My Retraining- Week 1

My first thought- my first second to think on my first day- as I was leaving the hospital today was “what the hell am I doing here?” Not because I don’t want to be here or because I am scared for myself. It’s because on that day I did not think that I can possibly do anything at all here. It seems so far gone that nothing I can do will ever change it or make it better for anyone.

That night I though of my mosquito net-encased bed as my hide-away. When I got home all I wanted to do (after taking mildly hot shower) was to climb in. I imagined the mosquito net protecting me from the outside world, which I never knew could be as bad as I saw it today. And the funny thing is, I know that it will get much worse. Nobody died today. Nobody even almost died today. Although I can’t stop thinking about the woman I left who was laboring with a breech, preterm baby with a BPP of 2/10 (for those of you who don’t know, that means it is very sick) & I dread tomorrow when I will try to find her to find out what happened. The baby is too small to likely survive so no point in doing a cesarean section for her. “Try to find her.” Those words make me sick to my stomach. That is what happens here. Patients are there one second then the next time you check on them they are gone. Moved, delivered or dead? It’s hard to find out which.  I dread seeing the faces of the patient and her husband when I find out the baby has died. The line between life and death is so blurred here, every time I try to pin it down I feel like I am trying to hold on to sand. Our cut off for survival of a fetus in the US is theoretically 24 weeks & sometimes even less than that. Here it is 28 weeks or 1500 grams or anything that would cause a baby to need intubation as they do not have any ventilators in the NICU.

But then I think about the mom who delivered the first twin at home with a traditional birth attendant only to find out there was a second “retained” twin. We admitted her and monitored her closely, treated her when she became infected, and performed a cesarean delivery when she did not progress in her labor. The care we gave her saved her life and the life of her second twin baby. In the hospital system here the residents do the surgeries by themselves with only a scrub tech to assist. So I sent her off to the “theatre,” as they call the operating room- everything here is based on the UK system- and I don’t know what happened to her after that.

My favorite patient that day was a primip (as we call women pregnant with their first baby). She spoke perfect English & was accompanied by her friend, both of whom were clearly pretty & fashionable. She would grab my wrist and push my hand into her back so I would rub it to ease the pain during a contraction. Here there are no epidurals and only minimal IV pain meds as they are reluctant to have a "slow to start" baby (understandable when the nurses are the ones who do all resuscitation and there is no ability to "call the NICU"- as we do so easily in the US). 

I spend all day on the labour ward trying to monitor the fetuses. I am being retrained in when fetal monitoring is indicated. Here we all listen with fetoscopes (something I am still trying to get the hand of) & only do electronic fetal monitoring when it is absolutely necessary. The paper for the machines is in very short supply so I am being trained to guard it with my life. We keep it locked away & dole it out in small stacks at a time, after questioning- "is it really needed?" We only have 2 machines for a labour ward with 20 beds & 15,000 deliveries per year.  That's over 3 times more deliveries than our busy labor & delivery in Syracuse, NY. There was only 1 registrar (resident) who was mostly doing cesarean sections all day. The interns were on strike because they had not been paid in 6 months. So me (the attending aka consultant) & 1 midwife, along with many nurses & some clinical officers (similar to PAs) took care of all the patients. 

It makes me laugh (but mostly cry) now how much discussion we have about epidurals in the US. There is no such thing here. And that’s not even the start of it. I think about all of the women- and all of us healthcare workers- in the US who have NO IDEA how good they have it. In this labor & delivery there are no sheets on the beds. When a woman breaks her water or pees or we use a catheter to empty her bladder there is nowhere for the fluid or urine to go except to pool underneath her. The midwife showed me how she presses down on the bed to try to make a path for it to flow onto the floor so it doesn’t flow up & soak into the patient’s clothes. I tried hard to find a blanket for a patient who was chilled (likely from an early infection) & I could not find one. There are no towels with which to wipe my hands after I wash them- I was told that the curtains separating the beds was the best I was likely to find. When a baby is delivered we hope the mom or her family has brought baby blankets to keep it warm because we do not have any to provide them with. 

The rest of the week was much better as I got the hang of how things work. The interns returned once they started getting paid again, and the interns & residents (called registrars) are eager to learn, conscientious about caring for patients, and wonderful to work with. Plus when it is less busy it is easier to handle. Still no paper towels & no vicryl suture. Another third degree laceration, another stillborn.   I am starting to enjoy it & see the benefits of my work. The patients are so thankful and so are their husbands. Everyone is smiling all of the time, no matter how much pain they are in or how sick they are or how much work they still have yet to do.

Meetings with administration of the registrar program make me optimistic about what I may be able to do & hopeful that it will actually happen! I will be using my skills & experience in graduate medical education (both from being a leader in my residency & my experience working in the national graduate medical education organization) to improve the training program here. Think about what an impact that can have both on the care of the patients here now and the patients of these future ob-gyns of Kenya!

A long post for a long week! Luckily by the weekend I figured out where to buy some wine so I am drinking a glass as I write & then crawling back into my hide-away to rest up for another long week! Below are some pictures (not such great quality because I am taking them quickly as I rush through my day)

Outside the hospital family members & visitors relax & wait on the lawn.

Our room for ultrasounds & non-stress tests (only 1 other similar monitor to push from room to room when needed)

One of the 5 labor rooms (this room has another side for total 6 beds, other rooms have only 1 side with 3 beds)

NICU rooms

Market stalls in downtown Eldoret

 Crazy street driving.. still haven't tried driving yet but hope to do so soon!