Christmas Previa

I am sitting at home this evening when I am called in by Sister Patricia, one of the Labor Ward midwives, to see a woman with antepartum hemorrhage. I take a bodaboda into the hospital, pick up the ultrasound at our clinic, and head over to Labor Ward.

I can’t find Sister Patricia, and another midwife helps me figure out that she has taken a baby to the OR for rescusitation. Another woman, who tells me she is an OR nurse, helped me figure out which patient was the one bleeding.

As we are preparing the ultrasound, Sister Patricia and the anesthetist arrive in Labor Ward. I greet the anesthetist and ask about the baby. He tells me “We have failed,” meaning the baby died. I ask Sister Patricia the details. The baby was full term, but had a long second stage of labor (pushing), and a lot of caput. It sounds like birth asphyxia. I think of the mother, who is still lying on the delivery bed, exposed, legs wide open, with the umbilical cord still hanging out, waiting for the placenta to delivery. She doesn’t know yet.

I scan the woman that Sister Patricia called me about. Right away, I see a very clear placenta previa. It is completely covering the cervical os, and is well below the baby’s head. She needs a cesarean or else both she and the baby could bleed to death.

I don’t see any blood, but she is wearing several kangas around her waist. I ask if she is bleeding actively. The anesthetist and OR nurse are translating for me, but they speak only minimal Japadhola. It sounds, though, like she is still bleeding actively.

They know, as I do, that she needs a cesarean. They seem resistant, insisting that she will be sent to St. Anthony. I tell Sister Patricia that the woman needs a cesarean. She tells me that we can’t do it because there is no anesthetist and no OR nurse. I look around and realize that the anesthetist has disappeared – he has gone off duty, and the anesthetist who was supposed to be on hasn’t arrived.

“Why didn’t he come?” I ask

“Probably because of Christmas,” says Sister Patricia.

The patient will be referred to St. Anthony. St. Anthony is a private hospital in Tororo. It is not far, but it requires payment, unlike Tororo District Hospital, which is a government hospital and therefore care is free.

“What if she can’t pay?” I ask.

No one answers my question, because there is no answer. I ask several times, but I never get an answer.

“The last one who was sent to St. Anthony with antepartum hemorrhage came back 24 hours, still bleeding,” I say. I know this because it was the now-off-duty anesthetist who had told me.

Here I am, a trained specialist in Obstetrics and Gynecology, available to do a lifesaving cesarean, and I can’t do it because one person went off duty and the other one didn’t show up.

I don’t know what to do. I try to insist, but what can I say? I write a note in the patient’s Antenatal book, emphasizing the previa and the need for urgent cesarean. I tell the patient’s husband, through a translator, that if the people at St. Anthony refuse to do a cesarean tonight, they should come back tomorrow morning and I will do it (and hopefully there will be an anesthetist and an OR nurse).

I think about Christmas, and the story that people are celebrating, and I wonder what would have happened if Mary had had a placenta previa. She would have bled to death in a barn because someone didn’t show up for work.

Furrowed Brow

A fellow Einstein resident used to point out with amusement that when someone would say something inane or incomprehensible, I (apparently) would make an expression of confusion consisting of a furrowed brow. Yesterday was the day of the continuously furrowed brow.

--

I arrive on labor ward yesterday.

MIDWIFE: Hello Doctor! Maybe you can come and review this patient. She has cervical prolapse. We were going to refer her to St. Anthony.

We start walking toward Antenatal Ward.

ME: Cervical prolapse? I can see her. But why is she on Antenatal Ward? Is she pregnant?

MIDWIFE: 32 weeks.

MY INNER THOUGHTS: Cervical prolapse in pregnancy? Can that exist? Is this one of those Only-In-Africa things? How am I going to manage this? Who can I email for advice? Oy.

At the midwives’ table, I meet a medical student, who says he is a fourth year student. Medical students here do clinical rotations twice – once in third year and again in fifth year. In my experience, they are generally much stronger than American medical students because so much is demanded of them. So he should know something about Ob/Gyn.

The patient is sitting on a bench. She is sent to her bed for me to examine. The nurse brings gloves.

I look at her external genitalia, which are normal. I don’t see a prolapsing cervix.

ME (to the student): Where is the cervix?

MEDICAL STUDENT: It is inside. Examine and you will feel it.

ME: Inside where? Inside the vagina?

MEDICAL STUDENT: Yes.

ME: (Furrowed brow)

ME: Then how is it prolapsed?

MEDICAL STUDENT: (Silent confusion)

ME: What was her presenting complaint?

MEDICAL STUDENT: She came in with APH [Antepartum Hemorrhage]

ME: She was bleeding?

MEDICAL STUDENT: Yes.

ME: Did you do a speculum exam first?

MEDICAL STUDENT: No.

ME: So she was bleeding and you put your fingers inside?

MEDICAL STUDENT: Yes.

ME: (Furrowed brow)

ME: When did the bleeding start?

MEDICAL STUDENT: 5 days ago, when she arrived.

ME: She’s been here 5 days, bleeding?

MEDICAL STUDENT: Yes.

ME: (Furrowed brow)

ME: Is she still bleeding?

(Discussion in Japadhola)

MEDICAL STUDENT: No, but the water.

ME: Water? What water?

MEDICAL STUDENT: The water was still coming, but now it’s not.

ME: When did the water start coming?

MEDICAL STUDENT: Before the blood. The same day.

ME: So she’s been leaking water for 5 days?

MEDICAL STUDENT: Yes.

ME: And you put your fingers inside?

MEDICAL STUDENT: Yes.

ME: (Furrowed brow)

me: She has water leaking. What does that make you think of?

MEDICAL STUDENT: (Silent confusion)

MIDWIFE (shouting from outside curtain): Ruptured membranes!

ME: Exactly, ruptured membranes. So examining her could cause infection, or could cause her to bleed if she has placenta previa. Ok, I can’t do an exam. I need to do a speculum exam.

MEDICAL STUDENT: There are no speculums.

ME: What do you mean, there are none?

MIDWIFE: They are not sterile.

ME: Ok, let’s put them in the autoclave.

MIDWIFE: We cannot use the autoclave.

ME: When did it break?

MIDWIFE: It is not broken. We cannot use it.

ME: Why not?

MIDWIFE: There is someone sleeping in that room.

ME: There’s someone sleeping in the autoclave room so we can’t sterilize speculums?

MIDWIFE: Yes

ME: (Furrowed brow).

ME: Who is sleeping in there?

MIDWIFE: Someone.

ME: Who?

MIDWIFE: Someone.

ME: (Furrowed brow)

MIDWIFE: So we cannot use it. So we have no speculums.

ME: (Continued furrowed brow)

MIDWIFE: We can get one from theatre.

ME: Ok, do that.

MIDWIFE: Or maybe we bring her to theatre.

ME: Ok, that’s fine. We’ll examine her there. I’ll go get the ultrasound.

The nurse in-charge arrives.

ME: Hello Sister. I have a question. When will we fix the autoclave?

IN-CHARGE: It is not broken.

MIDWIFE: No, but he is sleeping in there.

ME: Who?

IN-CHARGE: Someone is sleeping in there, so we cannot use it.

ME: Who is sleeping in there?

IN-CHARGE: Well, the cleaner.

MIDWIFE: And he is smelly, so we cannot use the room.

ME: The cleaner is smelly?

MIDWIFE: Yes. (waving hand in front of nose).

ME: (Furrowed brow)

ME: And he is sleeping in the room where we sterilize instruments?

MIDWIFE: Yes.

ME: (Very furrowed brow).

ME: We need speculums. He needs to sleep somewhere else.

IN-CHARGE: I will tell him to move tomorrow.

On arrival in the OR with our ultrasound, I see a kidney basin with sterilizing fluid, half a vaginal retractor, and a ring forceps.

ME: What is that?

MEDICAL STUDENT: That is a speculum.

ME: That’s not a speculum, that’s half a vaginal retractor. Do we have a speculum? Or the other half?

MEDICAL STUDENT: No, we don’t have.

ME: (Furrowed brow)

I try to start the ultrasound.

ME: Is there gel?

MEDICAL STUDENT: Yes, there is gel.

15 minutes later, the medical student and OR tech have searched everywhere.

MEDICAL STUDENT: There is no gel.

ME: No gel.

MEDICAL STUDENT: Well, there is gel, but the anesthetist has locked it in the cabinet.

ME: They lock up the gel?

MEDICAL STUDENT: Yes.

ME: So we don't have gel, and we don't have a speculum.

MEDICAL STUDENT: No, we don't have.

ME: So why did we come to theatre?

MEDICAL STUDENT: (Silent confusion)

ME: (Furrowed brow)

Luwo Neko

When you scratch the surface, you realize that the mortality of birth is everywhere.

Driving from Kampala to Tororo, I was speaking with a doctor who was sharing the ride with me. She told me that she lost her first born in utero. She had been 30 weeks and developed severe pre-eclampsia. The obstetrician tried to delay delivery for the sake of the baby, and the next morning, there was no heartbeat.

She tells me that the woman in the bed next to her had the same problem - pre-eclampsia at 30 weeks. After the first loss, he took her immediately to the OR for a cesarean. He delievered the preterm infant successfully, but the baby died soon afterward.

Then she tells me of a friend she saw in the obituaries recently. The friend had developed eclampsia at 26 weeks - she had a seizure at home and was brought to the hospital. After she arrived, her condition improved, but her pressures were still high. Knowing that her baby would not survive (the earliest possible survival in Uganda is 28 weeks), the doctors tried to induce her labor in order to spare her a cesarean for a non-viable infant. The first day, the induction failed. The second day, the induction failed. The third day, the induction failed. On the fourth day, she finally went into labor, but when she became fully dilated, she had another seizure. The baby was delivered, and she seized again. Below her, the doctors found a huge pool of blood. She had developed DIC (disseminated intravascular coagulopathy), which meant that was unable to clot her blood, and she died.

I remark to the doctor that in the US, where we have made pregnancy much safer, few people realize how common these complications are, and how dangerous pregnancy can be without access to medical care. She says "In Uganda, after you deliver a baby, we say 'Luwo neko' which means 'You have survived the battle between life and death.'"

I am going to take that as a compliment

In the Operating Theatre, the plastic apron I put on goes all the way down to the floor.

"I am too short," I say to the nurse.

"You are like an African, not an American," she says. "You are small. But not so tiny. Anyway, you are wide."

Relief

Since my last post, things got worse. After I saw the woman with preeclampsia, the Medical Officer for Maternity Ward saw her, and disagreed with me. He told the nurses that the baby was too small and would die, and because the woman had not yet had a seizure, she should not be delivered.
For the non-obstetricians out there, this is crazy talk. At 31 weeks, the infant does have a chance at survival, albeit lower in Uganda than in the US. And regardless, the mother is at high risk of death. Waiting for her to seize is not an option - once she seizes, her survival is unlikely here.
The Medical Officer had ordered two antihypertensives for her, and no magnesium.

I am stunned when I hear this. The nurses have no choice but to follow his orders. I start to doubt myself - maybe I don't understand a low resource setting, maybe priorities are different here, maybe I'm wrong. I go and speak with several of the Ugandan Medical Officers in our study, all of whom agree with me. They are shocked and horrified at the doctor's management plan, and are just as certain as I was that this woman will die soon if we don't do something. But what to do? The Medical Officer had made his decision, and there is no one left in the hospital to overrule him at that hour.

I sleep poorly, thinking of the woman. The next morning, I am relieved to find her alive. She still reports headache, scotomata, epigastric pain, and a total lack of fetal movement. I brought the ultrasound with me to see if the baby was alive - to my relief, it was, and with even less amniotic fluid now. I try to comfort her and her family, but they are very concerned about her headache and the obvious swelling in her feet, hands and face. Rightly so.

The other woman - the one with the ruptured membranes that I was inducing with misoprostol - is still pregnant, too. She had a lot of pain with the medication, but had not delivered. I examine her, and her cervix is still closed. What to do? This could take many doses, and the misoprostol is too expensive. She and her family are begging me for an alternative. I know I can do a D&E easily, but with what instruments?

I pull a nurse aside and ask her to take me the the Operating Theatre to look at the instruments. To my excellent luck, I run into Dr. W, an excellent family physician from Kampala who also works in Tororo, and whom I know and trust. I tell him about the woman with preeclampsia, and halfway through my story, he is already exclaiming that she must be delivered Now Now. He announces that I have his support, that the hospital knows and supports me, and that this patient will die if I don't deliver her. He tells the anesthetist that we must do this cesar right away.

The nurse helps me organize and consent the patient, who also wants a tubal ligation (she had 6 children already). The cesar is challenging. The lack of instruments is not a surprise - I had seen it in Mbarara, and as long as I have something that clamps, something that cuts, and something that ties, I am fine. I am a little confused by the sutures - some things have different names, one suture seems like it will be Vicryl but isn't, it is hard to find the right size suture for anything - but I deal with it. There is, of course, no stool for me to stand on, and the bed can't go any lower. As soon as I open the uterus, I find placenta where I don't expect it, trying to come out before baby. I have a very hard time getting the baby out - she hadn't been laboring, the head is floating, the scrub tech has no idea how to give fundal pressure, and the placenta is in the way. It takes so long that I use profanity once, but only once. And then I get the baby out. He is pale, small and has a weak cry, and I pass him off to the nurse. Looking at the placenta, I realize it looks about 50% abrupted. Later, I go to see him, and he is doing ok. He is pale but warm under the lights, and I encourage the midwives and the family to do kangaroo care.

After that cesar, I have to do the D&E. I look at the instruments in the OR that were prepared for me. They are as follows:

Half of a speculum
2 Regular-sized ring forceps
1 Small ring forceps
1 Curved allis clamp
4 Dilators - all the same (small) size, labeled "6"
1 Tiny sharp curette (about the size of an endometrial biopsy pipelle)
1 IUD hook (what for, I don't know)

I have no tenaculum, no real speculum, no suction, no MVA, no large curette, no large forceps, and no ultrasound.
The dilators go into the cervix easily (being all the same size, I only need 1), but I still can't even get my pinky finger into the os. By no small miracle, I manage to get the procedure done. It takes over an hour, the allis clamp shreds her anterior cervix and I think I grossed out the nurse, but I manage to do it safely and completely. Go go gadget family planning training.

Two mothers and one baby safe and healthy. In one day, I have gone from frustration and despair to exhilaration and relief. And I am sure there is much more to come.

Frustration

Today was all about misdiagnosis, overuse and misuse of antibiotics and delays in care. Of course all of these happen at home, but not to the same degree. Sometimes you can only sigh, roll with it, and do what you can do.

I saw a woman on labor ward yesterday who had been diagnosed with "pelvic infection" at 15 weeks gestation. This didn't make sense, because pelvic infections (like PID) are extremely rare in pregnancy. When I spoke to her (using a nurse who spoke Japadhola), I found that she was tender only over her bladder (but not her uterus) and had pain with urination and urinary frequency - so it was more likely a urinary tract infection. (At home, I would get a urinalysis and a urine culture. Here, no such luck.) She had been prescribed Ampicillin, Metronidazole, and Ceftriaxone (they tend to throw loads of antibiotics at everyone here, regardless of diagnosis). Nothing had yet been given (also typical), so I told them to give only the Ampicillin. Today, she was feeling much better.

There was another 15-week pregnant woman on the ward, who was diagnosed with a urinary tract infection. When I spoke to her, though, this sounded incorrect. She had been having pain and bleeding for almost a month, had been seen multiple times and been given antibiotics multiple times (see antibiotic overuse, above) but hadn't gotten better. She was understandably frustrated. An ultrasound 3 weeks ago had been normal. Concerned about the source of the bleeding, I wondered about vaginal or cervical lesions, or potentially spontaneous abortion in progress. I asked the nurse for a speculum to be prepared (this usually takes at least an hour). I never got one yesterday, so I came back today.

The same woman was still there, and still having bleeding. I had brought two of the study's medical officers to practice ultrasound (she needed one anyway), and we started to scan. Immediately I noticed that the entire fetus was collected in the lower uterine segment, and there was no fluid whatsoever. On interviewing her further, the "blood" that she had been seeing come out was very watery. Her membranes had ruptured over a week ago, probably, and the pain she was feeling was slow cramping, preparing to abort, most likely. I explained the situation to her. She was upset, of course, but wanted resolution. I had the husband go and buy some misoprostol at the pharmacy. (Later he told me that 2 pills cost him USh 20,000 - about $10. That means that a medicine that costs pennies at home costs $5 here.) She started the first dose, and almost immediately the cramping increased. I think she will deliver after 1 or 2 doses. I hope so, because I'm not sure the family can afford any more.

Another woman we did an ultrasound on said she was 3 months pregnant, but when we did the ultrasound, we found nothing in her uterus, just some small blood collected near the lower uterine segment. Discussion with the nurse revealed that the patient had had heavy bleeding the night before, and had likely miscarried.

During that ultrasound, the nurse asked me to see another patient who had just come in with pre-eclampsia. Her blood pressure was 180/120, her urine protein was 4+ (very high), she was having a severe frontal headache, scotomata (seeing spots), and epigastric pain. She looked ill uncomofortable, and glassy-eyed, although was conscious and responsive. The nurse had already given her some sublingual nifedipine, and when we repeated the blood pressure it was 110/70, but she still had all of the symptoms. I asked the nurses to bring some magnesium, which 2 hours later, she still hasn't received. I also asked for gloves to do a pelvic exam, which took 15 minutes to find. Her cervix is unfavorable.
No labs have yet been done, and the nurses don't think that the hospital lab can do liver function tests. (They have never heard of creatinine, so don't know if it can be done).
Our ultrasound reveals a 31-week fetus with oligohydramnios.
Clearly, this woman needs to be delivered, but there are several problems
1. There is no anesthetist in the hospital
2. She has no labs done, and her clinical picture is highly concerning for HELLP syndrome. If we do a cesarean and she is coagulopathic, she could die. Then again, if we don't deliver her, she could die.
3. We could induce her labor (she has had 5 previous vaginal deliveries), but with no fluid and severe pre-eclampsia, who knows if the baby would tolerate it and if she would survive the long induction process? There is no ability whatsoever to do an emergent cesarean - it takes hours to get a patient to theatre.
4. She is preterm. In the US, we wouldn't worry much about a 31-week fetus in this situation, but here, survival is more limited. The absolute minimum survival here is 28 weeks, but even then it's precarious, and 31 weeks certainly is not guaranteed. But the mother could easily die of her preeclampsia - and soon - so she must be delivered.

I stop by the lab to see if they can, in fact, do liver function tests, but the lab is empty and locked (for lunch?). There is a young man in a wheelchair looking very ill, grunting and gasping. His family is waiting with him outside the lab. Who knows if he will get seen in time.

We find out that there is one anesthetist around (how? why? I don't know.) and willing to do the cesar. But first he wants the ward doctor to see the patient and make his recommendation. This could take hours. The midwives and hospital staff don't know me yet, so it's understandable that they want the ward doctor to see the patient. But I don't know how long this will take, and I can only wait and hope that he comes soon and that the woman and her fetus remain stable until then. I also hope that as time goes by, and the hospital staff get to know me, this will happen less. Until then, I can only sigh.

And Buries Her

I had high hopes this week to do lots of ward rounds and cesareans, but that was thwarted by a new TIA development - the lack of an anesthetist. One anesthetist has been transferred to another site, and the other one is on leave, so there is no option of doing any surgeries whatsoever. The midwives informed of me of the problem this morning.

All patients must be referred to out to St. Anthony's, a private hospital in Tororo (where, of course, they have to pay for services if they are to receive them).

Since no cesars can be done, and the cesarean patients usually take up most of the beds because they stay so long, there are almost no patients on the wards.

Instead, I decided to teach ultrasound to some of the Medical Officers working on my study. As I was teaching one Medical Officer, the midwives asked me to scan a woman who had just been beaten by her husband.

Interviewing her was difficult, because she spoke Japadhola and not a word of English. The nurse kept dashing away to deliver a baby or clean a bed, so I could only get 1 or 2 questions in at a time. I finally managed to establish that she was punched and kicked in the abdomen by her husband, and had no vaginal bleeding.

I did an ultrasound, fearing the worst, but found a healthy, kicking, happy 28-week fetus inside.

At home, we would automatically offer to admit women who had suffered domestic violence - to allow them a safe place to stay, and access to social services. Of course, there is none of that here. I was asked to do the ultrasound so they could send her home. A new midwife arrived who spoke Japadhola, and had more time to translate.

ME: Sister, can you tell her that the baby looks good?

(She does, and the patient smiles, relieved)

ME: I can see the baby moving. Does she feel it now?

(Discussion in Japadhola)

MIDWIFE: She first started feeling the baby move this morning.

ME: Started? I thought it stopped.

(Discussion in Japadhola)

MIDWIFE: Ehhhhh.... (which is a noncommittal yes)

ME: Did it start or stop today?

(Discussion in Japadhola)

MIDWIFE: The baby started moving this morning.

ME: OK...so it's moving now?

(Discussion in Japadhola)

MDIWIFE: Ehhhh......We can discharge her?

ME: Where is she going to go?

MIDWIFE: She says to her mother's house.

ME: Why did he hit her?

(Discussion in Japadhola, lasts a long time)

MIDWIFE: She says he is going to kill her.

ME: Kill her?

MIDWIFE: She says this is her first pregnancy, and they are just married, and he has already taken another woman. She says he is going to kill her.

ME: She shouldn't go back to him then.

MIDWIFE: Ehhh....But her is her husband. He probably paid two cows dowry for her. She must go back to him.

ME: Even if he kills her?

MIDWIFE: And buries her.

Welcome to My Soapbox

Inspired by the complete and total idiocy of certain American politicians, I am going to use this opportunity to imagine what our country would look like if abortion were criminalized.

Let's take the example of Uganda, where I am currently living. Abortion is illegal in Uganda, except in cases where the mother's life is at risk.
Then again, when is it not at risk? The (official) maternal mortality ratio in Uganda is 440 per 100,000 live births (in contrast, that number in the United States is 13).

A report by the Guttmacher Institute estimates that 297,000 induced abortions occur in Uganda every year, and 85,000 women are treated for complications of abortion every year. (Imagine how many have complications and are not treated.)

Half of all pregnancies in Uganda are unintended, and one in five pregnancies ends in abortion.

Unsafe abortion causes 13% of maternal deaths worldwide.



Making abortion illegal doesn't make it any less frequent. In fact, the opposite is true. Abortion rates are lowest in Western Europe (12 per 1000 women), somewhat higher in the US (21 per 1000 women), and while the worldwide average is 29 per 1000 women, the rate in Uganda is 54 per 1000 women.

While politicians grandstand about conception and life and babies from the comfort of their privileged lives, women are making risky choices and dying because someone else wanted to make that choice for them. They show up in the hospital septic, bleeding, and unconscious, with holes, sticks or cassava stems in their uteruses.

Women shouldn't die because they got pregnant. Maybe it's time to stop lamenting the morality of abortion, and start recognizing the reality of it.

Misoprostol Will Save the World

I went back to Labor Ward today to check on the woman I had started inducing with liquid misoprostol, and was thilled to find that she had delivered vaginally.

She told me that she had kept taking the liquid miso as directed all night until she felt contractions. She started the miso at 2:30pm, labor started around 2am, and she delivered around 9am. Perfect!

The baby was small - 2kg - but it's hard to say whether it was preterm or growth restriction. With the oligohydramnios and intact membranes, it really could have been growth restricted, in which case it's good that she delivered. The baby boy seems fine - tiny and adorable. She asked me to name him, but I felt weird about it, so she asked me for my brother's name. So Daniel and mother are doing well and will likely go home tomorrow.

I'm very excited that the miso worked in this way. This could make a huge difference, especially in avoiding cesareans.

Postnatal Ward

After 3 months of hard work, we finally finished most of the preparation for our clinical trial, and we finished the training yesterday. Today I was finally able to go over to Labor Ward and Postnatal Ward to round and help out.

On Labor Ward, two mothers were progressing well and expected to deliver soon, so I was not needed there. The midwife there told me that there were some post-cesar patients with bad incisions that I should see.

It was really nice to see patients again. Then again, it was bewildering to do so in this setting. I know what I would do in the US, but is the same thing appropriate here? What can they afford? What is asking for too much?

I soon noticed that it was asking too much to expect all four vital signs (blood pressure, pulse, respiratory rate and temperature) to be taken . If I need vitals, I need to pick the most vital.
For a woman with oligohydramnios (low amniotic fluid) and a severe headache for one day, I picked blood pressure (which I took myself). It was 90/60.
For a woman complaining of fever and dizziness, I picked temperature. It was 38 degrees Celsius.
I take heart rate myself, which I did on the woman with fever (it was 96) and a woman who had a blood transfusion after hemorrhage for a hemoglobin of 5, and was still quite pale (it was 100 sitting and 120 standing).

For the woman with fever, I think she had endometritis. She was already on Ampicillin, which her family had bought. So what do I do? Do I add Gentamicin? Clindamycin does not seem to be an option here. Is Amp & Gent enough? Or should I switch to Ceftriaxone, which everyone seems to get here for endometritis. But then she wastes the Ampicillin her family just bought for her.
As it turns out, the decision will be made based on what is available in the pharmacy. Tomorrow. When the In-Charge Nurse is there. Nothing can happen tonight, so I told her to continue the Amp anyway.

For the pale woman with orthostatic tachycardia - blood count isn't repeated after transfusion. I could request it, but she might have to pay for it, and do I really need it? She is asymptomatic, aside from fatigue. She is ambulating well, no shortness of breath, no chest pain. Would a blood count really make a difference? She's asymptomatic, so I wouldn't transfuse her anyway (especially given the paucity of available blood and the abundance of HIV). I sent her home.

Another woman had delivered triplets 4 days ago. They were clearly preterm - between 2.1 and 2.3 kg. She had six boys before, now she has 9 boys. To my surprise, when I went to see her, she and her mother were spoon-feeding water with glucose to the infants. I didn't know that you could spoon-feed a newborn, much less a preterm newborn. But these tiny little infants were sipping successfully from a spoon. Of course, I encouraged her to breastfeed in order to bring more milk down.

I saw several women who had had cesareans and whose wounds were infected or separated. It is truly remarkable how many of the women here have had infants die. The first woman had 3 babies, and 1 had died. The second had 6 babies, and all were alive. The third had 12 babies, but 3 had died. The fourth had just delivered her first child, but she is HIV-positive, and since mothers have no choice but to breastfeed here (and don't get HAART after delivery), it is highly likely that this child will die or develop HIV or both. The last woman had delivered 2 infants, and both were alive, but the third, which she had just delivered, had been stillborn. The woman with anemia who had a transfusion had delivered twins, but the second twin had been stillborn.

The last woman I saw was brought to my attention by her family member, who took my hand as I was leaving and asked me to see her. It was the woman with oligohydramnios and a headache. By her menstrual period, she was 37 weeks, but on ultrasound, the femur had measured 32 weeks. The fluid was low, but not specifically measured. The nurse had found her to be dilated only 1cm, and the doctor by phone had suggested either induction or cesarean. She had 2 prior normal vaginal deliveries. On my exam, I found her to be 2cm. Clearly, induction was preferable.
But how to induce? It seems that people often get Cesars here because of a lack of good options for induction. Oxytocin IV is not possible - there is no monitor for the IV drip. Misoprostol is used occasionally, but I discovered a few weeks ago that when they use it for induction, they give the woman 200 micrograms orally (or buccally, not sure). 200! This is almost 10 times the dose we use in the US, and has been clearly associated with uterine rupture and birth asphyxia. But how to correct midwives who have been doing their jobs for 10 or 20 years?
Luckily, this time I didn't have to. I decided to use the technique told to me by a highly respected Obstetrician in Kampala - dissolving a 200 microgram tablet in 500cc of water, and having the woman drink 60cc every four hours. The nurse sent the family member to buy the water and the misoprostol from the pharmacy in town, and she was back in less than 20 minutes. We dissolved the tablet, measured out 60cc, and she drank. We also had her eat some food to improve her headache.
When I went back 3 hours later, her headache was improved, she was feeling some cramping, had seen her mucus plug, and soon was ready for her next dose. The evening nurse was all prepared to give it to her, without my having to ask. I was surprised at the lack of resistance.
I told the woman I hope to come in tomorrow morning to find her holding her baby. I am keeping my fingers crossed, hoping it works, and hoping this method will be adopted by the midwives.

Abayudaya

This weekend I went to visit the Abayudaya - a village of Ugandan Jews. It was a nice experience. Some reflections:

1. If/when you go, bring directions. And a phone number.

2. Driving around the Mbale area at dusk is a good way to get very lost.

3. When a strange man with a huge gun on a dark road in a small village gets in your car, sometimes he will actually help you get to the place you are looking for.

4. I’m not very Jewish (this one is not new, just a reaffirmation).

5. I’m not sure what being Jewish is – is it wearing a yarmulke, reading the Torah and turning out the lights on Friday night? Or saying “oy,” eating bagels and lox and exhibiting a self-deprecating sense of humor? Or a factor of maternal lineage?

6. Ugandan Jews are more Jewish than I am.

7. The Ugandans said “Shabbat shalom” as they greeted us. This is as foreign to me as the Swahili “Habari” - I can pronounce it and know what it means, but it’s not my language. I felt very silly saying it in response and did my best not to giggle.

8. There are a lot of Jewish songs besides Dayenu, and they can all be approximated by singing “watermelon watermelon.” (Thanks, Deb).

9. People sometimes define community in superficialities, but I’m not sure I agree.

10. Things are as profound as you want them to be.

11. Religion in Uganda is private and respected, but not worn on one’s sleeve.

12. There are many religions coexisting in Uganda. Within 5 minutes’ drive of the Abayudaya, we saw a mosque, a catholic church, and a Jehovah’s Witness hall.

13. Hospitality is a human trait, but is especially a Ugandan trait, and this was evident during our visit.

14. Ugandan Jews are Ugandans, full stop.

8 Days in Cape Town

I spent 8 days in Cape Town for the FIGO 2009 conference. The conference was great and Cape Town is seriously amazing.

First, the conference.

I reconnected with old friends



and saw some great presentations. The conference was so good I was reluctant to miss any of it to go sightseeing.

One of the most memorable was one of the smaller sessions in which these 2 women from Montevideo, Uruguay presented a program for reducing unsafe abortions there, called Iniciativas Sanitarias.
Abortion is illegal, but doctor-patient confidentiality is sacrosanct. So they designed a pre-abortion and post-abortion counseling program.
Women considering abortion came to their clinic, received counseling, evaluation, and information on unsafe abortion, and on misoprostol (which is still illegal as an abortion method, but widely available, and much safer than surgical abortion with non-sterile instruments). The women were then sent home.
Around 12% decided not to have an abortion, and around 85% had a safe, successful ("illegal") abortion with misoprostol.
It's a phenomenal idea. As one of the FIGO speakers said "While countries waste time in a sterile discussion of whether or not to do abortions, women continue to die of unsafe abortions."

After the conference, I had time for sightseeing, and there is a LOT to see in Cape Town.

Winelands:





Bo Kap, a colorful Malay neighborhood :




The District Six Museum

Beautiful mountains behind beautiful buildings



Live music at Mama Africa







A very tiny cannon



Table Mountain, first attempt - cable car closed due to wind





Table Mountain, second attempt - successful







Robben Island - where Nelson Mandela was imprisoned for 18 years





Questionable clothing labels



Good coffee and muffins



And great company.







All in all, a wonderful trip.
Who's joining me in Rome for FIGO 2012?

Scott's Drawings

Scott has an extraordinary talent for drawing, among other things. While he was here, he started drawing again, and it became a wonderful way to interact with people. As soon as he would start drawing, people would collect around him, discussing his drawing with each other in local languages, and occasionally exclaiming, "Fine artist!" They had good reason to be impressed. His drawings were vivid and inspiring, bringing out the color and spirit of the subject. I would be sitting there watching him draw a scene and think "Wow, I want to be there" - even though I already was there.


This was the view from the window of a beautiful house we stayed in in San Francisco.




This is a street scene in Tororo.




Sipi Falls




A shop owner and her three children. She was very amused to pose for Scott, and when he showed her the completed drawing, she burst into raucous laughter and showed everyone in the shop. One of her young daughters really took to Scott, calling him "my mzungu" and frequently asking him to "write the baby" (read draw a picture of her infant sibling).




The market




A tailor




The Bo Kap neighborhood of Cape Town




A woman in Tororo





There are so many and they are all so beautiful.

Safari

Before Cape Town, I went on Safari outside of Johannesburg at Madiwke Game Reserve.

We stayed at the Mosetlha Game Reserve - a cute little place that had no power or running water. It was very quaint for three days - I imagine any longer than that would be a pain in the ass.
In order to take a shower, you had to take a bucket of water, drag it to the water heater, pour it into the water heater and then back into your bucket, drag it to the shower, lower a bucket on a pulley, pour the hot water in, list the bucket back above your head, and shower. There was enough water only if you shut off the water while soaping up. But the shower wasn't quite enclosed, so there were chilly breezes that would make you somewhat cold if the water was off.
Still, it was very cute. We stayed in comfortable little cabins



We drove around in an elongated jeep, which was remarkably comfortable given the circumstances. Each game drive was four hours long, from 6am-10am, and 4pm-8pm.

The car



Some days, we saw lots of game. Other days, we saw very little. But over the 3 days we were there, we managed to see a lot:

Kuru
(incidentally, I had some Kuru carpaccio in Cape Town - it was delicious!)



Springbok





Ostrich



Elephant



Giraffes





Rhinos



Lions

South Africa

I just arrived in Cape Town. We were outside Johannesburg on Safari - I'll post about that later.

At the moment, I am remembering the comforts of industrialized life, including the following things:

1. Sushi
2. Insanely fast internet
3. Smooth roads
4. Lanes in the smooth roads
5. Brie
6. Architecture, esp. Art Deco
7. Pervasive hipness
8. Attentive restaurant service
9. Salad
10. Mustard
11. Sidewalks

It's also refreshing and slightly confusing that everyone understands me when I speak. I am so used to having to enunciate and convert my accent that it's hard to stop doing.

I've been in Cape Town for 2 hours, and I'm already in love with it. It seems so beautiful and fascinating. I think there are too many things to do - I'll definitely have to come back.

Gardening

Between our large yard and Uganda's fertile soil (Eggplant grows as a weed. Seriously.), it was hard to resist the idea to start a garden outside our house.

We decided to start with plants and flowers first, because they are readily available in town. If it works well, I might venture into vegetables.

We went to a lady who sells plants near the hospital and picked out the types we wanted, then picked the best-looking one of each type. Once I see how they take, I will come back for more. Of course, once I had picked all the plants, paid her USh 10,000 ($5) and packed the plants in a box, we tried to hop on the Mate to go home, and it broke! The starter pedal just clean broke. (More on that later) So I took a boda home.

We started by choosing a patch of grass to use for the garden and breaking it up with a hoe, then pulling up all the roots.





After a lot of hacking and pulling, the ground was finally prepared.



I had left the plants we bought just inside the front gate, but when I went to get them, they were missing! Recently our security guard had his bike and radio stolen while he was on duty (yes, you read that correctly), so I assumed that they had come back for my plants. But why would anyone steal plants?
As it turns out, the same security guard had assumed that the plants belonged to our neighbor (a mzungu who works with me) and had brought them to her house.

So once that was cleared up and the plants were back in our possession, we were ready to plant. We created the border for the garden using empty wine bottles. The smaller area of the garden had poorer soil than the larger area, so we avoided it for now. We had started a compost pile, so in a couple of weeks I will mix the compost into that side.

We planted the plants we had bought, and put some limestone in for prettiness, and poured lots of water.





I'll be in South Africa for the next two weeks, but I'm excited to see how the garden will be doing by the time i get back.

We did more cooking this weekend.

We fired up the Braai (grill), which involved over an hour of effort from Scott to get the charcoal going. Now I appreciate quick-start charcoal. Cheating, schmeating.

We made steaks rubbed with salt, pepper and Tandoori spice, and beef kabobs marinated in balsamic vinegar, olive oil, tamarind, salt pepper, BBQ seasoning and honey.
We made string beans in tomato sauce - a long time favorite of mine that mom makes (of course).

Scott also found these weird tiny vegetables in the market. They're green and the size of half a finger. When you ask, they tell you the Luganda name for the vegetable, which doesn't help.



We couldn't figure out what they were, until Scott finally bit into one and it tasted like a cucumber. They were tiny, tiny cucumbers.



I chose to stir-fry them, for lack of ideas on what to do with tiny cucumbers - half in soy sauce, half in soy sauce plus tamarind. The ones with the tamarind were decidedly tastier. I don't think I'll make them again, though, because they were a pain to slice up, being so super tiny.

For dessert, we grilled a pineapple, which was the most delicious thing ever.

We were highly satisfied with our cooking effort, as was Joseph, our night guard, who proclaimed our cooking to be of "high quality." Next time, we want to make a BBQ for the whole house - probably not on a weekend, though, since everyone flees to Kampala.

Next project: Meat Omelet.

Anemia

A mzungu family medicine resident from California was working here for a month, and he rotated through all the wards. On the pediatric ward, he saw a child with the following lab results. (Keep in mind, this patient is alive.)



Hemoglobin 1.2!
I didn't know that was consistent with life, but apparently in Uganda, it is. Go figure.