Sunday, August 31, 2014

Compound Life

I am the only non-African on this MSF Mission in Jahun– the others  are from Kenya, Sierra Leone, Ivory Coast, Congo, Malawi, Ethiopia and Burkina Faso The MSF compound where we  all live is walled, and there is razor wire along the top of it.  From my room next to the wall I can easily hear the sounds of sheep goats chooks and people in the side street and  from the house in the  next compound, of kids mostly, of their early morning recitations from the Koran, of their crying and grizzling, playing, shouting…and often at night a generator is tuned on that drowns out everything. Last night welcome heavy rain drowned even that noise out, and cooled everything down.

Big steel gates open to let the vehicles in and out, and there is a watchman on duty all the time, but there are no guns. Inside, there are several buildings close together, basic offices, an eating and kitchen area, an aircondtiotned  lounge room with soft chairs, and old books and a satellite TV, and we each have a room of our own with shared bathrooms.  Theres no hot water. Our lunches and dinners are cooked every day by a local woman who serves it in large plastic  containers with lids supposed to keep it warm, and we serve ourselves whenever we  can. Typically we have rice, potato or sweet potato, or noodles or couscous, with chicken or a meat casserole, some spinach, chopped up cabbage and carrot , and various spicy tomato sauces. Once she served up some sort of  local dish that was so slimy and gelatinous it reminded me of mucus with peas and mince swimming in it – just couldn’t bring myself to even try it but the Africans all scooped it up! Today there are nine of us resident, but last weekend we had a few extra guests who came up from Head Office for meetings..
The Security Area
My daily routine is more or less unvaried – I am either eating, resting in my room, sleeping or busy at the hospital. Occasionally I watch the news on TV and have a choice between CNN, Sky, Al-Jazeera and BBC World, but its all Ukraine, or ISIS and Syria and nothing much else. The Business reports don’t interest me but the sport  sometimes does and I found I could watch live Rugby if only it didn’t coincide with the need to be at work. So I managed to see the first Wallabies-All Black match, the one that was a draw, but unfortunately missed the next one , the one where the Wallabies got hammered!  It would have been great to watch that!

To get to the hospital I walk to the front of the building where the Security guys are and they drive me in – I could walk there in five but we are not allowed to.
In addition to myself there are five young Nigerian doctors and a Nigerian Specialist who rotates from a nearby major center for  six days at a time, to share the Specialist Call with the MSF Specialist. So, if he has been on Call for the night, I go in for the morning, he covers the afternoon and the night is mine.

All of these Doctors have taught me an enormous amount – the  volume, the severity and the complexity of the  cases that we see here are beyond – way beyond – anything I have  had to deal with before, even in South Sudan and Ethiopia – and we have had to deal with these women with more or less complete absence of any sort of Laboratory tests or other back-up to help.  The very fundamentals of Medicine, which is history taking, basic observations, careful examination, clinical judgement and experience is all we have to go on – and fortunately for me, these guys have seen it all before, many times, and usually can work out what to do.

So, at 8am each day we do a round of the  Intensive Care Ward There are eight beds, the room is airconditioned  but the resemblance to a real ICU is slight – its really just a place where we can more closely monitor  the vital signs – ie Blood pressure, Pulse, Temperature, Respiratory rate and urine output of critically ill women – there are no fancy machines of any kind and no access to any tests other than of haemoglobin and no X ray.

All the postoperative patients go there initially and once stable get sent to the “Annexe” a huge  open ward like a shed, recently built by MSF for the postnatal patients, designed I believe for 40 but often crammed with 60 or 80, along with their family supports, many on the concrete floor. It is so big, and there are so many patients that the few nurses working there take for ever to get to see everyone, and several times while I have been here, the nurses or the Doctors have simply stumbled across people “in extremis” who have been quietly deteriorating, unnoticed  in the crowding and noise and bedlam of the place.

After ICU we go to the PreDelivery Ward, the place where all the frantic action and obstetric  calamities are unfolding, also often full, there may be women on matresses on the floor or even sharing a bed for a short time. Once we have seen everyone and sorted them out, I remain in the PDW at the desk, and as new work arrives, help out as I can.
The PreDelivery Ward looking unusually quiet and under control
Now, I apologize to the non-medical reader  in advance for what follows, but it is a list of the actual patients we saw on the PDW round the other morning, a snap-shot of a typical caseload - you will notice a number of women with "Eclampsia" - it is such a rare condition that in all my years of practice in Australia and New Zealand I saw three cases - seeing three in a DAY here is not unusual:

Bed One : Eclampsia : 18 year old woman, second pregnancy, brought in because she had been fitting at home ( having convulsions ) She was so restless and confused she was tied to the bed, Labour to be  induced. Eclampsia is the MOST feared pregnancy complication : it kills mothers and babies
Bed Two : Eclampsia and Malaria, and by the  Coca-Cola colour of her scant urine has HELLP syndrome as well ( dangerous complication of an already dangerous disease) . Also confused, semiconscious  and tied to the bed
Bed Three:  Eclampsia  and Malaria in a 15 year old,  in Labour. BP 180/100
Bed Four : Heart failure  2 weeks after home delivery. 25 years old. Responding to diuretic therapy. Cause of heart failure unknown and unknowable out here. The woman is just sitting there breathing fast and looking weak and near collapse but theres little more we can do.
Bed Five: Eclampsia : 17 years old Admitted for Observation of high BP, 1st pregnancy, then began fitting. We have to induce her labour and deliver the baby in the next 12 hours.
Bed Six : two women on one mattress on the floor ; one had a normal birth of a live baby, the other is half way through her sixth pregnancy but the baby has died. We don’t know why the baby is dead. We hardly ever know why. We have to induce her labour.
Bed Seven : Eclampsia : 1st Pregnancy, began fitting  in labour at home. Tied to bed. Baby alive.
Bed Eight :  Placenta Praevia at eight months – previous Caesarean ( this woman has dangerous bleeding from the placenta)
Bed Nine : Severe anaemia  (Hb 4.3) and malaria in pregnancy ; For blood transfusions.
Bed Ten : polyydramnios ( a hugely distended pregnant abdomen becauase of excessive fluid around the baby which is abnormal)

Bed Eleven : She came in with lots of bleeding during labour. The baby is out and they are both OK.

Friday, August 29, 2014

Family Planning

This is me delivering a baby by caesarean section at Jahun on Thursday morning. 

The mothers story is unremarkable – for this place – but back home, a million alarm bells would have been sounding. For a start, this is baby number seven ; two of her babies were stillborn  and one died as an infant; she has had a caesarean in the past, she has not had any antenatal care, she is anaemic, she has malaria, and she has been in labour at home for many hours and the baby is stuck. 

Any one of those items of history would mark her out as high risk in any setting but to have them all at once – this is the sort of woman that comes in the door every day, a woman with not one but a handful of dangerous processes at work, a potential  stillbirth or maternal death, an obstetric disaster hovering like a darkening thundercloud over another poor family. Fortunately they brought her here in time – the baby was still alive though jammed down awkwardly in the pelvis, serious infection had not set in, and the scar from the previous caesarean hadn’t quite ruptured. The operation was quite tricky because all the tissues were stretched and thin and fragile, her bladder was pulled up high and at risk of injury from the surgery itself, and there were lots of adhesions from the earlier operation which had been done by a vertical cut down from her belly button. It was a very different procedure from the one I did on the Fistula patient the other day, but it went well, and I was hugely relieved at the end.

What I would have liked to do as well as deliver the baby, was perform a sterilization procedure so she wouldn’t ever have to come back to the edge of the cliff. Maybe she would have wanted me to do it too – but as her husband wasn’t available to give me permission, her wishes were irrelevant. Community leaders have forbidden MSF doctors here to talk to women about contraception, apart from in the setting of an emergency caesarean, as in this womans case. They don’t want us to introduce the proven western concept that fertility control is a huge benefit to the health of women and babies and families – these are just women after all. I take it you all noticed the fistula patients record showed she was already married and living in her husbands home when she had first period. I was told that if these girls aren't already  married at puberty, and have husbands who make them pregnant they just start having rampant sex with anyone. Oh really? And would it be men they would be having sex with? 

God help us! What hope is there for women when community leaders have attitudes like that?

Tuesday, August 26, 2014

The Medical Record

I had a half hour walk in the market on Friday
I did a caesarean this morning on a beautiful young woman who had the most exquisite skin, incredibly soft and smooth and a very deep chocolate brown, not a stretch mark or blemish to be seen anywhere on it. I delivered a beautiful baby boy that was in perfect condition. The operation went really well, there were no complications, the blood loss was minimal, the spinal anesthetic worked perfectly and it was such a pleasure to be part of the team in the operating room.

In contrast, we rushed a woman in there late Saturday night to do an emergency operation after she unexpectedly collapsed with unrecordable blood pressure a few hours after she had given birth to her seventh baby. Such women often lose a lot of blood at the time of the birth or shortly after and need resuscitation, but she hadn’t, so it was a perplexing turn of events. Dr Abdul, the Medical officer on the ward called me in and we both agreed she must have ruptured her uterus and was bleeding internally. Unusally, for catastrophes that occur here, this was something I had seen before, in Australia - once -  a woman collapsing after giving birth with a uterus that must have ruptured almost at the moment the baby was born – at any earlier time in labour the baby would not have been born, or survived. I had seen it once but Abdul had seen it innumerable times….

So we ordered lots of blood and rushed her into theater. I asked Abdul to assist me because he was vastly more experienced than I am in this sort of catastrophe, and though I had managed another ruptured uterus in theatre a few days earlier without too much trouble it was nearly midnight and I was already exhausted. So we opened her up and as expected, as soon as we entered the abdomen, blood flooded out like a bath being emptied onto the floor. We reached into the pelvis and lifted up the uterus, looking for the rent in its side – or at the front – or behind? – and found nothing amiss.  The ovaries? Normal!  And still the blood welled up and the clots were scooped out as we began a search for the source of all this blood.  This was completely beyond anything I had ever experienced, and I was relieved when Abdul said he hadn’t come across anything like it either – we found a massive clot in the middle of her abdomen and it was from underneath it somewhere the blood had been coming – or so we suspected. Clearly a major vessel had burst somewhere and I decided I wasn’t going to go anywhere near it. I consulted the other Specialist who supports MSF,  Dr Gaya a Nigerian from a major town nearby who shares call with me – and, wonderful kind Muslim man that he is, he came bustling in at about 1am and agreed, we should just pack the abdomen with cotton surgical packs and close her up. We could then transfer her to somewhere else in the morning – if she lasted till then.

By now we had measured blood loss of over 5 liters of  and whole blood was pouring into her arms at a great rate. Her tongue and conjunctivae and teeth were all the same colour - bright white, the blood in her veins looked like pink water and her pulse was almost uncountable and very weak. But there was no more we could do – except pray as everyone often will tell you, if its Gods will she will live.

And in the morning, remarkably she was still alive, she spoke a few words, her blood pressure was restored and the transfusions had bought a little pinkness to her tongue. And later, she was transferred out, alive but still in desperate circumstances to a hospital where a vascular surgeon will have to  reoperate, gingerly remove all the packs and see if he can repair the blood vessel that has burst in her abdomen. It will be vey difficult.

But the woman I operated on this morning – what was that all about you may have been wondering? Her story is also quite remarkable, though not at all unusual in these parts. Like almost all the women here she cannot read or write – women sometimes receive “Islamic” education which apparently is Arabic religious instruction and that’s all. Her first baby died and after the second one she developed a fistula, a false passage that allowed urine to drain continuously down her legs. The fistula has now been repaired , and to protect the repair, any more babies that she might have need to be born by Caesarean. 

The photo above is of the front page of her Record from the Fistula Hospital. It is worth reading closely – in particular it mentions where she was living when her periods started (Menarche), underneath that it gives her age when Married, and right at the bottom her medical history records “Eclampsia”, a condition regarded as the most lethal of all obstetric diseases. Those three facts are all unremarkable here, but anywhere in the west would be regarded as shocking. 

But she has survived all these traumas, and at least today I hope is feeling a little happier about the future.

Sunday, August 24, 2014

The Hospital at the Bottom of the Cliff

Faces at the market 
The Predelivery Ward is the place that makes Jahun unforgettable, but theres no way it’s a tourist destination. 

Any place where women are giving birth is confronting to an ordinary person, even where  the process is as near normal as it can be the challenges to our sensibilities about expressions of deep human emotion, of seeing and hearing women in pain, of  the exposure of body parts, naked ness and near nakedness, tears, laughter, fear, blood and odour . Birth is always confronting but the truth is, mostly always ultimately joyful and healthy and successful.  Not here. Oh no.

The PDW in Jahun is something altogether different. It is like the place at the bottom of the cliff that has no safety fence at the top, the protective barriers of education, of the rights of women and girls, of health, of nutrition, maturity, antenatal care, of monitoring and understanding all gone. What is left is the arbitrary mercy of mother natures cruel midwife aided and abetted by cultural and religious custom that consigns women to a relentless reproductive career that begins at the earliest possible age and continues unabated till it becomes impossible by reason of age or death or disability. “Womens choice” is an oxymoron out here. Here they have almost no reproductive health rights and return again and again closer and closer to the edge of the cliff, no matter how close they get to falling off, time and again they return till the inevitable slip and down they plummet.

And yet, even though Nigeria is the richest country in Africa, the home of  20 of the 55 African billionaires and the richest African man and richest African woman, despite all the massive wealth of this country, out here there seems to be no  one trying to save them as they go over, let alone create the safety nets and warnings and signposts at the top, to stop them going over at all, or at least to stem the flood. 

And that is precisely why MSF is here at the bottom of the cliff in the outback of the poorest state in  Nigeria, trying to catch the bodies as they fall.  If not MSF then who? 
The Hospital Entrance 
Its more desperate than anything Ive ever seen.

Friday, August 22, 2014

Jahun General Hospital

The Jahun  Hospital Compound full of trees
If you came to the Hospital and you weren’t pregnant you would have to be seen in the part of its that’s run by the  Governments Ministry of Health. From what I am told, the facilities there are very limited, and the two doctors still working there are struggling to keep up, managing only to achieve a bare minimum of medical care. It sounds very much like the set-up I encountered in South Sudan, where the MOH run facility is almost non- functional, and people lie about and survive by good luck more than anything else.

The Hosital Gate looking out
But what you might first notice as you enter the hospital compound is a tidy cluster of newly painted cream buildings with British racing Green roofs and trim, looking rather efficient and ready for action. In the sandy courtyards between them, among more of those nice trees with straight trunks and thick green leaves that line the road you will then notice a huge animated crowd of bright colourfully dressed women and children sitting on mats on the ground, wandering about with pots and cups and bags. 

And most of them are facing in the direction of the MSF part of the Compound, areas that can only accessed by passing through a strong gate manned by two  friendly MSF Security guys. These women and family members are waiting to visit and look after family in the hospital but not many of the patients being waited for are in the MOH wing - most of the patients are women in the Maternity Annexe, which is more or less the entire MSF project in Jahun, and people are flooding into it from near and far, from all over the state and even from beyond. In Aweil, South Sudan where I was last year, the MSF projected also cared for neonates and children up to 5, and had a feeding program for malnourished children. This meant we had other MSF doctors there besides nurse anaesthetists and obstetricians and midwives – we had paediatricians and physiscians, but here in Jahun there are none. It is all Obstetrics. Crowd control is paramount.
To avoid upsetting anyone I take my photos when there aren't too many people about...the place is rarely empty like this
If you were pregnant, the security guard would let you through into a small room where your story is taken and some basic tests are done. Your Blood count is checked, you are tested for HIV and Malaria, your BP and temperature are taken and then a decision is made if you should come forward for further assessment, or be given some advice and simple treatment and sent home.

This all sounds quite tidy and orderly – in fact theres usually a constant stream of people pushing about, trying to squeeze through, shouting and clamouring and not so infrequently a  small mass of people pushes in with a half collapsed woman in the middle of them, groans, or worse, silence from her lips, spots of blood, anxious shouts and panic and she gets hurried through to the “PreDelivery Ward, (PDW) maybe shes about to have a baby, maybe shes had one and lost half her blood volume afterwards, maybe shes been in labour for two days and is half dead with infection, the baby is dead and stuck inside, maybe shes been having convulsions…..