The Horn of Africa

Hospital, Part One

At dinner on the night I arrived, I met one of the five or six doctors here. His name is Dr. Qaws and he is, I believe, the main surgeon for the hospital. Over dinner, he mentioned that there was a c-section planned for this evening and that I ought to join him and assist. I jumped at the chance, but had to point out that I'd never been in an operating room before so perhaps simply observing was best for this time.

After dinner, we went downstairs to the hospital and I scrubbed in on the c-section. Final preparations were underway as the nurses laid out the surgical tables, the pediatrician prepared himself to receive the baby in the next room over, etc. At this point, I was already feeling slightly hot and anxious. I'd never been in an operating theatre before and here I was, on a few hours of sleep, two days on busses, eating terrible food, and I was about to observe my first c-section.

The doctor soaked her belly and thighs in betadine while one of the nurses administered ketamine to put her out. Without any fanfare, it began. One quick stroke opened up the dark skin of her belly, exposing the white marshmellow beneath. Blood started to spot against the white and he cut deeper, teasing back the fascia, muscle, and scar tissue of two previous c-sections.

(Tense change!)

Within a few minutes, I can feel myself heating up sharply and sweating and I want to stave off feeling faint so I slip into the adjoining dressing room to take a breather. Back and forth and soon the baby is out, handed off to a nurse who rushes it into the next room to the waiting pediatrician. The baby is grey and completely limp.

The next minutes drag by as Dr. Amir, the pediatrician, tries to resuscitate the baby. Oxygen, manual stimulation, CPR compressions, a shot of epinephrine, suction, the heating pad. He's sweating and pushing the pace, trying to get some response. I'm thinking the baby is doomed and when I return to the operating theatre and see the amount of blood spilling out into the floor, the inadequate suction as Dr. Ouse stitches the uterus closed, I think we might lose the mother also.

Finally, after a good eight to ten minutes, the baby starts to poop and to cry. There's relief and smiles all around. Dr. Amir administers a shot of vitamin K to encourage clotting and begins to talk to me about determining the age of a baby. The cracks on the feet, the cracks on the scrotum, the descension of testicles, pinching the nipple, folding the ear. Each of these things gives you an indication, down to the week, of how old the baby is. "Mothers are not precise, you know? But these signs, they are accurate. I can tell."

In the other room, the mother is done being stitched up and seems stable. I go up to my room and collapse onto the bed. Even only as an observor, the event was stressful and emotional.

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The nursing team here is comprised exclusively of locals that have all been trained, in a three year program, by Edna and her staff. Edna herself is a nurse, trained in England. The head nurse, currently, is a Tanzanian woman named Paschazia (from the Swahili "Pasca" -- Easter, since that's when she was born) and the head nursing instructor is a Nepalese woman named Sitara. Sitara is here on behalf of the UN.

The physician team is equally international. Dr. Derrick is a Ugandan and his wife, Dr. Hawa, is also a physician here. (They have a beautiful 11 month old who's learned a few commands: "Clap your hands!" "Show your tongue!") Dr. Amir, the pediatrician, is an Egyptian, working at the hospital at the behest of the Arab League. Dr. Qaws and Dr. Dehk, I believe, are both Somali, though the latter also has Canadian citizenship. The head on-site doctor, Dr. Thereza, is Rwandan.

Thankfully, the common language is English, albeit spoken with varying degrees of skill.

My schedule has become somewhat routine over the last few days. In the morning, I'm up at 5:30a or 6:00a, after the first call to prayer at the mosque across the street. Breakfast is at 7:00a and then Dr. Derrick and I do rounds starting at 8:00a. This continues until lunch, at 1:00p, which is followed by a three hour siesta. People retire to their quarters and nap. Things start rolling again at 4:00p and starting at 5:00p, I go to to the outpatient clinic with Dr. Dekh and we see whatever comes through the door for a few hours.

This hospital is private, albeit not-for-profit. While the name includes "maternity," and that remains a big part of the mission here, we see cases of all sorts, excluding trauma. (I'm hoping, while I'm here, to spend a few days at the main government hospital where all the trauma cases go.) Typhoid is common. Malaria less so. The UN claims HIV levels at 15%, the local lab technician claims less than 5%. In the few days I've been here, we've discovered a number of HIV+ individuals.

Two days ago, we visited a patient with severe oral thrush. It was exciting to see, in person, what looks like a textbook case. My first thought was, "HIV. Thrush, Kaposi's Sarcoma, pneumocystis -- always point to the possibility of HIV." Outside the clinic, afterward, Dr. Derrick turned to me and said, "In Uganda, there are certain things that always point to HIV... oral thrush, Kaposi's Sarcoma, cerebral toxoplasmosis, pneumocystis..." He was thinking the same thing I was. The nurses drew blood and had him tested and sure enough...

Today we went and talked with him privately, approaching the topic obliquely, encouraging him to get tested, asking him what he would do if he was positive, what he would do if he was negative, etc. HIV/AIDS has a huge stigma here. Nobody wants to talk about it, nobody wants to get tested. They're aware of the problem, of course, and the symptoms, etc, but everyone thinks it won't happen to them. In that regard, it's an awful lot like the US. Half the HIV+ population doesn't know it because they've "always been careful" and "feel totally fine," etc.

Medicine here lacks a measure of precision due to the lack of tools available. Everyone is trying their best, but things are tough. A headache that doesn't change for four days can't get a head CT because there isn't one in Hargeisa. The baby the first night I was here needed intubated, but there're no infant-size ET tubes available. Some antibiotics are given out willy-nilly because we've received a large donation of them and they're all about to expire anyway. Others simply aren't available. We turn to the medical library here and try to sort out what the fourth or fifth choice antibiotic is for a given disease because the first, second, and third choices simply don't exist here.

I'm learning a lot. There's a well-stocked medical library here and I spend much of my "down time" reading up on things we saw in the clinic earlier in the morning, etc. The doctors are all happy to discuss things with me, though language can sometimes be a problem. While this is no substitute for formal education, I think it'll help me "get hooks in," making the same topics more familiar and engaging when they come up during PA school. I'm also hoping I'll see some things here that you simply don't see in Europe and the States.

Speaking of that, I've received a few email acknowledgements of receipt of my PA application and, for Duke, a request for a supplemental application to be filled out by August 15th. I'll do that as soon as I get back in the states as internet access here is too dodgy. I'm more excited than ever about PA school... I can't wait to learn all of this stuff. I'm just scratching the surface here.

posted by daviduri @ 12:20 AM