the subject, refusing to discuss it and becoming defensive and rude to Rose. I can sense Rose’s frustration, and also her fears for the baby. Safila’s viral load was quite high before starting ART; if she doesn’t take meds before delivery, she will have a high chance of transmitting to the infant. In addition, Safila’s own health is terrible, and these drugs could really save her life. Without them, she will die soon.

Rose and I strategize on how to talk to Safila. I offer to counsel her further, but Rose knows the language issue will get in the way of having a real, firm conversation about medication adherence. Rose brings Safila to talk with one of the TDH midwives, who gives her a serious talking to about the importance of ART and the consequences of non-adherence. It’s unclear if it helps, but it does improve Safila’s anger surrounding taking the meds.

I get a repeat viral load after 2 months on ART, and it has not decreased. That is not a good sign.

I arrive at work on a Monday morning and Rose tells me that over the weekend, her sister has become paralyzed. I am alarmed, and ask her to tell me what happened. On Saturday, Safila suddenly had severe weakness of her legs, and couldn’t move them at all. On Sunday, she regained a little movement but was still extremely weak and could only walk with 2 people supporting her. I ask Rose to bring her into the clinic.

I am feeling out of my league. I try to examine Safila thoroughly, doing a neurological examination that I remember from medical school. I ask about associated symptoms, test for sensation and strength, and try to work it out. I call two doctors in Kampala for help, and they advise me on additional examinations I can do. I email my mentors in San Francisco. I also contact a friend who is a neurologist for more help.

I get a lot of excellent advice. Unfortunately, most of it involves tests that I don’t have access too, and all of the possible diagnoses have terrible prognoses. The pattern of muscle weakness is very strange, and hard to categorize into one particular phenomenon. The basic labs I send off do not help. The weakness improves over a few days, to the point where Safila can walk supported by only 1 person. When the weakness improves, pain arrives, and Safila complains of a pins-and-needles sensation, especially when walking.

A few weeks later, I hear that Safila has gone into labor. She is preterm – only 34 weeks. I go to see her in the labor ward. Rose is there with her, in a private room on the ward. She is in early labor. Rose is very grateful for my presence; I couldn’t imagine not being there. We discuss the labor pattern and it sounds to me like the midwives are doing everything right. We confirm the timing of the ART and I reassure the midwives to continue with their plan. I also get some advice from San Francisco on what medications to give the baby, especially in light of the fact that the viral load is still high.

Safila will need someone to care for her overnight, but I also know that Rose needs to work. I ask Rose what she is going to do. She says she will sleep in the hospital caring for her sister all night, and then go to work in the morning. Amazing.

The next day, I hear that Safila is close to delivering. When I arrive on the labor ward, Safila is almost fully dilated. The labor pattern is good, and Safila seems to be tolerating labor fine. She is as stoic as ever. I notice that she is able to squat to urinate, which is a good sign of muscle strength improvement.

I know that Rose is going to deliver her sister’s baby, and I am worried that she is going to take risks to do it. The midwives do not have proper gear, and they are constantly exposed to HIV-infected blood. I encourage Rose and the other midwives to be careful, to protect themselves, and remember that their safety is the most important. I can tell that Rose is very concerned about her sister.

Soon, I hear that Safila has delivered, so I rush back to labor ward. Safila is doing ok, and the baby, a girl, is fine too. Very small (1.8 kilograms) but cute, and healthy. Rose looked relieved and thrilled. She tells me the story of the delivery. The baby was breech, and the delivery was very difficult. They had a hard time getting the head out, and nearly had to call me, but then Rose managed to get it out. The baby was tired and required immediate resuscitation, but perked up immediately and was crying well. Rose marveled over how beautiful and perfect the baby was. She is so relieved that the delivery turned out well. I can see the weight lifted from her shoulders.

We agree that Safila should not be discharged too soon, both for her and for the baby. We start the recommended medicines for the baby, and continue Safila’s ART. The next day, Rose approaches me with concern about breastfeeding. Safila’s milk has not come in, and Rose is concerned that it won’t because Safila is so severely malnourished and emaciated. It is a valid concern. In addition, Rose is concerned about HIV transmission through breastfeeding, but it is clear from the data that infants who are not breastfed (especially preterm, low birthweight infants) have a high risk of death. We agree to have Safila continue trying to feed, and I tell her I will look into alternatives, just in case.

The next day, Rose tells me that Safila’s milk still hasn’t come in, and Safila seems to show no interest in trying to breastfed. Rose has started buying cow’s milk and diluting it for the baby. There isn’t really any very good other option, so we stick with that. Once it is established that both mother and baby are doing well and have no signs of infection, I discharge them. I know they will be well cared-for by Rose.

On Monday, Rose stops me in the hallway. She tells me that the baby died over the weekend. I am stunned. I can tell she is upset, despite the Ugandan reserved stoicism. I pull her into a room and ask what happened.

She is clearly overwhelmed and still processing. She tells me that she suspects her sister killed the baby. She recounts the story for me, and I can see what she means. The baby died overnight. It is not clear what happened, but Safila’s response was completely inappropriate. Rose tells me that Safila insisted on sleeping with the baby for the first time, and Rose did not want to separate a child from her mother, so she gave Safila the baby. Safila did not wake Rose for any problems overnight, and in the morning did not say anything at first. After Rose had made tea, Safila told her “Your little thing is dead.”

Rose grabbed the infant and started resuscitation, but it was futile. The infant was long dead. Rose suspects that Safila smothered the baby. Rose tells me that she is not pleased with her own reaction. She became angry with her sister and accused her. As she recounts the story, I can tell that Rose is rethinking everything she did, blaming herself for not seeing it coming. She defends her decision to allow Safila to care for the baby that night – but who would separate an infant from its mother? Rose did nothing wrong – there was no way she could have anticipated this.

I try to consider all possibilities. I explain the phenomenon of SIDS (sudden infant death syndrome). This infant had several risk factors for SIDS – including being preterm and sharing a bed with her mother. In addition, malnutrition could have played a role (although the baby was still quite young to have starved just yet). I can see Rose’s point, that Safila’s behavior is suspicious.

Regardless of whether she killed the baby, her reaction is inappropriate. Not once in the days after the baby’s death did she express sorrow. We discuss this at length, and it is clear that Safila has been suffering from severe depression, probably for years. She seemed detached from the pregnancy all along, although we just assumed it was cultural stoicism. Whereas Rose had poured hope and love into that infant, Safila seemed to have viewed the baby as a burden. Safila had already buried 4 husbands, and seemed to have given up on life. Was this infant a sudden imposition of hope that she didn’t want to have? Was the baby an obstacle to Safila’s passive descent into death?

I try to comfort Rose, but there is only so much I can say. I would like to get Safila psychiatric treatment, and Rose agrees but doubts that Safila would be open to it. There is not much available in Tororo; there is a mental health clinic with nurses, but no real therapy or treatment available. At least we could try. (Later, Rose brings it up, and Safila swiftly declines to discuss the matter.)

In processing the situation, Rose tells me more about her sister’s behavior in the past. Rose admits that she has always thought that her sister was selfish and reckless, including how she cared for her two living children, often carelessly and needlessly exposing them to contracting her HIV. It is amazing to me that given this history, Rose still fought tooth and nail for Safila’s (and her baby’s) life. She dragged her from the village, got her HIV testing, found her treatment, moved her into Rose’s own house (with her family), fed her, cared for her, slept in the hospital with her, and delivered her baby. All of that extraordinary effort was validated when a healthy baby girl was born, and Rose loved that baby immediately.

A few days later, the DNA PCR (HIV test) results return from the baby at birth. The baby was negative for HIV - we had managed to prevent transmission. It is almost sadder to know it.

Every few days, I check in with Rose. She is still caring for her sister. Miraculously, the weakness and muscle pain resolve almost completely soon after the baby died. I am not sure what to make of that, but it is interesting. Rose also seems to have more success at getting Safila to take her meds observed. However, Rose is worried that her sister will return to the village, now that there is no longer motivation (ie. the pregnancy) to continue coming to the clinic.

I go on vacation, and when I return, Rose has news for me. She tells me that her sister died while I was away. Safila decided to go back to her village, despite Rose’s request for her to stay. In the village, Safila stopped taking all her meds, including Septrin, the daily antibiotic that prevents opportunistic infection. One evening, according to the neighbors, Safila seemed well, was talking normally and had taken food and water. That night, she died quietly. They had the funeral while I was still on vacation. I was very sorry to hear I had missed it.

Rose tells me that, despite her resistance, Safila recognized how much effort we had put into helping her. A woman who was with Safila in the village before she died told Rose that Safila had frequently expressed gratitude for the care. She had said, “My sister did everything to help me get better. She even got me a mzungu doctor!” Rose and I laugh about this appreciative comment, but at the same time we are saddened by a truth that we had told each other all along: you can’t save people from themselves.

The next day, there is a note posted on the clinic message board, and a copy of it on my desk. It is a sincere note from Rose thanking those of us who helped her to care for her sister. “This is to thank all the IDRC and TDH staff who stood with me at the time of my sister’s sickness, up to the time of death. May her soul rest in eternal peace. Special thanks go to Dr. Veronica and Dr. Julia for all the efforts they made in an attempt to save her life and to all the entire staff. God bless you indeed.”

It is hard to describe how moved I was by this letter, and by Rose herself. A compassionate woman who cares for people not only because it is her job, but because she truly cares. Although she is employed by the research clinic, she often goes to the Labor Ward after work to help out the Labor Ward midwives when they are overwhelmed. I have seen Rose’s selflessness in action many times. When I told her about a terrible rape case I had seen, she rushed over to console and counsel the young girl herself, and arranged for a social worker to come. When I told her that one of my surgical patients had unexpectedly tested positive for HIV, she accompanied me postoperatively to provide HIV counseling to the woman in the hospital. When the TDH midwives were arrested, Rose went and covered the labor ward for them so that the patients wouldn’t be unattended. Most movingly, she stood by her sister despite a history of bizarre behavior, despite great difficulty and resistance to Rose’s attempts to help her.

I know that Rose is grateful to me, but I am in awe of her: her strength, her selflessness, her loyalty and her resilience. She is an inspiration to me.

MVA Training

2010-05-12T04:22:00.011-04:00

A manual vacuum aspirator is a wonderful thing.

It allows for uterine evacuation very easily. Without suction, a D&C requires a lot of scraping, which is slow and more dangerous (higher risk of uterine perforation)

An MVA looks like a giant plastic syringe with a long tube on the end of it. The long tube is called the curette. It is plastic, bendable and soft, which has a lower risk of perforation than a metal sharp curette. By pulling back on the syringe, a vacuum is created inside, and once the curette is inserted into the uterus, the vacuum creates enough suction to remove the uterine contents (aka products of conception).

It is remarkably easy to use, and is efficient and gentle enough that it can even be done without anesthesia in the right patient.

I thought that learning how to use an MVA would be great for the Labor Ward nurses. Normally, when a patient comes in with incomplete abortion, they need to call for a doctor who may never come. If she is bleeding and in pain, the best thing for her is to take care of the problem quickly. Since her cervix is already dilated, there is no need for painful manual dilation. In fact, once the pregnancy is removed, the patient feels better so quickly that the whole MVA process is essentially rapid pain relief.

So the other day I had a training with the TDH midwives to introduce them to MVAs.

I had heard that a papaya (or paw-paw, as it is called here) is a good replacement for a uterus because of the size and the texture inside. I bought 2 papayas at the market (for $1) and brought 2 MVAs to the Labor Ward yesterday.
Hence the papaya seeds inside the "products of conception."

The training was a great success. The midwives seemed apprehensive at first, but in the end, each one wanted her proper turn, and demanded to have her photo taken while suctioning the papaya!

Now that they have practiced using the MVA, I hope to teach them when real incomplete abortions come in, so that at least a few of them get comfortable with it. Instead of calling a doctor who won't come, or referring a bleeding patient to a place where she will be turned away for lack of money, they can quickly and safely evacuate the uterus and save the woman's life.

Medico Legal

2010-05-09T08:14:00.003-04:00

I went on vacation for a couple of weeks recently. When I returned, everyone on labor ward welcomed me back warmly.

“We missed you!” they said. “We had to refer SO many mothers!”

Sigh. Apparently, if I’m not around, no one does the cesareans, and they all get referred to St. Anthony, the private hospital.

As I was chatting with some of the midwives, I learned that while I was away, a woman died after delivery. I feel guilty. I know in my head that it is OK to go on vacation, but it seems terrible that a woman should die just because she had the bad luck to deliver when I was on holiday. It’s just as bad as a woman dying because she comes in after 5pm. It makes me wonder what is going to happen when I leave in 2 months. I guess this was the preview.

She died of hemorrhage. She was delivering her seventh child, and she came in and delivered very rapidly, and started hemorrhaging right away. When a woman gets postpartum hemorrhage, it can be a slow, insidious hemorrhage that just won’t stop, or it can be a rapid, frightening, unbelievable amount of blood. The uterus has a massive blood flow in pregnancy and if that’s not reduced after delivery, she can die within a matter of minutes.

This woman died in two hours. In that time, the midwives were unable to give oxytocin because the hospital had run out. They were unable to give ergometrine (methergine) because it had run out. They were unable to give Hemabate because it is too expensive and isn’t available in Uganda. They were unable to give misoprostol because the hospital has never had any – it was banned in Uganda until this past June because of fears that it would be used for illegal abortions.

The midwives here are quite good at infant and maternal rescusitation – they can do bimanual massage, hang fluids and give the right medicines if they are available. But they can’t do anything surgical. They called for help, but no one came.

The lack of oxytocin is a reflection of a larger problem. The hospital has not received its shipment of many supplies and medications because the payment to the National Medical Store, which is transferred directly from the Ministry of Finance, has not been made yet. The hospital usually operates at a bare minimum, and now they have reached far beyond the ridiculous. The hospital is out of metronidazole (a common antibiotic known as Flagyl, one of the few antibiotics they ever have), HIV testing kids, and syringes, to start. They have been out of skin cleanser for weeks, so instead of scrubbing the patient’s skin before surgery, we pour saline over it, which is pointless, but makes us feel better. Gloves are scarce. Patients (or their family members) are being sent to town to buy gloves and syringes so that medication can be given.

The midwife who tells me about the maternal mortality told me another story, equally disturbing in a different way.

A few days ago, three TDH midwives were arrested.

What?

Yes: Arrested.

This is what happened, as it was recounted to me. A woman was admitted to Labor Ward with severe malaria. She was started on IV Quinine, and during her admission, she went into labor. Her labor course was normal, but when she reached around 6cm dilation, she started pushing. This was her first baby, and she was thrashing wildly and not listening to the midwives as they exhorted her to stop pushing.

Pushing against a cervix that is not fully dilated is not a good idea. It can cause the cervix to swell – which can impede dilation - and pushing against a cervix can hurt the baby if it is prolonged and forceful enough. This is one of the myriad benefits of pain management in labor – it reduces the urge to push before the body is ready – but that is not an option in Tororo.

Finally, the patient reached full dilation and managed to deliver. Upon delivery, the baby seemed very tired, as the midwives say. The stress of labor had caused the oxygen in the baby’s blood to decrease, and the acidity to increase. This is what is known as birth asphyxia, a frighteningly common outcome in poor resource settings.

Some infants who look hypoxic upon delivery are merely transiently depressed – they get resuscitation and perk up immediately. Resuscitation can include stimulation, oxygen, assisted ventilation, chest compressions, and administration of dextrose. In my experience, the midwives here are pretty good at resuscitation – they aren’t as structured or formal about it as we are in the US, but they do everything they can do. However, often oxygen is not available, and that is a key component.

Some infants are worse off– the ones who have been compromised for longer – and do not perk up with resuscitation. In order to predict the long-term outcome of the infant, we use the Apgar score at 1 minute after delivery, and 5 minutes after delivery. The first number tells you the almost immediate status of the infant, and the second number tells you how the infant did with resuscitation. If that second number is still low, it is not good.

In this case, the infant had Apgars of 3 and 6 (out of 10). So it did improve, although not completely at 5 minutes. Eventually, though, the infant looked well and was put under heating lamps, and later given to the mother.

The midwives decided to give the infant Gentamicin (not sure why, it is common here), and when it was time for the dose, they had to send the husband to town for syringes. When he returned, they went to give the IV Gentamicin, and found that the baby looked unwell and re-initiated resuscitation. The resuscitation failed and the baby died.

A few days later, the Tororo police came to arrest the midwives who were involved with the care of the mother and the infant. From what I hear, there was some confusion, and a lot of stalling for time. The police seemed perturbed to be arresting the midwives without being allowed to make a formal complaint.

The three midwives were taken down to the police station, and other midwives gave statements from the labor ward. The three arrested were charged. The midwife who delivered the baby was charged with assault (apparently the woman was charging that the midwife had beaten her and caused the baby to die). The midwife who performed the resuscitation was charged with child neglect. And a third midwife was charged, but I am not sure with what.

I heard the story from various people, and everyone had different pieces of information. It was confusing for that reason, and also because in the end, it made no sense. Why would a midwife beat a laboring woman so badly that it would cause the death of a full-term fetus? The woman would have to have some serious injuries for that to happen - did she? And there are usually many people in the labor ward – it could never happen without being witnessed (abetted, really) by other midwives, patients and family members. The idea of it is just preposterous.

In addition, the way the matter was handled was suspicious. If the patient and her family were unhappy with the care they received, why didn't they go to the hospital administration immediately, instead of waiting to be discharged and then going to the police? And why was the matter reported to the Kampala police when the incident occurred in Tororo? And on top of that, why were the Kampala police commanding the Tororo police to arrest without investigating? It was not consistent with proper procedure, and the Tororo police were not happy about it. There were suspicions that some family member of the patient had connections in Kampala with either the police or an important politician. It's all conjecture, but it is highly possible, given how strange everything was.

It sounds as if that baby had plenty of reason to do poorly. The woman went into labor while being treated for severe malaria – malaria in pregnancy is associated with both stillbirth and neonatal demise. An earlier episode of malaria might have weakened the fetus even before this episode. Pushing against a closed cervix for a long period of time can be dangerous for the fetus – the uterine forces combined with valsalva can be a lot of pressure on the fetus’ head, and if it is prolonged, can cause damage. It would make sense that the feuts had a localized swelling on its head where it was being pressed against the cervix. Lastly, this was the patient’s first delivery. Most likely her labor course and length of pushing was longer than multiparous women – more time for birth asphyxia to develop, especially in a previously compromised fetus.

I heard from one of the midwives that the family had taken the body to Mbale for an autopsy, and that the autopsy result was apparently absurd. The report, I was told, declared that the infant died of “poor resuscitation” and “neglect.” In case you are wondering, neither of these is a cause of death. A cause of death is something like “respiratory failure” or “trauma” or “hemorrhage.” Furthermore, the person who wrote the report could never have known if the resuscitation was “poor” and the child was “neglected” unless they had been there at the delivery. If this is really the autopsy report, there is suspicion that someone was paid off to make this report, or else the person who did it was non-medical.

The midwives, needless to say, were up in arms. If those three can be arrested (and I know all three – they are good, skilled, competent midwives), then any of them can be arrested. And for that matter, so can I. These midwives work for pennies, they always show up for work (unlike almost everyone else) and they work HARD. I am volunteering my time – I don’t need to be there at all, and yet I go there to work 7 days a week. None of us needs the threat of prosecution added to our concerns.

After being charged, the arrested midwives needed someone to stand for them to be released on bond. Each was able to have either her husband or a fellow midwife stand for her, and they were released and told to return on Tuesday.

The midwives clearly needed to vent, and they talked over each other to tell me the different parts of this crazy story. Finally I asked them what I could do to help them. (In some situations here, having a mzungu helps but in some, it hurts. If money is involved, you will always be charged more if you have a mzungu with you.) They asked me to go and speak with the hospital administration and ask for their support of the midwives.

It was Saturday when I first heard the story, and I stewed all the way until Monday, anxious to speak with the Senior Hospital Administrator. When I did meet with him, I first asked him what the situation was. He recounted the story for me from his perspective, which was similar to the midwives’ perspective. He was not here when the police came – which would explain why he was not able to go to the police station that day.

I then told him that the midwives were very upset and I was alarmed. He was quite sympathetic and concerned, and together we decided to call a meeting with the midwives to reassure them of the hospital administration’s support of them. We also agreed to have the Nurses and Midwives Council Representative contact the Council in case they needed further assistance, like legal representation.

By coincidence, we had scheduled the meeting for the exact same time that the midwives were scheduled to report to the police station, so we decided to delay the meeting. Several midwives were planning to accompany the accused midwives to show support. I asked them to decide whether it would be better or worse to have me there. They decided it would be very helpful, and so I dropped everything to go down there. In addition, the Operating Theatre staff also wanted to attend to show support.

We gathered in groups to walk to the police station, about a 15 minute walk. I walked with several of my favorite midwives. It was a great walk. We laughed, held hands, made mzungu-Ugandan jokes (“Mzungus talk funny!”) One midwife started singing a civil rights song, and then I started in with “We Shall Overcome.” One midwife started explaining to the others that mzungus bring so many things to Africa to help Africans, and that mzungus have taken on the burden of Africa. I tried to explain gently that it was a bit more complicated, that mzungu countries are not exactly innocent (in the past or now), but they didn’t really care. They were mostly trying to say they were grateful for the mzungus who come to help, so I didn’t push the discussion.

When we got to the police station, we waited. The three arrested midwives were sitting inside an office, and as a large group, we waited outside. Then I decided to take some photos since I had so many midwives in one place, and they were all dressed up beautifully. I tried to have a random man take a photo of us with me in it but he couldn’t handle framing the photo, holding the camera still, and pressing the button (which I’ll admit I have always taken for granted), so the picture is askew and cuts off several heads. Still, I got some good ones.

We waited and waited. We chatted about various things. More people arrived, including both anesthetists, some nurses from other wards, a clinical officer, and eventually the Senior Hospital Administrator. We were probably at least 20 people at that point. We kept expecting the police to finish their paperwork and then head down to court for the hearing, and all of us planned to follow.

Finally, after about 45 minutes, the police told the midwives that they were still not sure about this case, and they wanted to investigate further. They told the midwives to go back to work, and the police would call the midwives if/when they were needed.

I didn’t understand at first, but it turns out this is a very good outcome. It means the Tororo police (we think) are not happy about being forced to arrest without being allow to investigate, and are suspicious that the charges were made in Kampala and not Tororo. Hopefully, this will lead to a quick resolution for these falsely accused midwives.

Nonetheless, the episode has put everyone on edge. It is scary to think that this kind of thing could happen again (although admittedly it is rare). Working here with the bare minimum – and now even less than the bare minimum, without even syringes to give medication – bad outcomes are going to happen. We can do our best, but these are not the best circumstances. Babies are going to die, and sometimes mothers. The only way to prevent this is to improve the system, and that takes political will.

Addendum:

One of the midwives who walked with me to the police station asked me about the malpractice situation in the US. She was thinking about applying for a nursing job there, but was scared off by all the rumors she had heard about lawsuits. Thankfully, physicians, nurses and midwives in the US are not at much risk of being arrested, but the threat of litigation is indescribably stressful and has damaged the practice of medicine.

In Uganda, bad outcomes are assumed to be part of life – despite what we do, sometimes they happen. In the US, we have reduced the morbidity and mortality associated with birth to such a degree that we have forgotten what nature really does. We can control it – or so we think. When bad outcomes do happen, we are shocked because they are so rare, and we assume it must be someone’s fault. If the outcome is bad, there must be someone to sue. Babies don’t die being born, women don’t die in childbirth.

We tell ourselves that our litigation system provides the motivation for doctors and nurses to do the right thing. Working here, I doubt that theory more and more. These midwives are not in fear of litigation and make very little money, and yet they work extremely hard under frustratingly limited circumstances. Their work ethic rivals that of even the most hardworking health professionals in the US, and I think job satisfaction and camaraderie have a lot to do with that.

Because they are not blamed when bad outcomes happen, they can take risks that we can’t. They deliver breeches vaginally. They can wait for a protracted labor to take its course. When a cord prolapse happens (the cord comes out before the baby), they don’t run to a crash c-section; they know the baby is going to die. It means the c-section rate is lower, but it also means that infants die when they don’t have to. Is this good, or bad?

In the United States, we are schizophrenic. We blame obstetricans for over-medicalizing birth, and yet when bad outcomes happen, we want to sue them for not preventing it. We beat our chests over the high c-section rates, and yet birth asphyxia, stillbirth, neonatal death and maternal death are unacceptable outcomes. We allow the natural birth movement to make a lot of noise, but we can’t accept what nature actually does during birth. We want to have our own personal physicians care for us for nine months and then come in at the drop of a hat to catch our babies, but we don’t want to pay doctors enough to make that possible.

Where would I rather give birth? Hands down, I would rather be in the United States. I want safety, resources and an epidural.

Where would I rather work? I am not sure. I am tired of working long hours, skipping meals and giving up my personal life to care for patients in need, only to hear stories at parties and on TV and in the newspaper about how terrible, greedy, arrogant and selfish doctors are. I don’t mind working hard, but the constant haranguing is demoralizing.

I want to work in a place where I have the appropriate resources to help my patients, but I also want to work in a place where people appreciate what I am doing. But it seems that the more resources we have, the less we appreciate it.

Rape

2010-04-02T18:09:00.001-04:00

(Disclaimer: This story is both upsetting and has one gross part. I will put a warning before the gross part.)

P., one of the medical officers I work with in the research clinic, tells me breathlessly that he was asked to review a patient in labor ward and is really afraid she might die. He has recommended transfer to St. Anthony, the private hospital nearby.

I know that transfer to St. Anthony can mean being turned away if the patient can’t pay, and if this patient is in such bad shape, she really could die if that happens. And besides, how can a critically ill patient travel to another hospital on her own?

I dash over to labor ward to assess the situation myself. The patient is only 15 years old. She was 9 months pregnant, and delivered her baby at home last night, sometime after midnight. It is now 9am, and the placenta is still in place.

A retained placenta occurs when the placenta – or a part of it – does not detach from the uterus. This can happen for a number of reasons, but the bottom line is that it can cause the patient to bleed heavily, and/or get a severe infection, and can easily cause death if not treated.

Everyone tells me the same story – that the patient is too combative and won’t allow the placenta to be removed. They tell me that they had 6 people tried to hold her so that someone could remove it, but she was too strong. Now, everyone has given up and is letting her lie in the bed, ostensibly until this transfer occurs at some point.

I know that this placenta needs to come out. One good thing is that P. correctly ordered for oxytocin to be given – in the hope that this would increase uterine contraction and expel the placenta.

I walk over to the patient and immediately notice the distinctly fecal stench. It’s hard to know if this is a result of having delivered and not cleaned up yet, or something more abnormal. I try to talk to the patient, but she is sound asleep. I am informed that she was given Valium in an attempt to calm her down and remove the placenta, but she still fought. I can see bloody cloths lying on the floor around the patient, and blood on the floor. It looks pretty bad.

I wake her up and try to get her in a position where I can try to do an exam, but she is hard to move. She finally turns on her back, but the minute I try to bend her legs, she resists and turns on her side. I enlist her grandmother and a medical student to try to help her into position. The medical student tells the patient not to resist, that we are trying to help her.

In residency, we would often get combative patients coming in delivering. Sometimes they were on drugs – and that often makes them extremely agitated and remarkably strong – but sometimes even sober, sane patient would go nuts from the pain and the fear. You had to learn to move fast, and do what was needed to have a safe delivery, even while the patient was kicking and thrashing.

This is no different. I know that she is at risk of dying if I don’t remove that placenta. The patient resists, and is very, very strong, but I push back. I reach in, grab the placenta, and within 10 seconds, I am able to pull it out completely. While she fights me, I press on her uterus to make sure it is firm, contracting and not bleeding. It is fine.

The patient lies down and goes back to her Valium sleep. The medical student looks vaguely stunned, but relieved. While I was pulling out the placenta, I noticed that the patient had a vaginal laceration that would need repair, but I know that she will not let us repair it right now.

The midwives are still worried about whether the patient needed transfusion, because she is so pale. But her hemoglobin is 6 – extremely low in the US, but in Uganda anemia is more common, and it would not be a level that requires transfusion. Her blood pressure and heart rate are normal – indicating that she is tolerating the anemia well, and should not need a transfusion.

Over the weekend, the patient does not seem to get out of bed. I see both her mother and her grandmother at her bedside. She speaks some rare dialect that makes it difficult for even most of the midwives to talk to her, although the medical student seemed to be able to communicate with her in Luganda.

The patient came in on a Friday, and the first time we can get her to the OR to repair her laceration is Monday. I know that the 3 days of healing will make the repair difficult.

I have the medical student obtain the informed consent from the patient and the mother because he is able to speak to them. Before we bring the patient to the OR, he tells me what he has learned about the situation, and what he tells me leaves me flabbergasted.

The father of the baby is the patient’s brother. He raped her while strangling and beating her. He had raped her in the past, and before her, he had been raping her sister. Their mother does not care that he rapes his sisters. The brother himself has two wives and five children. Now, since the delivery, he has run away and cannot be arrested because they can’t find him. (It is unclear whether they would arrest him even if he were there.) The patient confided this to the medical student, and while she was talking, the mother stayed quiet. The grandmother also told him the same story. The grandmother seems bothered by the situation, but powerless against the mother and the brother.

Good grief. This poor kid. No wonder she has stayed in her bed for three days – she is probably traumatized and severely depressed. At home, there would be a major support intervention for something like this. There would be social workers and psychiatrists, in-hospital security measures for the patient, extensive counseling, and of course, the police would be called. I have no idea what can be done here, but probably not much.

Before I can worry about that, I need to repair her laceration. It looked pretty big, but I am hoping it is just through the vaginal muscle. The anesthetist sedates the patient, and we examine her. What we find is horrifying.

*****GROSS PART STARTS HERE*****

The laceration goes through the thin vaginal wall lining, the vaginal muscle, the capsule to the rectal muscles, the rectal muscles themselves, and the rectal lining. It is the worst laceration you can have in a vaginal delivery, and needs careful stitching in order to avoid an obstetric fistula in the future.

In addition, she has had 3 days of healing, so a while layer of granulation (healing) tissue has formed over the lacerated surfaces. If I were to stitch those surfaces together as is, they would not heal closed, and the wound would fall open again. The granulation tissue is pretty revolting, with some green tissue that looks unhealthy. There are flies that were surrounding the patient on postnatal ward, and they have followed the patient to the OR. Now that she is asleep, they are landing everywhere, including inside. It is one of the most disgusting things I have ever seen.

The anesthetist fends off the flies for me by thrusting splashes of alcohol at them. It actually works.

In order to close the wound properly, I have to shear off the white and green healing tissue. I do this with a scalpel and a pair of crappy forceps. It is difficult and slow-going. Healthy tissue bleeds, and so once I remove this tissue, I am glad to see that the tissue underneath has started to bleed, but it makes everything harder to see. I have to be especially careful around the rectum, because I don’t want to remove too much tissue, or there will be nothing to sew, and that would be horrible.

Finally, I have removed enough tissue. I stitch her up, layer by layer. This poor girl has got enough problems – I want to at least give her back a functional vagina and rectum.

During the repair, the power goes out – of course. The anesthetist holds up an electric lantern, and I continue stitching. Finally, I finish. I am pleased to see that the stitches look beautiful (yes, we gynecologists sometimes say that in reference to a vagina), and she will hopefully heal up like new. That is, if she can get away from her brother.

*****END OF GROSS PART*****

Everyone in the OR is horrified by the situation. The medical student and anesthetist keep lamenting that the brother can’t be arrested. I am glad that this is their reaction – sympathy for the girl, anger toward the brother. But then after the case, the two OR nurses say things like “Why did she let it happen?” and “Why didn’t she run away?”

Finally, I say, “Where should she run to? To live on the street? So someone else can rape her?” They acknowledge my point.

The next day on the ward, the patient is lying in bed again. I can’t get anyone to translate for me, so I don’t find out very much.

The day after that, I stop by again. The mother and grandmother are there, and all three are eating lunch. I go to find a translator. This time, I find the medical student, and a very sympathetic midwife, S, whom I like and respect a lot. I need to figure out what we can do to protect the girl and how to rectify her awful social situation. I bring them to speak with the patient.

When we get to the bedside, only the grandmother is there, and the food is gone. The midwife tells me that yesterday, the mother was beating the girl.

“Beating? What do you mean beating?” I ask, alarmed.

“She was beating her, she was hitting her. She was hitting her where you stitched. I had to pull the mother away and I threw her out of here.”

What. The. %@$!&#. What? WHAT??

I thought the story was bad before, but now I am just dumbfounded. Why on earth would anyone, much less the mother, hit a girl IN THE VAGINA after she has just DELIVERED A BABY and TORN THROUGH HER RECTUM and then been STITCHED UP. Much less a young girl who has been brutally raped by her own brother and nearly died of hemorrhage after delivering his baby. Why?

The midwife tells me that the mother blames the girl for being involved with the brother, for “tempting” him. The mother is angry with her and was trying to hurt her. Now the girl is saying that she wants to go home, but she has nowhere to go, no money to clothe the baby or take care of herself.

I am confused because I just saw the mother here, eating lunch with them. Apparently, I am told, the mother is no longer staying with the patient, but is still bringing food to the hospital. Only the grandmother is staying, because of what happened yesterday.

There are so many things to address here. The trauma, the depression. The girl’s feelings about her baby, the product of this incest/rape. Does this girl even know what rape is? Does she understand that she is a victim, that she is not at fault? I have no idea. Then there are the practical aspects. Where is she going to live when she leaves the hospital? How will she care for the baby? What if the brother comes after her again? What if he does it soon – he will tear open her stitches and probably give her a fistula.

I realize that I need to have this conversation with her, but it’s so hard given the language barrier. She obviously trusts the medical student, so I have him and the nurse translating.

“Tell her that what happened is not her fault,” I say. “Ask her if she knows what rape is.”

He does, and then says, “She is just narrating to me what happened. I don’t think she understands.”

I have him explain the concept of rape. I repeat that it is not her fault. I tell her that we are here to help her. I ask if she understands what happened since she came to the hospital. When the patient replies to this, both the medical student and the nurse can’t help laughing.

They translate for me: “She is giving her perspective. She is saying that she came here, and she was bleeding and she was having pain, and you took her somewhere and gave her an injection that caused her to die. Now she is here, and the pain is better.”

It is both endearing and a little overwhelming to realize how little she understands – and how this probably reflects what many patients here understand. Some of the things I do must seem so crazy and foreign to them. No wonder they still go to traditional birth attendants and take herbal concoctions – they seem just as crazy and improbable.

We explain in simplified detail the retained placenta, and the laceration. When we tell her that she almost bled to death, and that’s why I had to hurt her to pull out the placenta, she looks me in the eye for the first time.

In English, she says “Thank you.”

I am taken aback, but pleased. I take her hand. We explain the rest of the situation.

We ask her feelings about the baby. She says she feels good about the baby. She is breastfeeding him and caring for him.

We ask where she will live. She tells us that she will stay with her grandmother. Her mother had separated from her father a long time ago and remarried another man. When the brother started raping the girl, the mother didn’t believe her. When she ended up pregnant, the mother blamed her, and so the girl moved in with her grandmother. But the grandmother is elderly and doesn’t have much money.

I ask if the brother lives far. She says he lives near the grandmother.

Great, just great.

We ask if she is in danger of being raped by her brother again.

“No,” she tells us, “I will stay away from him.”

“How will you stay away from him? What if he forces you again?”

The medical student shakes his head before translating her response. “She is saying that if he tries to force her, she will raise an alarm and people will come and help. She is young, she doesn’t understand, she is not thinking about it.”

Sigh. Now what? The midwife, the medical student and I discuss different options. There are no shelters, no safe houses. There is no counseling, no psychiatry, no social work available. There is no support. And without the family’s support, the girl is unlikely to get any help from the police.

We are also worried that she will abandon the baby. Apparently, it is very common here – people leave babies in garbage piles, in ditches, in medical clinics and hospitals, on the side of the road. Can we find somewhere the baby can stay until her situation stabilizes? But she seems to have good feelings toward the baby, and it can’t possibly be good to separate them.

While I am trying to think of something I can do to help, keep repeating supportive things to the girl, and I occasionally take her hand. Culturally, this might come off as really weird here, I’m not sure. But I can’t think of anything else to do.

Finally, we decide that she will stay for a while until her stitches heal completely. That way, she will be safer for now, and maybe we can think of something in the meantime.

Every day, I stop by and see her. The stitches are healing very well, and there doesn’t seem to be any damage from the incident with the mother. I can’t tell if she is improving emotionally, but the medical student says he has seen her walking around, and talking more.

There is a midwife in our clinic, R., who used to work on labor ward. I tell her about the situation, and she says she knows of a social worker for the hospital. The next day, R. tells me that she went to see the patient and had a long talk with her. R. then informed the social worker about the case, and is hopeful that the social worker might be able to arrange social and even financial support for this girl given her extreme case. I am so glad to hear that there is something like that available.

Today, I go to see the patient, but she is gone. A midwife tells me that the patient was not discharged, but she left on her own. No one knows to where or with whom. “It happens all the time,” she says.

Molar Pregnancy

2010-03-23T17:35:00.004-04:00

“There is another woman you should see,” says the medical student, “It is another fascinating and horrible case.”

I chuckle a bit at his wording – how awkward it is, but also how true. Medicine is full of cases that are fascinating and horrible. Patients who are suffering don’t want to be fascinating; they want to be cured and go home. But we, as doctors, went into medicine because it is fascinating. I love medicine. I love to talk about it, think about it, hear about it. We doctors don’t wish ill on patients by being fascinated. We are just genuinely interested and passionate about the practice of medicine. It’s what makes us good doctors.

“What is the case?” I ask.

“It is a molar pregnancy. I have never seen one,” he tells me.

A molar pregnancy (or “mole”) is truly a pregnancy gone awry. It started out as a pregnancy, but the genetics are all wrong. It becomes something that looks like just a huge placenta, and grows much more rapidly than a normal pregnancy would. Usually, there is no fetus. Rarely, there can be a normal fetus with a mole, but this is a very uncommon situation. There is a significant risk that the mole can have a malignant transformation – a pregnancy that becomes cancer. Most moles are not cancer, but it is nearly impossible to tell before it is removed and the pathology evaluated.

Classically, a patient with a molar pregnancy presents in the first or early second trimester of pregnancy with a uterus that is much bigger than expected for her gestational age. Sometimes she has pain, and often she has bleeding. Immediately, her labs are checked, and the Beta-HCG (the pregnancy hormone in the blood) is astronomically high. She sometimes has symptoms similar to hyperthyroidism – her blood pressure and pulse might be elevated, she might even be breathing a little rapidly. Sometimes her ovaries are enlarged from overstimulation. An ultrasound is done, and the contents of the uterus contain not a fetus, but a “snowstorm” appearance – a homogenous hazy quality similar to the fuzz on a malfunctioning black-and-white television.

If that pregnancy were allowed to continue, the woman would either eventually begin to miscarry on her own – at which point she would hemorrhage, likely to death. A molar pregnancy is extremely, extremely bloody. Therefore, a D&C is required upon diagnosis. Or the mole could transform into cancer, and she would then develop metastases. The most common site of metastasis is the lung. So before the D&C, the patient would typically have a chest x-ray to verify a lack of lung lesions. If malignancy is suspected or confirmed through testing, the D&C might be avoided and a hysterectomy performed.

This particular patient started bleeding at home very heavily, and came to the hospital. She was sent to the hospital ultrasound unit, where her husband paid USh 5000 ($2.50) for an ultrasound, which revealed a molar pregnancy. One of the hospital doctors was notified, and I see his note ordering oxytocin and misoprostol for induction, and something about a D&C.

At this point, I am not sure whether to be confused, stunned or horrified. This patient should not, under any circumstances, undergo an induction. It will only cause her to hemorrhage further. She needs a D&C – NOW. I say this to the medical student, who then insists that the doctor had ordered this medication only as backup for the D&C, in case of hemorrhage. I am pretty sure the student is fabricating, because the note does say “induction,” but whatever.

First I decide to fully assess the patient before making any recommendations. I review the chart further. She is 45 years old, and has 10 living children. This is her 11th pregnancy. Her last delivery was 1 year ago, and that child is still nursing. Her last menstrual period was in November. She doesn’t speak English, but her husband does. Her husband looks extremely frightened, and has come out of the Gyn Ward to the hallway to hover around me and the medical student as we discuss.

I go in the ward to examine her. She looks every one of her 45 years, and she looks uncomfortable. I ask about the bleeding, and am told that she has been bleeding very heavily for 2 days. Right now, the bleeding is lighter. She is also having abdominal pain. I notice that she seems to be breathing just a little bit heavily. It could be from discomfort and pain, but immediately I become concerned about lung metastases. I review the ultrasound report, which is pretty convincing for molar pregnancy, and the labs. Her hemoglobin is 5.9, which is extremely low. In the US, a patient would be transfused at that level. Here, she would not, but since she is currently bleeding and will likely lose blood in surgery, it is concerning. She is very pale. I also notice that her Urine HCG is negative.

Urine HCG is another way of measuring the pregnancy hormone. It is less sensitive than the Beta-HCG, but since the Beta-HCG should be astronomical in a molar pregnancy, the UCG should be positive as well. This is strange. In addition, there is the matter of her age. A 45-year-old has a low chance of spontaneous pregnancy, although if pregnant, she has a higher chance of an anomaly (including mole).

I turn to a midwife and explain that we should absolutely not induce the patient. “We know, Doctor. We saw that note and we were suspicious, so we wanted you to see her. We waited for you. We have not done anything.”

I am relieved to hear that. Love these midwives. Unfortunately, it’s 4pm on Friday afternoon. How am I ever going to get a D&C now? And if not today, then how can she wait until Monday if she is bleeding? The patient arrived around 11am. I wish someone had called me earlier, because I could have gotten the D&C done.

In the meantime, I reevaluate the situation. How definite is the diagnosis of molar pregnancy? It is important not to get stuck in the first diagnosis made by someone else, but to consider all possibilities. A 45-year-old has a low chance of being pregnant at all. But she has a 1-year-old child, so obviously she is a very fertile person. Another possibility is endometrial (uterine) cancer. The incidence of endometrial cancer increases with age, and although 45 is still a bit young, it definitely happens with increasing frequency after age 40. She has no risk factors for endometrial cancer – she has many children, she is not obese, and has no exposure to exogenous unopposed estrogen. However, if a uterine cancer were very advanced, it could possibly grow into a large intrauterine mass that might look like a molar pregnancy. That would also explain why the UCG was negative. Endometrial cancer does also present with abnormal, sometimes heavy, uterine bleeding, which would be consistent here.

On the other hand, the woman did miss her period for several months before the bleeding, which is more indicative of pregnancy. And one would not expect an endometrial cancer to form such a huge mass within the uterus (making the uterus visible and palpable from the outside) before metastasizing. It would be more likely to bleed before reaching that point, unless it was some kind of more rare uterine cancer, like a leiomyosarcoma or a carcinosarcoma. But it is doubtful that those rare tumors would look so much like a molar pregnancy on ultrasound.

Regardless of whether this is a benign molar pregnancy, a choriocarcinoma (malignant molar pregnancy) or endometrial cancer, this woman will need a D&C for diagnosis. She may need a hysterectomy later, but she needs a D&C now.

I bring my ultrasound over to scan her myself. It often helps to see the images oneself, not just read the report – which is one reason I am glad I was so well-trained on ultrasound in my residency. When I do the scan, I see exactly what the ultrasound report said – it looks very much like a molar pregnancy. I can’t be 100% certain, but molar pregnancy is highest on my differential.

The next step is getting the D&C. The midwife has tried to call the anesthetist for me, but he is gone for the day and his phone is off. I know that the chances of getting an anesthetist over the weekend are not good, but I can only hope. If not, it will be Monday.

On Saturday, she looks a little worse. The breathing is a little more labored, and her husband tells me she had severe abdominal pain overnight, although the bleeding is still minimal. I am getting more nervous. The anesthetist is available, but he refuses to do the case unless there is blood available. But there is no blood available in her type – only in B+, which we can’t use for her. Aargh. I try to make arrangements for the hospital to get blood from Mbale (where they usually get their blood supply), hoping we can do the case tomorrow, if the anesthetist is around.

On Sunday, she is even worse. Her breathing is more uncomfortable. I am even more nervous. Is this breathing problem really caused by possible metastasis? If so, that’s really bad and scary. It’s still possible that it’s being caused by a combination of her pain and the pseudohyperthyroidism from the molar pregnancy, although it is now seeming a bit too severe for just that. I try to listen to her lungs to see if there are crackles or wheezes, but it is hard to get her to take a deep breath. That is not uncommon here – patients never understand what I want when I ask them to breathe deeply, even with a translator – but it might also be because she is breathing too fast to take a deep breath.

I hunt down the anesthetist, but he still refuses to do the case without blood. I am really frustrated that the hospital didn’t acquire any blood yesterday. But what did I expect? It’s the weekend, and there is no one who is accountable for this problem. And now it’s Sunday, and the blood bank in Mbale is closed. The first time we will be able to get blood is tomorrow, probably in the afternoon when our research car goes to transport lab tests. Which means I won’t be able to do the D&C until Tuesday.

At this point, I am really wondering if we need to wait for available blood. I know she is severely anemic, and that moles tend to bleed heavily during a D&C, but how long can she wait? I remember one particularly scary mole I operated on in residency – we all were prepared for massive hemorrhage, but the bleeding wasn’t so bad at all. Maybe this will be ok too. But then again, if I do the D&C, and she does hemorrhage, and I don’t have blood available, she could easily die, and I would never forgive myself.

The husband has become increasingly panicked, and often comes to find me in the clinic or as I am walking by the labor ward. It is touching to see how concerned he is for his wife; I can’t say that most of the women on the labor ward have a husband who is so involved and concerned. I wish I could help them immediately, because I know how awful this must be for them. I feel terribly that my hands are tied. I have discussed the option of going to Mbale for treatment with him, but he very clearly can’t afford it. There are the transport costs, the costs of testing and medication, and the possibility that they will have to bribe one or more people when they get there.

On Monday, the patient looks awful. She has decompensated into full respiratory distress. She has retractions – use of the voluntary chest wall muscles to breathe, not just the diaphragm. There are tears in her eyes from the pain and fatigue of trying to keep breathing. In my head, I let out a string of curses, mostly toward myself. In my hope that she would be ok, I let myself believe that her breathing wasn’t as bad as it really was. But she was obviously getting bad so fast. Why didn’t I see this coming?

The husband says something that catches my ear – the patient has been having fevers. No one had told me that before. Maybe Occam’s razor is wrong in this case. Maybe she has a different reason for the respiratory distress. Pneumonia? It could be. I listen to her lungs. It is still hard to get her to take a deep breath, but I think I hear crackles on the left. Nonetheless, I have to try something, because she isn’t going to last long. I decide to treat her for pneumonia with Ceftriaxone. Her has to buy it from a pharmacy in town, as it is not available in the hospital. He starts to leave, then pulls me aside to ask if there is anything we could use in the hospital that he wouldn’t have to buy. I feel for him. They are so poor. In the hospital, then have penicillin (useless for anything other than syphilis, but used all the time), Gentamicin, and Flagyl. It’s possible that they might work, but the first line of treatment is Ceftriaxone. She is so sick that I don’t want to take any chances – if I wait until morning to see if the other antibiotics work, she could be dead. I know that Ceftriaxone is very inexpensive here, and although I feel badly for making him spend what little money he has, I know it is necessary. I gently insist.

Her respiratory distress could also be a pulmonary embolus, but if so, there is no hope. I won’t be able to get her adequate anticoagulation. But with this history of fevers, pneumonia is a definite possibility.

I am worried that she won’t make it until her husband gets back from town with the Ceftriaxone. I pull the midwives in to see the patient, and they all realize how sick she is. They help me drag the heavy oxygen concentrator all the way over from Labor Ward, and hook her up to the nasal cannula.

I hang around, writing notes and seeing patients. As soon as her husband comes back, the nurses give the Ceftriaxone. The patient reports some slight improvement on the oxygen. As we are standing there talking to her, the Principal Nursing Officer appears in the window, requesting the oxygen concentrator for a very sick child on Peds ward.

After the incident on Peds ward, I am determined not to lose another patient. I go over to the lab to find out about the blood situation. The head of the TDH lab is a very nice man, and he always welcomes me with a warm handshake. I tell him my problem, and he takes me over to the blood bank refrigerator, where I can see lots of blood in the B+ shelf, and all the other shelves are empty. I tell him that we have a car going to Mbale today, and that we can pick up blood for their blood bank. He is very grateful, and gives me a cooler to transport the blood, as well as a requisition form. I see he has requested for 10 units of my patient’s blood type, as well as multiple units of other types. I give the cooler and the requisition form to our driver to take with him on his afternoon trip to Mbale

The next day, Tuesday, the patient looks remarkably better. Her breathing isn’t perfect, but it is much improved. Her retractions have lessened, and she looks more comfortable, especially when on oxygen. Her husband reports that she slept better overnight. I am relieved, but will be more relieved when this pregnancy is out.

I go to find out about the blood. I learn that although our driver was able to obtain blood yesterday, they only had 1 unit available in my patient’s blood type. AARGH. Seriously??

I am fed up. I am not waiting anymore. This one unit will have to suffice. I can’t wait for her to decompensate completely. She needs this molar pregnancy out of her body today. I call the anesthetist, and he agrees to come and see the patient.

An hour later, the husband finds me walking across the hospital grounds, and he is very upset.

“This man came, and he is telling us why don’t we go to Mbale. I have no money, I can’t afford Mbale,” he tells me.

“I am not referring you, don’t worry. Who is this man?” I ask.

“He is from the blood bank.” That doesn’t make sense, so I walk with him to the Gyn ward to see if the man is still there.

When we get there, it is the anesthetist who is there, doing a preoperative evaluation. Now I realize he has been telling the patient’s husband to go to Mbale. I pretend not to know any of this.

I greet him. “So, can we do the case today? She is really suffering, I would like to get it over with. If we use the MVA, I can do it very quickly.”

To my surprise, he doesn’t say anything about Mbale. He agrees to do the case, although he complains about her respiratory difficulties. I agree that it is a problem, although now that I am treating her pneumonia, it is improving. He says something about how he can’t use ketamine with this patient because it can cause respiratory depression. I am not in a position to argue; I just want to do this case, and I don’t care what kind of sedation he gives. He tells me he will use a small amount of morphine instead. I know that morphine can cause respiratory depression, but I don’t put up a big argument, because we will probably be using small doses, and so it won’t matter anyway. This woman needs her D&C, and this anesthetist has stalled too long. We agree to meet in an hour in the theatre.

When I arrive in theatre, the anesthetist is not there, nor is the patient. I go to Gyn ward, and find her there with no one ready to move her. I ask the midwives to help me get her moved to theatre. I call the anesthetist to find out where he is. When he picks up, there is a lot of noise in the background, and he tells me that he has gone to St. Anthony to do a cesar. St. Anthony is the private hospital nearby, and apparently he has a second job there. So although he knew we were going to do this case, and this patient was very ill, he left to go do a case somewhere else. I am annoyed, but I can’t show it. He tells me to look for the other anesthetist. Fine, whatever.

The other anesthetist is there, and is perfectly willing to do the case. Phew. I find two theatre nurses reading the paper. They tell me that the D&C kits – which contain all the instruments needed for the D&C – are locked in a cabinet, and only the first anesthetist has the key. He has gone with the key to St. Anthony.

You have got to be kidding me. No way. I have spent 5 days trying to get this poor woman a simple D&C, then the guy disappears at the last minute, and takes the key to the supply cabinet with him. What the hell? I am about to be furious.

I make several confusing phone calls to him, trying to figure out what the hell is going on. I keep getting disconnected, or else he doesn’t understand and thinks that the second anesthetist has the key. There goes my last nerve. I don’t want to show my extreme irritation, so I try to stay very quiet, and just manage the completely ridiculous situation.

The second anesthetist helps me look for additional instruments. He opens the autoclave and starts pulling out instruments that might be useful. I am very appreciative that he actually seems motivated to get this case done, unlike the other guy. I start looking through the instruments myself, but I can’t really find what I need. There is no speculum either, but I suppose I can use an abdominal retractor in the vagina. Sheesh. But I can’t find a ring forceps or anything similar. I am nervous to do this case without at least a ring forceps to pull out a mass of tissue. She could really bleed, and I need to have at least some semblance of adequate instrumentation.

Finally, the first anesthetist tells me by phone that he is finished at St. Anthony, and he is bringing the key. I get an MVA from our stash in the clinic, and I change into scrubs. The theatre staff gets the D&C kit out. I put on a plastic apron and a gown, making sure to cover from head to toe in case of heavy bleeding.

I love the MVA (Manual Vacuum Aspirator). A typical D&C (Dilation and Curettage) is done using mechanical suction, which requires electricity. The suction allows you to remove products of conception and blood quickly, and less scraping (curettage) is needed. Here, the D&C is done without suction, because of a lack of appropriate attachments to the suction machine (which is hardly used even when needed). They just scrape away with a metal curette. It takes much longer, and is more crude and rough on the uterine surface. The MVA eliminates the need for mechanical suction. The MVA looks like a giant syringe, and on the tip of it you attach a plastic curette, which is blunt/round at the end, and has a hole with a slightly sharpened surface for scraping while suctioning. You engage the air seal, then pull back on the syringe handle, creating a vacuum in side the syringe. You then insert the curette into the cervix, and release the air seal. The vacuum pressure then causes suction to remove all products of conception from the uterus. You do that as many times as needed to completely clear the uterus.

Many things are nice about the MVA. It is extremely portable, so you can bring it with you anywhere – to the ER, to the OR, to Uganda. It doesn’t require electricity. Its suction is more gentle than mechanical suction, so usually the pain is less if the patient is awake. If a patient is really bleeding heavily in the ER, and you think that moving her to the OR will cause a delay that will allow her to bleed even more, you can just insert an MVA very quickly and finish within 2 minutes. It’s truly amazing.

In this case, the MVA is fantastic. The second anesthetist gives the patient light sedation with ketamine (apparently not a problem for him). Her cervix is already dilated enough to accommodate the curette. I set the airseal, create the vacuum, insert the curette, and release the seal. Immediately, blood and products of conception zoom into the syringe chamber. The products look exactly the way one would expect for a molar pregnancy.

To my surprise, there is no immediate hemorrhage when I start the procedure. I work quickly, emptying the syringe and reinserting the MVA over and over. There is a ton of stuff in her uterus. I save some of it for pathology, and dump the rest in a large orange garbage bin just below the operating table. I keep going and going. The anesthetist and the theatre nurse become curious, and move closer to observe the MVA in action. It is so neat, and so efficient, they can’t help but marvel.

As I continue the suction, I finally feel her uterus start to contract down and become smaller. What a relief. I continue, being sure to clear everything out of the uterine lining. Finally, it is done. All four walls of her uterus are clear of products, and feel gritty when I scrape. I have done the entire procedure with the MVA. I massage her uterus to confirm that it is firm and that no more blood is coming out. It is several times smaller than when I started. Before the procedure, it was between the size of a watermelon and a pineapple. Now, it is the size of an orange.
The theatre nurse and the anesthetist want to see how this amazing MVA works. I demonstrate the air seal and the vacuum, and they marvel over the device.

The patient didn’t lose much blood other than what was already in her uterus, which was a lot. But since she is so anemic and so sick, we agree that she should receive the unit of available blood. It might help her respiratory distress as well.

The next day, the patient looks great. Her breathing is almost normal, she is comfortable, and she is even smiling. I haven’t seen her smile since she arrived. I am overjoyed. Her husband looks relieved, and breaks into a huge smile when he sees how thrilled I am with her appearance. Everyone in the Gyn ward gathers around, even the ones who are not related to the patient. They know how sick she had looked, and can see how much better she looks now. My reaction is confirmation for them – everyone breaks out into smiles and chatter with each other. Several of the women gathered around shake my hand, as does the husband.

I keep her in the hospital a couple of more days. She is still very fatigued, and I want to complete the treatment for pneumonia, just in case she really did have it. Finally, I send them home with instructions to see me in my Wednesday clinic in 2 weeks. I take the pathology specimen with me to Kampala, and drop it off with a pathologist I know for evaluation. I hope that this mole doesn’t have malignant transformation, but I will deal with that possibility later. For now, I am so relieved to have finally done this much-needed D&C, relieved that it helped the patient so dramatically, and relieved that she didn’t hemorrhage during the procedure. Go go gadget MVA.

Growth Restricted

2010-03-19T15:42:00.001-04:00

Every Wednesday, I hold a clinic in the Antenatal Clinic at TDH. It was originally intended to be a high-risk clinic, in which I would see women with complicated obstetrical problems, HIV, etc. The nurses in the clinic called it the “Risk Mothers Clinic.” In reality, I see any patient that the midwives don’t know what to do with. Sometimes, these are complicated cases, but sometimes they are very simple, like urinary tract infections, or benign abdominal pain of pregnancy. Still it makes me realize how much the nurses need the help – they are trained to be nurses, not diagnosticians, but they are forced, by the lack of trained physicians, into a diagnostic role that they are unprepared for.

There is no chart or patient file in the clinic. All information is recorded on an antenatal card, which is very limited in what it can contain, but also very dense. It has a lot of information about the pregnancy (dates of visits, blood pressure, fundal height, fetal presentation, doses of malaria and worm medication, bed net distributon) but not a lot of information about anything else – like pregnancy complications. The patient carries the card with her to each visit, and home after the visit. Surprisingly, it is very rare to get a patient showing up for antenatal clinic or in labor without a card. The women are very careful with their cards.

Usually, I can tell from the card why the woman has been sent to my Risk Mothers Clinic. Some of them have previous cesarean deliveries, some have HIV, some have abdominal pain. But sometimes, I can’t tell at all, so I ask the patient.

One particular woman was sent to me today. She is wearing a lavender dress in a style common in the villages here, and her hair is shorn very short. She speaks English, which is a relief for me. When I ask her why she has come to see me, she smiles broadly but sheepishly.

“When I lie down, my belly goes away.”

What? That doesn’t make any sense. She is laughing as she tells me, knowing it doesn’t make sense. I look at her abdomen – she looks about 30-32 weeks pregnant. I look at her card to see her last menstrual period. I use my pregnancy wheel to determine that if her period is correct, she should be 39 weeks pregnant today – her due date is in 1 week. That’s strange, as she looks too small to be full term, but perhaps she carries well. I ask her for her last menstrual period, and she confidently confirms what the card reads.

I have her get up on the examining table, and when she lies down, I see what she means. Her belly has disappeared. Now it is only a tiny mound on her abdomen – it looks about 22 weeks in size. I measure the uterus with a tape measure, and find that it measures only 24cm – equivalent to 24 weeks of pregnancy. How could that possibly be? She giggles at my surprise – knowing that I see now what she sees. Bizarre.

A nurse comes in, and I show her what I have found. She is surprised, too. She palpates the abdomen (they never use a tape measure) and declares that the head is low, and that the baby feels about 32 weeks in size – still smaller than 39 weeks. She hears a fetal heartbeat, but very deep.

It is clear that this woman needs an ultrasound, so I have her wait until I see the other patients, then I bring her to the research clinic to do the scan.

On the ultrasound, I see a head that looks bigger than 24 weeks. Then I notice that there is no fluid. I check for a heartbeat – it is there. Phew. I measure the fetus, and what I find is very strange. The head measures about the size of a 30-week fetus, the abdomen measures the size of a 24-week fetus, and the femur measures the size of a 34-week fetus.

When a fetus is growth restricted, it usually occurs in one of two ways – symmetric or asymmetric. Symmetric growth restriction means that the fetus is growing slower than expected, but all of the parts are proportional. It usually reflects some kind of intrinsic problem – a chromosomal abnormality, or bone abnormality, or even just a small but healthy baby (especially if the parents are small). Asymmetric growth restriction usually results from placental insufficiency – the placenta is not giving enough blood flow to the fetus.

The placenta implants early in first trimester, but its period of rapid growth is in second trimester. This is also when the fetus is growing rapidly. If something occurs to disrupt the growth or attachment of the placenta to the uterus, then the placenta can’t match the fetus’ requirements and gives an insufficient supply of oxygen and nutrients. This is placental insufficiency.

Placental insufficiency is usually slow in onset. The first reaction of the fetus is brain-sparing. The fetus shunts blood to the head, to preserve brain growth and function. This means that the abdomen is usually starved for supply, and the abdomen slows growth while the head continues. Before the overall growth restriction is evident, the abdominal circumference will be smaller than the other measurements. This is called an AC (abdominal circumference) lag. Sometimes, it means nothing, but sometimes it can be the first sign of impending growth restriction.

Once the placental insufficiency worsens, the fetus can no longer spare the brain, and the head growth slows as well. The femur length – the large long bone of the thigh – usually matches the actual gestational age fairly well, as those bones don’t tend to be as affected by overall growth restriction, but it can be slightly small.

At that point, the fetus will measure very small overall for its expected gestational age. However, it is still reasonably stable. Once the placental supply diminishes too much and the feuts is no longer getting sufficient blood flow to function, it ceases to urinate. This causes the amniotic fluid to become low, and eventually disappear altogether. Last, as the fetus becomes weaker, it will stop having spontaneous movements, lose muscle tone, and finally its heart will stop beating.

In this woman's case, her fetus clearly has severe asymmetric growth restriction, and anhydramnios (total lack of amniotic fluid). The fetus has a heartbeat and is still moving spontaneously, which is good. But it is clear that the fetus will not survive long in the womb. It needs to be delivered.

The first question is, what is the gestational age? The woman is very certain of her last period, had quickening and abdominal growth at the right time, and so should be about 39 weeks. But the femur is measuring 34 weeks – perhaps that’s the real gestational age. It is impossible to know. Regardless, a 39-week fetus and a 34-week fetus will do well outside the womb, and will die inside. This will not change my management, so I stop worrying about it.

Second, how to deliver? Ordinarily, I would want to try inducing this woman. Especially here, where cesarean deliveries are so morbid, and women have so many children, it is worth trying an induction. But would the fetus tolerate the induction? There is already no fluid, and it might be severely compromised and not tolerate labor. There is no fetal monitoring at all, and it’s unlikely that the fetal heart will be auscultated more than once or twice a day, even during the induction. But again, this question doesn’t matter, because this woman had a cesarean for her last delivery. Because she has a uterine scar, I can’t induce her labor. It might be possible back home, but it is much too dangerous here, with no real monitoring of oxytocin dosing, contraction frequency or fetal heart. And misoprostol induction is definitely contraindicated when a patient has a uterine scar. Therefore, she needs to have a cesarean.

I explain all of this to the woman. She understands, but is surprised and nervous. She didn’t bring anything with her to her antenatal visit, so she would need to go home and collect her things. This is common here – no matter how sick they are, the patients are always allowed to go home and collect their things. I have had some really sick ones who don’t come back, and I wonder what happened. She tears up, and we ask her what’s wrong.

“I have no one to cater to me.”

Here, women have to bring at least one attendant to care for them when they are hospitalized. That person cooks their meals, cleans their clothes and linens, gives medication, and basically does everything for them, depending on how incapacitated the patient is. The attendants are usually mothers, sisters, sisters-in-law, cousins, aunts, etc. I don’t know why she doesn’t have anyone, but I feel badly that she is so upset.

“What about your husband?” I ask. She doesn’t answer. “Tell him the mzungu doctor says that he has to come and care for you so that his baby can be born.” She laughs.

We agree that she will sleep in the antenatal ward overnight, and I will do the cesar in the morning.

The next morning, she comes to the clinic early with her husband. I do an ultrasound right away – and see that the fetus is still alive. They are relieved. The husband wants me to explain what is going on, so I review everything for him again. I explain the growth restriction, the danger, the need for cesarean. He agrees, but says something cryptic.

“Doctor, I understand. She needs this operation. I have nothing. What can you do for me?”

I am not sure what he is asking. He repeats this a couple of times. He might be asking if I want a bribe, I am not sure. I am too unsure and uncomfortable to address this directly, so I pretend not to notice and instead I say “I am going to do this surgery. We are waiting for theatre to be available, and then I will do it. Don’t worry.” After a couple of repetitions back and forth, he stops asking.

Then they want to talk about family planning. I know that they have had three deliveries – the first two were vaginal deliveries, and those two are alive. The third child was a cesarean delivery, and was stillborn. I ask how many more children they want, and they say they don’t want more.

“What if this child does not live?” I ask. “It is very small. I think it will be ok, but it could have problems, and may die. It is hard to know.”

It seems that the husband is still certain he would not want more children, because he does not want his wife to go through more cesareans. But the wife does not seem so sure.

“It is her decision,” he says.

I discuss tubal ligation, and then I bring up the possibility of an IUD. People don’t use IUDs much here – they are not culturally sensitized to IUDs, and no one really discusses them with the patients. People really like the injection, called Depo Provera. I find that acceptance of contraceptive methods in every culture (including my own) has more to do with cultural acceptance, norms and myths than to individual preference or knowledge about the methods. It takes a lot of education to overcome those myths.

Tubal ligation comes up again. I offer that if the baby seems fine when it comes out, I can cut the tubes, but if the baby is not fine, we can ask the husband (the wife would be under general anesthesia) and he can decide. They consider that, but have a different question.

“Doctor, in our village, there is work, in the fields. Cutting the tubes, it is difficult for the work. Can you do something else? Can you turn the – the what? – the tubes?”

I don’t understand this at all. It sounds like they want a tubal ligation, but instead of me cutting the tubes, they want me to “turn” them. In the US, a common misconception is that we can “tie” the tubes instead of cutting them. It’s an unfortunate misunderstanding due to the fact that we say “tie the tubes” when really we are cutting them (or burning or clamping, but in any case we are permanently damaging them akin to cutting, and leaving them permanently blocked).

I try to explain this. I tell them that they may have heard from other women about “turning” but it is really all cutting. They are not following.

“Maybe it is not the tubes,” says the husband. “It is turning. Is it the womb? Maybe you can turn the womb, so she won’t have problems in the fields?”

I have no idea what they mean, so I bring them over to antenatal clinic, where I can get a nurse to translate, and I can show them an IUD.

There, the nurse greets them and reviews everything in their language. Then she turns to me to explain.

“Doctor, they are saying that they have two children at home, but one child had cerebral malaria and now is not ok, is not normal. So for him, he is counting them as two children, but for her, she is counting as only one. She is not counting that sick child. So, he wants tubal ligation, because he doesn’t want her to suffer with more operations, but she is not sure.”

This is the perfect lead-in to my IUD spiel. In residency, I did a study of transcesarean IUD insertion – which means inserting the IUD through the uterine incision during a cesarean. It is surprisingly easy – you take out the baby, take out the placenta, insert the IUD, and sew up the uterus. What I studied was how often the IUDs fell out. When you insert an IUD after a vaginal delivery, it falls out a very high percentage of the time, and if the IUD is expensive (which it is in the US), this is a real waste. (When it is cheap, who cares? Put in another one. IUDs are very cheap in some countries, like Mexico). But after cesarean, the cervix is often not fully dilated, and you can insert the IUD very high in the uterine fundus, so it is less likely to fall out. Inserting during a cesarean also avoids the discomfort of insertion, and avoids the possible contamination from the vagina. When I studied this process in Mexico, it seemed to have a lower rate of falling out, but I was examining records of patients who had already had it inserted before. I designed a study to test the hypothesis prospectively in my residency hospital, but graduated before I could complete it, and passed along the study to a fellow resident.

Still, here, the IUD is not expensive. And in this woman, who is about to have her second cesarean, and who has a highly complicated pregnancy, has a large stake in not getting pregnant again soon. The best part about the IUD is that it is as effective as tubal ligation, but is reversible. If she does want another child in the future – whether in 1 year or 5 years or whatever – the IUD is very easy to remove and she remains just as fertile as she would have been without the IUD.

So I bring up the IUD with the patient and the nurse. As soon as I mention it, the nurse takes my lead, and brings out helpful pictures to show an IUD inside a uterus, and we show them a sample IUD – which is always reassuring to patients because it is very small. I am happy to see that the nurse is as comfortable explaining IUDs as other methods, and doesn’t seem to have qualms about it. I talk about inserting the IUD intraoperatively, and the nurse has never heard of this, but likes the idea. The patient likes this option, and therefore so does the husband. We decide on transcesarean IUD insertion.

Then starts the arduous carousel of trying to get the cesarean to actually happen. I go back and forth between the labor ward, the theatre and my clinic, scheduling and juggling other things. There is another surgery still going, so we need to wait until it finishes. Then the power is out. Then the power is back. Then there is no water. Finally, I decide that water or no, I am doing this cesar. We wil use water from jugs to wash. Luckily, the anesthetist agrees to this. It still takes another hour to bring the patient from labor ward to theatre. I’m not sure why. I try to expedite, but she is not in her bed, and she is not in theatre – where is she? I see the patient’s mother – who is her attendant – waiting outside the theatre. She waves to me, but doesn’t know where her daughter is.

Finally, she arrives. I am doing the cesar with S, a family medicine resident from Wisconsin visiting for the month. S is also struck by the patient’s tiny belly. It’s hard to believe that there’s a viable fetus in there. We get started on the cesar, and things go very well. There are very few adhesions. The uterus is so small that I have to do a classical incision on the uterus – vertical instead of horizontal – in order to have enough room to get the baby out. We deliver the baby easily, and it is unbelievably tiny, but really, really cute. A girl. She makes crying faces and moves around, but no sound comes out. There is meconium on her skin – it’s the baby’s first defecation (which is sterile) – and a sign of either stress or fetal maturity. There is no amniotic fluid. We are getting this kid out in the nick of time.

We start to stitch the uterus before I remember the IUD. We have the nurse open the IUD, and then I insert it very easily. I hope it stays in place. Meanwhile, the midwife who is resuscitating the baby is remarking how this baby is tiny but has all the signs of postmaturity.

“She looks like an old man!” she exclaims.

Even the cry is like a full-term infant, not a preterm one. The midwives can recognize this better than I can. The midwife is laughing at her surprise in seeing such a tiny, mature infant. We close the uterus and the rest of the operation is uneventful.

After we are finished, I leave the theatre and I find the patient’s mother still sitting outside, waiting. She shakes my hand very warmly, and says “Thank you” over and over. I see her again later after the patient and the baby have been brought to the ward. The patient is still sleeping but the mother shows me the baby. She is tiny and perfect. I suspect she was actually 39 weeks and severely growth restricted. “This is your baby,” she says. I laugh and say, “Mzungu baby,” and the mother and the other attendants laugh as well.

I return to the clinic, where the father is waiting for me, still looking worried. Maybe he doesn’t know that the operation is over and went fine.

“Everything is fine,” I say. “Mother and baby are both doing very well.”

“Yes, doctor, thank you. But I have a problem now. The baby is over-crying. What should I do?”

“Over-crying?”

“Yes, it is too much. What do I do?”

I laugh. “There is no over-crying for babies. There is only crying. A crying baby is a healthy baby.” He looks skeptical. “Don’t worry. Your baby is perfect, she is fine. She was just in the womb, and now she is out, so she is surprised. She might be cold. You hold her, keep her warm. She wants love.”

“She wants love,” he repeats, and breaks into a huge grin. “Thank you, doctor. Doctor, do you like pineapple?”

I know what he is getting at, but I don’t want him to feel obligated.

“Don’t worry about it. You are welcome. Everyone is fine, don’t worry.”

“Do you like pineapple?”

“Ok, yes, I love pineapple. But really, don’t worry. It is fine.”

“You love pineapple? That is great. Ok, see you tomorrow doctor.”

The next day, I find out the baby’s weight, which was 1.3kg, or 2.8 pounds. I visit her, and she is tiny and adorable. The mother is doing well too – smiling and comfortable, even though there is no morphine or codeine for pain – only diclofenac, which is like an IV version of ibuprofen. This baby was so lucky that her mother came for an antenatal visit when she did. Otherwise, she probably had very little time left in that womb.

The mother has a surprise for me. She turns in her bed to face me, smiling. “Her name is Veronica.”

Oxygen

2010-03-07T14:50:00.000-05:00

I am in the Labor Ward tending to a very ill patient and giving instructions on her care to the midwives when the Principal Nursing Officer suddenly appears in the window. She asks to borrow the oxygen concentrator from Maternity for a very ill child on the Pediatric Ward.

Oxygen is one of the most basic medical treatments available. Oxygen is routinely given during and after surgery, because their respiration can be depressed from anesthesia. People are given oxygen for asthma, any respiratory ailment, any cardiac ailment, sickle cell crises, and even certain types of headache. It is a very valuable and often lifesaving tool.

In an American hospital, oxygen is ubiquitous. Every hospital room has oxygen that flows from the wall, so that each hospital bed is equipped with oxygen if needed. Stretchers and wheelchairs are designed to have a place to secure an oxygen tank, so that a patient can be remain on oxygen in transit. If you need oxygen in an American hospital, you will get it.

This is not the case in Tororo. Oxygen tanks are difficult and expensive to transport, so there are none at TDH. There are oxygen concentrators, but very few and they often break and are not repaired. The theatre is supposed to have an oxygen concentrator, but it works only variably, and none of my patients have ever had oxygen in surgery – even when under general anesthesia.

The Labor Ward also has an oxygen concentrator, used for resuscitating infants after delivery. Infants are often quite hypoxic (low oxygen) after the strain of delivery – in fact, fetal physiology allows fetuses to routinely maintain levels of hypoxia that would be fatal to an adult. However, some fetuses develop such severe hypoxia in labor that they are stunned and fading when they are delivered, and require resuscitation. Such efforts are remarkably lifesaving – an infant that seems blue, limp and lifeless can be screaming within a minute or two, as long as the right techniques are performed. Teaching basic infant resuscitation to midwives is very effective at reducing the incidence of stillbirth (because some of those “stillbirths” are still, but not yet dead).

The child in Pediatric Ward needs oxygen, but I don’t know what to do. My patient needs the oxygen – so much so that I went to great lengths to drag the heavy concentrator over from Labor Ward to Gyn Ward, remove a different patient from her bed and move that bed away from the wall plug to plug in the concentrator, and set up the nasal cannula (the only available attachment) so that it fit the patient. But if this child is sicker than my patient, then perhaps we should give the oxygen to the child.

I decide to go over to the Pediatric Ward to assess the child myself. I walk there, and find a nurse, who takes me into the triage area where a woman is sitting with a two-year-old child in her arms. The little girl looks terrible. Her skin is wan and dry, her eyelids are half-closed, she is limp and her head is leaning backward, supported only by her mother’s arm. She is gasping for breath weakly. Good grief. I don’t know anything about children, but this one looks bad.

The nurse gives me a quick history that the blood smear was positive for malaria, and the child had recently been admitted at a private hospital for several weeks, but was sent home. I quickly assess her skin for rashes, injuries or marks, then pull out my stethoscope to listen to her heart. I am having trouble hearing through the coarse cloth of her shirt, and the neck hole of the shirt is too small to fit the stethoscope down, so I pull her shirt up to expose her chest. As I do that, I see a subtle change – she was limp before, but she suddenly goes slack. What the…? It can’t be. I put a stethoscope to her chest, and I can’t hear a heartbeat. I listen all over. I know that pediatric stethoscopes are smaller than adult, so I try using the small side of mine, but can’t hear anything. I am feeling for a pulse on her neck when I see the nurse looking at me ominously. She knows. She shakes her head, confirming what I want not to be true. The child is dead.

We don’t say anything to the mother, because we are both a bit stunned. The nurse informs me that she is not the mother, but the stepmother. The mother abandoned the child during the previous hospitalization, and this is the husband’s second wife. “The husband has just gone home to get some supplies,” the nurse laments.

What am I supposed to say? It’s hard enough to inform family of a loved one’s death in my own culture, but this is a totally different culture. What are the right words, the right actions? And did this child really just die in front of me? Should we have brought the oxygen sooner? And should I be resuscitating right now? I look at the girl’s lifeless body, her ruffled black denim skirt and black shirt with a red heart stitched on it. I look at the size of her body, and picture the child CPR I am required to re-learn every year. Is there a point to doing CPR? Then what would we do? We don’t even have oxygen, much less a defibrillator, a respirator, or basically anything that would keep this child alive. No, the aggressiveness of CPR would just shock and horrify the stepmother and every other mother lingering just outside the triage door.

The nurse hands me the chart, and I search it futilely for information. There is no information I will find that will bring the child back to life. I know this; I am reading the chart to avoid accepting the reality, for just one moment, that this child is dead.

I look at the child again. Who is she? Who would she have been? Would she have been a mother? Would she have stayed in school and become an educated young woman? Would she be playing with her brothers and sisters right now in a yard somewhere, maybe crying when she falls down? Would she see me in the road and shout “Mzungu!” while shrieking with giggles? It doesn’t matter, she’s dead.

The nurse looks at the stepmother. “The child has died. You must be strong. She is gone. You must be strong for her. You must not cry. She was too sick. You brought her here, you tried, that was good. But she was too sick. You must be strong.”

The stepmother’s face doesn’t change much, but she listens intently. Like many people here, she is very stoic. Then I see her lips twist a little. The nurse says a few more words of comfort. The stepmother says, “Then let me go home.”

“How will you get the body home?” asks the nurse. The stepmother shakes her head. “You will leave the body here?” The stepmother nods. “You must call a mortuary,” advises the nurse.

I don’t know the procedures, the customs, the rules. I feel useless, standing here, not able to say or do anything helpful. But I don’t want to interrupt either. I watch their interaction until it seems to end, although I’m not sure what the decision is. And this child is still in her stepmother’s arms, dead.

“I’m very sorry,” I say. I put my hand on her shoulder. It’s what I would do in the US, at a minimum. I don’t want to be too touchy in case it’s inappropriate, but I don’t know what else to do, and I want to show sympathy. I usually get some leeway for being a mzungu; our strange behavior can be chalked up to our foreignness. She doesn’t acknowledge my sympathy, but she doesn’t recoil, either.

The nurse thanks me for coming to help them. She is genuinely appreciative. I watch her for a moment, and imagine all the children she must see die in that triage area, without any guidance or assistance from any doctor. I don’t know how she does it.

I walk out of the Pediatric Ward. The other mothers don’t seem to know that anything has happened. On the cement walkway between Pediatrics and Maternity, I encounter a Pediatric nurse and one of the midwives pushing a stretcher containing the oxygen concentrator. They are having a hard time maneuvering over the chipped, uneven concrete with the concentrator sliding around on the stretcher. I wave at them to stop moving in this direction.

The stop, and look at me apprehensively, knowing what this must mean. “The child has died,” I say. They are both disappointed. The midwife shakes her head mournfully, and the Pediatric nurse laments aloud – telling us how difficult it was to get the IV in the child, how sick she looked when she arrived.

I feel a little bit shut down. I haven’t processed yet. If I had sent the oxygen concentrator sooner, would the child have lived? Later, I realize that the child was well beyond that. She was severely malnourished, and the malaria pushed her over the edge. She had been that sick for several days, as they had told me. Oxygen can be lifesaving, but not for a child that sick.

Children are dying like that all over Africa and all over the world. I know that, and it would be easy to write off this death as “just another one.” I don’t ever want to be the person who does that. I want to stay the person who is upset and moved by death, who needs a moment to recover after something like this. That child was someone; she was me, really, separated only by geography and luck. Maybe mourning this death is naïve or sentimental. I am not a particularly emotional person, but I don’t want to be so cynical that I see this death as anything but awful.

"Why Did She Do This"

2010-02-26T16:13:00.004-05:00

The midwives have a few patients they would like me to review, and one of them, they say, “has a retained placenta.” After a delivery, the placenta should detach within about 30 minutes. On occasion, it does not, and this can lead to infection and excessive bleeding. In the hospital, we actually reach in and pull the placenta out manually, and if that doesn’t work, then we do a D&C. But when women deliver at home and this happens, they have to come to a health center, but often in countries like this, they die at home.

The midwife points out the patient. She does not look like she recently delivered a full term infant. She is skinny as a rail, wearing a tight, fashionable ankle-length skirt with a cute fitted top and I can see no bulge on her abdomen. There are 2 male family members accompanying the patient.

“They are saying that the fetus came out, but the placenta didn’t come. They say she was three months pregnant.”

Now the picture is a little clearer. She had a miscarriage, not a delivery. That would explain the lack of a visible bulge. But something doesn’t make sense.

“If she was three months pregnant, they shouldn’t have seen much of a fetus. How do they know the fetus came out?”

At three months, the products of conception usually look like a big mush after a miscarriage. The midwife agrees that this is strange, and re-interviews them.

“They are saying they saw it,” she says.

“How big was it?” I say. Maybe she thought she was three months, but she was really in second trimester. In second trimester, you do see a fetus separate from the placenta, and can identify each. The midwife translates.

“They don’t know how big it was, but they say they saw it and the placenta is still inside.”

OK, whatever. I go to examine the patient. Her face shows a mix of fear and something else. Sadness? Apprehension? But the women are often intimidated when they come to the hospital. Luckily, she speaks English. I ask her about the bleeding, which sounds like it was quite heavy.

I notice there is blood on the bottom of her feet. In residency, one of my attendings taught me the blood-on-the-bottom-of-the-feet sign. Women often come and say bleeding was “heavy,” but many women have never seen truly heavy bleeding, and think that a normal period is “heavy.” But when you see blood on the bottom of their feet, that’s when you know it was a serious hemorrhage.

I want to look for her chart, so I ask for her name. The two men tell me her given name. We ask for her family name. They look at each other confusedly, then, stuttering, give us a family name. Why is this so difficult? The midwives ask their relationship to her. One is the husband. Why would a husband not know his wife's name?

I go back to the patient to try to elicit the story from her, because I am guessing that she will be a better historian than the men, who are probably just freaked out. She doesn’t fully answer my questions, though. I am trying to ask when the bleeding started in relation to the pain, when the bleeding became excessively heavy, and when it became lighter. Her answers are vague non-answers. This is weird, because typically women are acutely aware of the onset of pain and bleeding in these situations.

The medical student and the nurse are trying to help me elicit the information. I know I need to get the ultrasound to see what is inside her uterus, but it would be helpful to have a history first. Then, suddenly, she tells us the truth.

“A woman came to the house. She removed it. But the bleeding was there.”

“Who was the woman?” I ask.

“A nurse,” she says.

“When did she come?”

“Last night.”

“When did the bleeding start?”

“After.”

“You have been bleeding since then?”

“Yes.”

Now I understand why the husband’s story didn’t make any sense, why the girl was being vague, and why she has that look on her face. I want to reassure her that it’s ok, that I don’t care, and that she doesn’t have to fear what she has just told me. I don’t want to be totally open about it in front of the midwife (just in case), but I know I should say something.

“It is ok. I am glad you told me the truth. You don’t have to worry. We are going to help you, and it will be fine.”

Her expression doesn’t change much, but she nods. Illegal abortions are done by all kinds of random people. Some are medically trained, some are completely non-medical, and some are people who work in hospitals and maybe have observed a D&C and so they think they know what they are doing. They stick instruments, sharp sticks, cassava stems or whatever they can find into the cervix. They don’t know the anatomy of the pelvis, and have no idea what to actually do and what not to do. Women can end up with life-threatening infections, or hemorrhage, and often have a perforated uterus – a puncture in the uterine wall from an instrument or stick jammed in with force. A small perforation might be inconsequential, but these are rarely small, and rarely sterile. Bowel can be injured if the stick goes too far. The more advanced the pregnancy, the thinner the uterine wall, and the higher likelihood and danger of a perforation.

It’s hard to know why this girl is bleeding so much. It could be that the procedure was incomplete, but it also could be that she has a perforation. I check her vital signs. Her blood pressure and temperature are normal, and her pulse is on the higher side of normal, which is ok since she is probably terrified and has been bleeding. She doesn’t seem to be septic. Her abdomen is not particularly tender. I do a pelvic exam, and find blood clots and an open cervix with more blood inside. She will probably need a D&C, but I need to make sure first that she doesn’t have a perforation.

As I am listening to her heart with a stethoscope, I hear the medical student asking her something. I take the stethoscope off and ask what he said.

“She says she is married, so I asked her why did she do this if she is married.”

“We don’t ask that,” I say, tersely. He picks up on my tone, and complies.

Later, I explain to him – with the midwife listening – why I cut him off. I tell him that women are desperate, and many will risk their lives to have an abortion. Once they come in having had one, there is no point in asking why, or making her feel bad. We are here to treat and help. I see the midwife nodding next to me. The medical student understands what I am saying, and agrees. I tell them that abortion is legal in the US, and women who are considering it can openly discuss it with a doctor, and receive counseling. Sometimes they choose to do it, sometimes they choose not to. But the abortion rate is much lower in the US, and it’s not a coincidence.

“That is good, the women can discuss” says the midwife. “And also women in your country are allowed to choose family planning?”

That too – American women don’t need their husband’s permission to use contraception. (There is no rule in Uganda that women need their husbands permission, but it is a cultural norm – so much so that a woman requesting contraception is nearly always asked what her husband wants. A woman who wants a tubal ligation is prompted to have her husband sign the consent form, but it doesn’t seem to matter if she signs. I always insist that she sign.)

I bring the ultrasound from the clinic. I see that her uterus is hugely filled with clotted blood, but there is no fluid in the abdomen or pelvis, and the uterus looks intact. A perforation seems unlikely.

So now she needs a D&C, but there is a problem: no power. Without hospital power, we can’t do the D&C. Another alternative is Misoprostol, the wonder drug. It’s the same drug that is used for induction, and it is also great for postpartum hemorrhage and as an alternative to D&C. She doesn’t seem infected, so we have time for the Misoprostol to work.

I haven’t been using Miso as a D&C alternative, because the patients have to buy it, and they are wildly overcharged. The medicine itself should cost pennies, but at one pharmacy, they pay USh 10,000 ($5) per pill. For this indication, I would need 3-4 pills, which is a huge amount of money for most patients here. I recently found out that there is another pharmacy that charges only USh 3000 ($1.50). This is more reasonable, although still many times the actual cost. In this situation, we have no choice because we can’t do the D&C. This patient is lucky that she is here with male family members. Men usually have the money, and can go and buy the medicine. When women come with other women as attendants (more typical), they usually have little or no money.

We send the men to the pharmacy. When I return to Labor Ward, the medical student is putting the pills in vaginally. Misoprostol is a versatile drug – the same pill can be taken orally (swallowed), buccally (sucked on until it dissolves), dissolved in water for drinking, vaginally or rectally. In this situation, I would have preferred that she take it buccally, since she is bleeding vaginally and this can make the pills come out. But what is done is done, so hopefully it will work out fine.

The next day, the patient is dressed in another cute outfit – she has style that would fly in New York. She looks calmer and relieved. She had some increased bleeding overnight after the pills were inserted, but now it has completely stopped and there is no pain. I bring over the ultrasound, and see that the uterus is now empty.

I ask the midwife to send her home, and she handles the paperwork for me while I dash to see other patients. Before I go, I tell the patient where to go for family planning and problems “like this” in the future, just in case. I hope she doesn’t need another abortion, but if she does, I hope she listens to me and chooses a safer place.

Kidney Failure, Update

2010-02-25T01:21:00.000-05:00

An update on the little boy with kidney failure.

It turned out that the hospital did not have IV steroids available, and I knew the mother would not be able to buy any, so I got some steroid pills (prednosolone) from our clinic and gave it to her. I told her to give two pills in the morning and two pills at night. When we have the family member administer the medication, it is much more reliable than the overtaxed nurses who have too many patients to care for.

I went back to see the boy every day. He stopped crying when I arrived, and it worried me because I thought it indicated he was weaker. He was looking more and more swollen – his head was now hugely swollen with fluid, his eyes so puffy they were almost swollen shut. The urine continued to drain well, and the scrotum actually became much smaller, to about the size of an orange.

One of the ongoing problems was the mother’s poverty. She had no money for food. She had no change of clothing for herself or the boy. She didn’t even have clean sheets – the two she was using were dirty, and she had nothing to use while she cleaned them. She had no family with her, and no one had come to check on her from her village.

Then two days ago, I went to visit him, expecting a frown or a whimper on my arrival. The mother was sitting nearby with some other ward patients, who were generously sharing their food with her. I walked up to the boy’s bed, and to my surprise, he looked at me and smiled. It was possibly the best smile I had ever seen. I held out my hand, and he shook it. I couldn’t believe it – he was finally used to me. I pulled out my stethoscope, and he reached up and pulled his sheet off his chest, knowing I would be listening to his heart. I was so moved by that, it was nearly overwhelming.

His heartbeat was no longer fast, and apart from the swelling, he looked ok. But the swelling was so bad and made me very sad for this poor little boy. A man who was among the people sharing food with the mother came over to help translate. I explained the situation. The mother repeated her sorrows – no money, no food, she wants to go home to raise money. I explained again – the man translated – that her son could die if he goes home. I had bought her a large sheet that I cut in half to make two sheets. I gave them to her, and had the man tell her that they were donated from some nice people in our clinic. (I don’t want to create the image of mzungus throwing around money, but I couldn’t bear to see the little boy lying in dirty sheets). She was very grateful for the sheets. I reminded the nurses to give him the Lasix, and confirmed that he was getting the steroids.

His labs finally came back, and they were surprisingly uninteresting. He was moderately anemic, but everyone is here. His creatinine was just slightly elevated for his age. His blood urea nitrogen was also a little elevated, but not remarkably so. I took some urine from his urine bag, and had it analyzed. It had a lot of protein in it, and some triple phosphate crystals.

I started putting together a differential diagnosis. It seemed very likely that he had a nephrotic syndrome that is not uncommon in children. The kidneys themselves are functioning, but they allow protein to spill abundantly into the urine. That protein is sifted from the bloodstream into the urine. Because of the lack of protein in the blood, the water component in the blood filters through the capillaries, and causes anasarca (fluid in the skin) and ascites (fluid in the abdomen). It is treated with steroids, and with adequate care, children usually make a full recovery. The question is, what kind of “adequate” care does he need to survive this?

The next day, the boy was lying in bed, between the sheets I had bought. He shook my hand and exposed his chest and belly helpfully when I needed to examine him. His swelling was still severe. A woman on the ward translated for the mother, who again described her situation. She begged to be able to go home. I asked if she could go and come in one day – and possibly leave the boy behind in someone else’s care? No – she lived far away, and would need several days at home to raise money to be able to come back. I explained that I felt badly, but I couldn’t tell her to take him home, because he could die. The woman translating understood the gravity of the situation, and explained it to the mother.

Every day that I saw the boy, I held my breath, hoping that that day, the steroids had started working. Today, I went to the ward to see him, and his bed was empty. Other mothers told me that they had seen the mother take him home a few minutes earlier – she left on a motorcycle.

I don’t know what will happen to him. I don’t know if he will survive the time at home, and whether she will ever bring him back. I have had other patients in Antenatal clinic who were very sick, and they left for “a few days” and never came back.