Only four months to go on my current assignment. Sometimes it feels like I have been here forever and other times like I just arrived and where has the time gone! It can be pretty exhausting and although I have wanted to post sooner, when I have down time (infrequent) and I have the choice of internet or sleep, sleep always wins.
It is about 104° here but the humidity is much less most days so it is way more bearable than it was when I first arrived. On 30 October, the South Sudanese government declared a national state of emergency. Thousands of people were displaced, including many of our local colleagues, who lost their homes, crops and livestock. To respond to the health needs, an emergency team was deployed from HQ and they joined us in our compound. This means that we have gone from about 25 expats in the compound to more than double that. There are people everywhere. What little privacy there was before is virtually non-existent and honestly, that has to be the worst part. The food is abundant and probably the best I have had on an assignment. My tukul is comfortable. Most of the time the internet works even if the majority of that time the signal is weak. Still, I really cannot complain, although it has literally taken me 3 days to try to write, edit and post this due to the painfully slow internet and now it is 4:30am and I am awake having coffee writing this because no one else is online and less demand means faster internet!
The flooding around the refugee camp is quite impressive. The UN has brought in large earth movers and they have made dikes all along the road to keep the rising water from washing out the road to the airstrip. So far they have been successful. The airstrip itself is at risk of flooding in which case we would not be able to land any aircraft. At that point they would likely start to evacuate us by helicopter, which is the emergency plan at the moment. Without the airstrip functioning, we would not get our food which is flown in twice a week. We also would not be able to evacuate for a personal medical emergency. But evacuation is a last resort and seems unlikely.
This morning we had a twin mom birth. She had 5 births prior to these 2. She labored all night and into the morning and was finally ready to push just before noon. The first baby was a girl and she came head down. The second baby was a boy and was presenting transverse. After a few tries to externally turn the second baby to no avail, (arm was persistently in the place where the head should have been) I went in after the feet instead. First I broke the bag of waters; the heart tones were dipping and we wanted to get the baby out. He was pretty resistant to my grasping his feet and kept pulling one foot back up. Eventually I got a hold of both feet and was able to bring the baby down and out just past the hips, at which point I asked the mother to continue to push. The left arm was born but the right one remained very high. I did a side to side maneuver after disimpacting first. The baby came down low enough that I could bring the other arm down, and with that the head came as well. Both babies were in excellent condition and were 2.9 & 3.0 kg respectively. Two placentas came about 30 minutes later and there was minimal bleeding. All three are now resting on the ward.
Once or twice a week we get patients flown in from other projects because we are the referral hospital. Sometimes I go to meet the flight when there is a maternity patient because someone from the unit has to go. It is actually nice to get out of the compound and see what is surrounding me because there is no way to see out. We actually live in a compound within a compound. It is easy to commute to work because I just walk out of our expat living compound and right into the hospital area. Both the hospital and the living area are housed within the UN compound. About 200 UN soldiers live next door, although we never see them, the wall is too high.
A patient that was flown in several weeks ago, came with his pregnant wife as his caregiver. This week, he was officially discharged by the surgeon. He had been shot and had his leg amputated above the knee. A lot of limb amputations are done here and most are for gunshot wounds. Keep in mind, patients usually do not get to us right after their injury, sometimes it is days or weeks. The happy ending to this particular story is that the evening before discharge, the mans wife came into maternity in labor. She birthed a beautiful, healthy baby girl. Spouses are never in the birth room when women are giving birth and this was no different. The man was still on his unit in his bed. The mother was getting washed up from the birth, so I bundled the baby up and with the moms permission, I walked to the next unit with the baby and placed her in her fathers arms. It was incredible to see the absolute joy on his face as he held his daughter. The entire ward was overjoyed actually.
Another patient flown in was a 22 week pregnant woman with severe polyhydramnios (too much amniotic fluid). This was her 7th pregnancy. The baby, on ultrasound, also had hydrocephalus and what appeared to be some pretty severe facial deformities – we could make out one very large eye socket. There would be no way to continue with the pregnancy because of the strain of the ever increasing fluid on her uterus. She was a very tall, slight woman and looked like she was carrying full-term twins. It was impossible to palpate a baby inside because her belly was so hard, nothing could be felt. She was also miserable. It was painful to be upright and walk around and it was painful to lie down and also difficult to breathe.
We don’t really have guidelines for this type of scenario so I had to be creative. Keep in mind also, there is no OB on the project. We have a general surgeon but there is no one but me managing the complicated OB cases. I have the help of the maternity staff but I am required for all the high risk and more complicated case and decision making. So my decision in this case was to drain as much fluid as I could and then induce labor. The baby was not viable at 22 weeks but it also had anomalies incompatible with life, which was explained to the mother. She agreed to our plan.
I asked the surgeon if I could use the OT to do the amniocentesis (fluid drain) because it really needs to be done under sterile conditions and the OT is the cleanest place we have. He didn’t mind at all. So early in the morning, I took the patient in and put a needled into her abdomen where there was a large pocket of fluid and drained about a litre. I had wanted to drain more but it just wasn’t coming. I had hoped for about 2 litres even though there were at least 6 litres, draining too much at one time isn’t safe, this is why we didn’t just break her water.
We started an induction with misoprostol that evening in the hopes of softening the cervix and maybe start some mild contractions. She was only 22 weeks pregnant so I wasn’t sure how easily her body would respond. Much to my surprise, after just the first dose of misoprostol, her uterus began to contract. In less than 3 hours she was in the birth room pushing. I had the staff prepare for hemorrhage, which seemed pretty likely given the circumstances. Because had birth several times before, she was a good birther. I was able to break the bag of waters and the baby’s tiny feet presented pretty soon after that. Then the body came. We could see already the baby had died and I was relieved that I would not have to watch a 22 week baby struggle to live once it was out. I have done that before and it just isn’t pleasant.
In this case I knew the head was going to be an issue because it was so large and misshapen. Once the body was out, I went in after the head which, once I got inside, was not discernible at all. There were no defined skull features, this wasn’t going to be easy. The mother was tolerating all the invasiveness, she was quite committed to get this over. I did the best I could to scoop what I felt was head and a large mass of tissue came out. I went in again to get the placenta and that too, was quite large and misshapen. When all was said and done, we were looking at nothing I had ever seen before. The head was completely malformed and much larger than a term baby’s head but as I said, it was all misshapen and there was no skull so it was all basically soft tissue. The placenta was much larger than a placenta at term as well. And it wasn’t very defined and basically looked like ground beef and not a placenta at all.
The mother did exceedingly well. She lost a minimal amount of blood, much to my relief. I looked at her afterward and said, you did a great job. Although I don’t speak her language, somehow she understood what I was trying to say and she gave me a huge smile and a thumbs up. I could see just how relieved she was to have it all over; not just the birth but the pregnancy itself.
Finding was to cope with the stress and not-so infrequent tragedies isn’t easy but I do find my way. My staff surprisingly understands my sense of humor, which can be dark and/or sarcastic at times. But each time they laugh at me, I am delighted. They also make me laugh. One midwife asked me the other day, “how long have you been wearing that skirt?” I wasn’t sure if he was asking days, hours or what. So I asked why he was asking. He said, “because it looks like it is from the 80’s!” I burst into laughter. Fashion advice in the middle of a refugee camp in South Sudan!
We have a lot of anemia so we do a lot of transfusions. It is not uncommon for a patient to walk in with a hemoglobin of 2 or 3. Families have to donate for any patient that needs blood and it is more difficult than it sounds. Sometimes you can have 5 willing donors and only 1 of them will pass the screening to donate even though you need 2 units. Often patients have to get by on just one unit.
Currently we are out of the reagent that goes with the hepatitis C test, so we can’t screen for it. It is one of the many things we screen for with the donors. So this has put donation at a screeching halt. Our bank has only a couple of units of blood left as we wait and hope the reagent is found and sent from Juba.
This is life here. Challenging, heartbreaking, stressful and unbelievably rewarding.
