Kampala, Uganda - Maternal & Child Health
MS4 Senior Elective 2019
I finally caught one!
Let me preface this section by explaining the experience of becoming a doctor—at least, as I am experiencing it. Initially, it's a fairly ignorant decision at best, but not intentionally so. You go in knowing you enjoy human science, logic, don't mind studying very much, and above all you have this genuinely strong desire to help people. And while you've prepped your mind to handle the long hours and infinite volume of information, you don't really know what you're really getting yourself into. It isn't until the truth of the journey to your medical doctorate slowly reveals itself in pieces along the way.
What you don't fully comprehend at your initial "yes" to medicine is the absolute business of health care. It's bureaucracy that will try to limit your valiant efforts to do what is best for your patient—a battle you will have to fight over and over again knowing that there is no change to this broken system in the near future. The sheer number of exams will try your patience and measure your will power. They will attempt to beat you down, and you start to question your sanity as you turn to face the oncoming exam and say "yes, may I please pay for another?" This is compounded with the exhausting number of times you'll have to say "no" or "I can't" to joining friends and family in their celebrations, although that's really where your heart is—it's not usually in the pages of the textbook that is desperately trying to grasp your attention. There is a real strain medicine puts on relationships. This includes the relationship you have with yourself as you will often find yourself needing to put personal goals, milestones and passions on a long pause. This is done all in the name of medicine, and you grin and bear it all because you know you need to finish this very long (and expensive) dream that you have been consistently fighting for. And so, at the end of the day, when you may find yourself deflated and frustrated, you really hope that it will all be worth the sacrifice in the end. For me, it's the moments like the one I am about to describe that reassure me that this naïve decision I made years ago was the right decision for me.
When we first arrived in Kampala, we spent most of our time doing 1-day stints in different departments. By the third week, I made it my mission to stick to the labor and delivery floor. I came in with a goal of learning how to deliver a baby on my own and I had no intention of forsaking it.
The mother I was to deliver was a 19-year-old prime gravid patient I had watched all morning as she handled the intensifying phases of labor. At times she would pace, bent at the hips, back and forth beside the bed, like a pained cat, tethered by her IV line. When the contractions grew stronger, she moved to the floor beside her bed and began hitting her thighs, trying to distract from the pain. Her voice changed from a sort of rhythmic chant in her native Lugandan to now screams that she tried to stifle. You see, she and all the others who come here to give birth have no anesthesia, save for those who go for surgery. The only pain medication they have is the mental strength they can muster. She became more and more restless as she now placed herself on the bed. She rocked back and forth on hands and knees as sweat dripped from a face that turned with each contraction. Finally, it was time. The midwives called me in to get my gloves and supplies ready. With careful hands and a pounding heart, I delivered her first baby boy! I placed him on her chest, vigorously rubbed his back, and he let out his little cry.
There was no feeling like it. Head first, this baby boy slipped into the world and I was there! As I placed him on his mom's chest and vigorously rubbed his back to encourage a strong cry, I recognized this intense feeling that this was what I was meant to do. Believe me, I know how corny this sounds, but it is my complete truth. As he cried, I couldn't stop myself from wishing him a happy birthday even though I knew he had no idea what I was saying. I tied and cut the cord and off he went with Joy to get his weight and to be swaddled. I looked down at his mother, who was so much calmer now and congratulated her. She had gone through one of the most natural and most painful experiences, and to look at her now, so quiet and reposed, without the context clues, you would never know it. She thanked me and I thanked her. It was beautiful, and cliché, and I would not trade it for the world.
Kawempe is a government owned hospital which is underfunded and under resourced. You enter and walk up a series of long and broad concrete ramps that connect at right angles, encircling the double elevators that run the middle. Walking up the ramps, one has to take care not to disturb the many people that lined the walkway floor, avoid the occasional bed headed down to theatre (what they call the operating room), and carefully maneuver around the very pregnant women making their journeys up to the different departments (Yes, here, very pregnant and very mobile. They move themselves on the labor bed and, at times, they walk themselves down to the operating room. I'll never forget the woman who was headed for an emergency cesarean who so politely asked me to help her with her shoes so she could walk down to theatre—I was shocked at the soft voice that came from a face that read contraction. But, I digress…). Oh, and depending on the time of day, you had to be sure not to be swept up by the brown river that the staff pushed from floor to floor to clean the hospital. There are plenty of windows to let in natural light and occasional breeze. Unfortunately, they also welcome the heat and insects.
The way Kawempe works is this: it's a free hospital. How so? It provides the doctor and the patient provides just about everything else. Women coming here are expected to come with these items in hand:
- Basin: for vomiting and bedpan needs
- Roll of raw cotton: to help absorb any fluids, clean the patient—essentially used in place of gauze
- 2 bed sheets: for the patient to use
- Plastic tarp: to protect the bed beneath them
- Sterile gloves: at least five pairs to be used for vaginal exams and delivery
- Baby blankets: something to wrap the newborns in
- Large wrap: for them to wrap themselves in
- An attendant: someone who will wait in another room throughout her hospital stay and be available to get supplies as needed
- A small bottle of bleach: to help sanitize the bed, floor, or the operating room after she delivers
The hospital provides pitocin, IVs, lidocaine, and IV fluid.
If a woman sustains a tear that needs repair, she needs to have her attendant purchase sutures. The hospital provides lidocaine, a local anesthetic. If she requires a cesarean, the attendant must purchase:
- 6 sutures
- Tramadol: anesthetic for surgery
- Sterile gloves
- Bleach bottle
- Bed sheets, plastic tarp, baby blankets
Where might a woman delivering in the middle of the night find these supplies? Next door to the hospital is a convenient little pharmacy that carries all these supplies.
I spent most of my time in labor and delivery on the fourth floor, 16 turns up from the bottom floor, which was a great daily workout. The labor ward was largely run by the midwives. There were medical students, residents and full-fledged physicians present, but the show was largely run by the midwives. Many had years and years of experienced and knew how to help deliver births that we would easily do a cesarean for: single breech delivery (when the baby is coming out foot, feet, or bottom first), twin breech delivery and just about anything in between. The midwives ran the floor! They taught first time moms-to-be how to push and knew when it was time for a woman to reposition, to push harder and when it was time to send her down to the theatre. They felt bellies with their hands to determine how the baby was lying in the abdomen and listened intently with fetoscopes--a very valuable tool as there was only one doppler available which was rarely found. These were the women who taught me how to deliver a baby.
The ward was one large room, which is very open, with only large walls that act as partitions between the different section. There were 4 sections, each with about 8-10 beds placed in two rows. As much as I would have thought it would be a shared experience between one woman and her neighbor, it very much was not. They rarely spoke to each other and I certainly did not see them comfort one another through the contractions. I think every woman there understood that this was a solo journey and, scared or not, only she would go through it.
Memorable moments on labor and delivery:
- Catching my first baby, all by myself, and handing him to one of my closest friends!
- Doing a vaginal exam and feeling a foot. That mother delivered a breech baby, and both she and baby did just fine!
- Finally learning how to properly stimulate and swaddle a baby—making a baby burrito as I call it.
- Placing and starting IVs successfully.
Alright, the Fun Stuff
While here, I did get to do a good amount of adventuring:
- Entebbe: I visited the botanical gardens where I learned about the local horticulture and their various uses, got to see Lake Victoria up close, and fed monkeys.
- Jinja: seeing the source of the Nile and the Equator
- Safari: We haggled out a deal to go on a two-day, one-night safari. We were able to spot hippos, elephants, water buffalos, crocodiles and innumerous types of birds.
What I Learned
For years I have been saying that I want to work in international medicine. However, I had no real idea of what that would look like for me. This experience was a first-hand look into how medicine is actually practiced outside of the states. Admittedly, I came in with a biased view of my medical education which was immediately confronted and corrected. It is not that low resourced areas are lacking in education—as I mentioned, midwives here are successfully delivering babies in scenarios that we would do cesarean sections for. Additionally, the medical students here are well equipped to do solo deliveries, fix repairs and be first assist in the operating room by the time they graduate. The knowledge is definitely here. I learned that clinical knowledge was not in short supply, however their tools were.
For instance, repairs of vaginal tears are often hand sown, without a needle drivers or pick-ups. The risk of having a needle stick it great and worse is that the status of a mother may not be known. I watched as a midwife in training stuck herself on a vaginal repair and asked me to pour bleach over her wound as she milked the blood from her finger. She was terrified that she might have caught something, and I can't say I blame her fear. The number of times we had to go looking for a fetoscope or a blood pressure cuff was frustrating. How can you properly care for any mother, let alone a mother with gestational hypertension, without a blood pressure cuff? Or a stethoscope? I was told that the government provides little supplies and that those supplies that are donated are often stolen by those who also have a private practice. Still knowing this, Joy and I bought a couple of fetoscopes and blood pressure cuffs before we left just to try to give back to the hospital that taught us so much.
After my time in Kampala, I have become very interested in connecting basic resources to where they are needed. To go into a setting, breakdown the disconnect and help to establish or re-establish the connection is where I think I belong, but only the future knows what will become of my international career. For now, I am very contented to have had this experience delivering babies and solidifying my decision to pursue ob/gyn.
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