Serenity in the Delivery Room

I find the familiar Serenity Prayer very applicable at this time.

God, grant me

the serenity to accept the things that cannot change,

the courage to change the things that can,

and the wisdom to know the difference.

I often find myself wondering where my expertise should outweigh their experience here. What would be good to change? What is best left as it is because through trial and error, it has proven to be the most effective? When should I insist on my knowledge and when should I rely on the years of experience of the nurses? I find this to be an extremely difficult balancing act. Again, here is an example…

Last week we had slew of bad outcomes—three uterine ruptures and 1 baby who died shortly after C-section at term for unknown reason. Indeed, I learned many lessons last week about the system, discussed areas of delay or poor communication with various departments, and in general was overwhelmed with sadness at the loss of these babies. While waiting for a patient to arrive from the maternity for what was supposed to be an urgent C-section, the scrub nurse had asked almost incredulously why I was so worried. “If the baby dies, you didn’t kill it. God decides who lives and who dies.” And while that is very true, the delay of a C-section can in fact cause the loss of a baby who might have been saved a half an hour earlier. On rounds in the C-section postpartum room, only 2 of the 6 mamas there had babies in their arms. At least there were still 6 mamas there.

My surgery shoes, for some reason went unwashed this week, but were reminders to me of the bleeding from the uterine rupture as well as blue from the blue dye test where we found a vesico-vaginal fistula after prolonged labor elsewhere.

After such unfortunate results, the knee-jerk reaction in the maternity ward was to prepare and ask for a C-section as soon as anything abnormal was detected. A pregnant mom came in with the fetal heart rate very high. I was told by the students and residents that there was fetal distress and therefore a need for C-section right away. Everything from my training was telling me that tachycardia (high heart rate) in the presence of contractions is not usually a sign of distress but commonly from maternal fever. Everything from the past week was screaming at me to just go along with their thought process and get that baby out before it died.

I decided to go with my training this time, a bit reluctantly. She did, in fact, have a fever. But the fever had been present for several days. Perhaps the baby was septic (infected) and suffering. But no, when I scratched the baby’s head, it moved a lot and the heart rate increased. That was reassuring. But what might malaria do to a baby? But no, there were no drops in heart rate during or after contractions to indicate distress. We gave Tylenol and started antibiotics, and waited… and the heart rate was still high. “We need to perform a C-section, I think,” the resident said again. And one of the nurses agreed. My gut just didn’t agree. “Wait. Please just wait. I think the heart rate should normalize with a bit more time,” I replied, not knowing if that time would be detrimental to the baby.

I called another experienced staff doctor over to see if he had any further insight. At first, he advised to go ahead with the C-section to avoid having another dead baby. Just at that moment, the nurse listened to the fetal heart rate and it had finally dropped to the upper limit of normal. Upon hearing this, the staff doctor agreed with me that we could continue to wait. Just before I left the maternity ward for the night, the lab result came back positive for a high level of malaria parasite in the blood. We started treatment for malaria right away, and then made both the lower level resident as well as the supervising staff doctor aware of the situation. They both seemed a bit skeptical but agreed to just continue to wait for labor and watch the fetal heart rate closely.

Some of the sutures we have available to use during surgery

I walked into the maternity ward in the morning, certain I’d find her in the post C-section room, hopefully with a baby, but maybe not. The nurses came out to greet me with a good morning, and I asked about the lady. To my surprise, they pointed in the opposite direction, to where ladies go after a normal vaginal delivery. I may just have let out a little whoop of joy. The nurses seemed a bit surprised but definitely joined in the celebration outside the maternity building. I think they are used to doctors who like to operate, so finding my joy so abundant at a normal vaginal delivery perhaps was weird. It was just the encouragement I needed. I’ve made plenty of judgment calls, some good and some less than stellar. Hindsight is always 20/20, and this is especially true in OB. Sometimes we all just need a good vaginal delivery to make it through the day…. Said no one but me probably. :) 

Later in the week, I saw evidence for change in the vitesse (quickness) of urgently-needed cesarean sections. Because of a few conversations I’d had last week with the OR staff and maternity, we sped up the process by eliminating a few of the steps (like going to the lab and finding a blood donor and paying up front and finding an IV bag and finding a catheter and shaving the patient, etc…), and significantly reduced the time between decision to incision. We were able to perform two cesarean sections back-to-back and both babies who had previously had heart rates in the 90s (normal is 120-160) were born alive! The OR staff was pumped that the surgeries were done so quickly, and one of the medical students exclaimed, "Wow, that was great! That was so fast! You saved those babies!" I immediately thought of the conversation with the scrub tech earlier in the week and pointed out, "If I take credit for saving these babies, I need to take responsibility for the death of the others. God is the one who decides, God is the one who heals. I'm just working to do my best."

I may not understand all the time, but I trust that God is good. 

The problem: 

Your wisdom and knowledge, they have deluded you; For you have said in your heart, 'I am, and there is no one besides me' - Isaiah 47:10b

A  good reminder:

"Where were you when I laid the foundation of the earth? Tell Me, if you have understanding."- God to Job in Job 38:4

The solution:

If you seek [wisdom] as silver and search for her as for hidden treasures; then you will discern the fear of the Lord and discover the knowledge of God. For the Lord gives wisdom; from His mouth come knowledge and understanding. - Proverbs 2:4-6

For it is God who works in you to will and to will and to act in order to fulfill his good purpose. - Philippians 2:13

To end, I'll end with an adaptation of St. Augustine's quote. It is one of my favorites. 

Work as though everything depends on you.

Pray as though everything depends on God

Because it does!

A Goat and a Bag of Peanuts

“I only have a goat and a bag of peanuts. Can you save my wife?” When I say that almost everything is different here as it regards to medical care, I mean, really almost everything: the language, the terminology and classifications used, the medications and treatments available, the depth of poverty, the lack of a safety net for the poor, etc. As someone who was supposed to come in as an “expert,” I am so thankful that I am being given the opportunity these first weeks/month(s) to do more observation and learning of the system, rather than being primarily responsible or acting alone. Stories are better than abstract principles, so read on…

One of the differences- this is a main road leading to the hospital. Some patients are carried as in this photo (a woman in labor who is sitting on a wooden chair which is tied up to a pole that is carried by two men on their shoulders), others come by motorcycle or pedal bike, and most walk.

I met her in the ultrasound clinic room. She had been sent from the local health zone prenatal clinic, which is run by nurses, to get an ultrasound because her uterus was not growing in size as expected and she reported no fetal movement for 3 days. During the ultrasound, I confirmed the dreaded news—that her baby had died in her womb at almost 7 months. But something else was not quite right. Despite the abnormalities that can be seen on ultrasound with a fetus which has not had a heartbeat for an unknown amount of time, something about this was just unclear. Something was blocking the cervical canal. The quality of ultrasound is a bit different than in the US, but I could see that the placenta was in the front and low in the pelvis. The placenta was potentially blocking the cervix, which is bad news for someone who has had more than one previous C-section. The risk that the placenta has invaded the muscle of the uterus within the previous incision site is >60%, which can mean a hysterectomy would be necessary.

I normally avoid doing a cesarean section in cases where the fetus has died in the womb, but I found there was no choice in this case. I mentally prepared myself for a cesarean section with hysterectomy, just in case. Upon hearing the news, the patient was understandably distraught, but even more so after I told her she needed an operation. Both she and her husband were in tears. Both looked chronically malnourished, with very short stature and thin frames. The husband looked at me, and understanding the seriousness of the situation, said very sincerely, “I have only a goat and a bag of peanuts. Can you save my wife?”

Because this was an urgent (and not by choice) operation, we were able to proceed despite their inability to pay in full prior to the operation ($80-120 is a typical surgical fee). As with most surgeries, though, the family is required to find someone to donate blood, hopefully with a matching blood type. Sometimes the medical students and residents volunteer to donate money or blood to their patients. It is not uncommon to have a post-operative patient make the decision between an antibiotic and pain medication! Just as heart-wrenching as it is to see this, it is equally hard to see starving mamas selling—not eating—the little food that they have grown during this dry season so that they can pay for things like school fees.

After praying briefly for the operation and the health of this mama, we opened her abdomen. It was a mess. As with the ultrasound, nothing was clear, except thankfully, that the bladder was not involved (as can sometimes be the case when the placenta comes through a prior incision). The incision into the “uterus” was our first clue as to what the situation actually was. The “uterus” broke open just like one might expect the bag of waters to break… because it was the bag of waters (amniotic sac)!  The placenta in the front had masked the fact that there was no uterine muscle surrounding the amniotic sac. In actuality, what was “blocking the cervix” was in fact the uterus itself, empty. It is a very rare form of ectopic (outside the uterus) pregnancy called an abdominal pregnancy. Usually it is caused by a fertilized egg that implants in the tubes, which after it grows big enough, breaks open the tube and then re-implants somewhere if it finds a good blood supply. In this case, the placenta had attached to the intestines, the fat in the stomach, and the tubes and outside of the uterus itself. The baby had died simply because its need for blood outmatched the ability of the intestines to provide that blood to the placenta. Because of its numerous attachments, we were forced to leave much of the placenta in place to resorb on its own.

A few days after the surgery, the husband found me walking outside the maternity building and asked where our house was—he wanted to bring us some bananas from his village in gratitude. Indeed, this could have been deadly for his wife, but thanks to the team effort of the nurses at the health zone level, the small level of outside donations provided to the hospital for these situations, and the willingness of doctors here in Congo to work in a rural setting, she was able to get timely healthcare. And, I’m happy to report that here the 10 year contraceptive implant that will continue to protect her life (while the placenta is still in place, it would be very dangerous to get pregnant again) is only $5 instead of over $200 like in the US, and I think that a bag of peanuts sells for more than $5. Hopefully their family can keep the goat.  

Second week... and how to (and how not to) party in Vanga

We had the privilege of having a great cultural and language interpreter this week- Katherine Niles. She is the daughter of late Dr. Dan Fountain who is credited with decentralizing healthcare for this area, starting a nursing school to staff the outside clinics, and has written several book about it. Katherine grew up in Vanga and speaks the local language. For her, it is like a vacation to come from the city of Kinshasa and be able to swim in the river every afternoon and stay in the house she grew up in.

I, Shannon, started work at the hospital this week, malimbe-malimbe, or slowly slowly as they say in Kituba. Katherine said it is better to start slow and observe a lot because hospital work is endless and can swallow a person before he or she knows what to prioritize or the global picture. More on that later.

Household progress

Working at the house (she had just woken from a nap, that's why she has quite the expression :)

Our other large task was organizing our household. We moved into our house over the weekend, but without electricity save the 3 hours given by hospital generator from 6-9pm, and also without any appliances like stove or fridge. We spent time organizing and orienting househelp, although at times it really felt like the other way around. J We have chosen, for now, to ask several people to work for us that have worked for years and years for other missionary families, including families who lived in our house. So many times, I just asked them how it worked, what they would like to do, or what foods I needed to buy in Kinshasa vs at the local market. I think it might take me a long time to learn what they know so well. But that is the best thing about hiring well-known and trustworthy people.

Ryan spent a considerable amount of time coordinating temporary workers. We had carpenters come and replace a ceiling tile that was rotted, painters come to paint a very dark pantry a welcoming bright white (as well as the replaced ceiling tile), a tailor come to recover a chair that is over 100 years old, etc. Ryan also removed old electrical lighting fixtures and put up new ones, installed some child safety locks, and went with the maintenance man to see his workshop and discuss needs at the hospital and at home.

Yesterday, Saturday, was a huge day because Katherine’s husband and son came overland with our oven, washing machine, solar panels, batteries, and cables in their truck. They got 4 large panels installed on our roof by lunchtime. It really was cool to see! And we have had electricity for longer than 3 hours in our house today (Sunday) for the first time!

Solar panels going up!

Medical Work

Monday morning, Dr. Rice and I were introduced to the nursing staff at their morning circle. Then, we were given an extensive hospital tour (which Ryan joined us for part of) for more introductions and also a better knowledge of patient flow, where to go for X-ray, ultrasound, labs, etc, and where the pseudo-isolation rooms are located, etc. Ryan commented that he was surprised by the immensity of the hospital. It really is quite remarkable to have a 500 bed hospital in a village like this. I met with nurses in the maternity, a couple of doctors who are on the OB/GYN rotation this month, and also with Dr. Rice to sort out a temporary schedule. On Thursday, I attended “grand rounds”with the residents and staff doctors, observed the prenatal clinic at the local health zone offices in the morning, performed and taught ultrasound in the afternoon while consulting on some of the difficult OB cases.

A little more should be said about the prenatal clinic. They are held every Thursday all over the health zone at each center. Some are held under trees, but here there is a nice large open room with plastic chairs for each patient to sit in. Two exam rooms are at one end. The room was packed this week just as it had been in 2012 during my visit. The ladies were split into new patients and old patients. The new patients gathered around for a basic talk on prenatal nutrition, and it was great to see the interaction between the wise and experienced nurse and the patients asking questions. “What do we call someone who doesn’t have squash seeds or greens or peanuts to eat?”They responded, “Lazy!” (because they grow in the soil here) And the nurse then said, “But if you don’t have fish or meat, it’s not your fault.”And they all nodded in agreement.

After the general education, each patient is registered and pays a one-time fee. They are given an HIV test, iron tablets, and three times a pregnancy a medication for the prevention of malaria. Their blood pressure, height and weight, fundal height, fetal heartbeat, and expected due date are all recorded on a sheet of paper which the patient is charged with keeping throughout the pregnancy. In my opinion, it is a system that works very well here, even though there are a couple of things I think could be improved with very little effort.

I haven’t started doing surgeries yet, but I will plan to start the observation process this week. A new group of medical students and other temporary doctors start their work this week, so it should be a good transition point for us all.

And now, how to party (and not to party) in Vanga

Sydney is sleeping wonderfully since we received a pack n play which we will borrow until a more permanent solution can be found. We are so thankful for this. We were excited to move up to our house this past weekend, despite the paucity of electricity. The village seems quiet, and after the hospital generator turns off at 9pm, the lights are out as well except for those with battery and solar power back-up. It is a great environment to sleep in… we thought, until Tuesday. The first warning was the eerie sound of a microphone feeding back. Then there was a sound of some piano synthesizer that was turned up way too loud for the system, causing the sound to be very muffled/unclear. A few notes were played, repetitiously, and I thought, “do they realize that it is 10:15pm?? I hope Sydney doesn’t wake up because it sounds like it is right outside her window!” In France, we were used to quiet hours starting at 10pm, and it really was quiet. Here in Vanga, our annoyances had been just the rooster, and occasional loud conversations or a goat stuck in a fence bleating. Surely this synthesizer will stop.

But at 10:30pm, the horrible sound had not gotten quieter nor any different. It really was just the same few notes played over and over and over and over and over and over and over... and we asked a night guard what was going on. He had no idea, but said there were quite a few people and he didn’t feel comfortable asking them to stop. Ryan decided to just stay up rather than be frustrated by trying to go to sleep with that racket. But alas, when I awoke at 5:15am, it was STILL just as loud and still going on. I wouldn’t even call it music, just noise! Ryan had given up around midnight. The sound didn’t stop until just before 6am in the morning! Not a cool thing in a “quiet”village!

Thursday night, there was a bit of a racket again, but this time it was quieter and much more musical in nature. We didn’t really mind it so much. And anyway, we knew that there was a big graduation for the nursing school Friday morning, and that nursing school along with its student dorms are just across the path from our front gate. Friday morning before the graduation ceremony, we heard the sound of drums—not African drums, but big band bass drums along with flutes. The sound came from the soccer field close to our house. As it got closer, I went outside to see a parade of children surrounding 5 flute players and 3 drummers as they played walking down the road. They paraded onto the grounds of the nursing school, where I lost sight of them.

I continued to hear the flutes and drums just until the time of the graduation ceremony, so I’m thinking that they picked up the students along the route and paraded them to the church where the ceremony took place. I was outside the packed church (and I mean packed, with kids sitting in the windows and crowds outside the doors and windows!) when the ceremony ended. People were dancing (especially moms of grads), the drums and flutes started again, and then the flouring began. This we had already seen a bit in Kinshasa. When someone receives a diploma or a passing score on a big exam, the student as well as his or her family gets showered with a white powder, which usually flour. It shows up brightly in their dark hair. The application of the flour reminds me of coaches who get iced after a big win. There is a chase, but really the person is quite happy to have deserved the shower.

Friday afternoon, there were receptions throughout the village with dancing and food for friends and family of the graduates. It looked like a grand time! And Friday night, not a peep of loud sounds was heard throughout the village. They had probably eaten so well and danced so hard that they were plumb worn out the night of their graduation. Now that’s a way to party!