Sunday, January 30, 2011

STDs and Exhaustion!

This week I have done 84 prenatals. That makes for one exhausted midwife! Of those 84, half were new patients. Where are all these women coming from? Don’t get me wrong, I love it, but I’m not sure I can keep this up much longer. I try to give them my best but by the end of a long day, my brain twitches.

Plus, a large portion of these women have raging STDs. It’s great they are getting treatment, but come on! Why are so many of them infected? I asked my translator what he thought and he just shrugged. So, I pushed him a bit.

-- “When these young women marry older men, are they faithful?” I asked.
-- “Some go to any man that comes,” he explained, “but not all.”
-- “So is it the men? Are they unfaithful?” I asked, already knowing the answer.
-- “Yes. The men have sex with many many.” he explained.
I continued to pester. “But if they have ten wives, are they still sleeping with prostitutes as well?”
He just nodded uncomfortably.
-- “But why?” I badgered. I wanted him to say it out loud.
-- “Because they can,” he admitted, “that is the way of things here.”

Frustrated by constantly cleaning up after these unfaithful men, I have to admit that my translator is right. Socially here, it is understood that every man will stray. Monogamy is laughable to them. So what if they pick up a disease and cause their wife infertility and pain. That’s not their problem. If she cannot produce a child, he’ll just leave her in squalor and marry some new young thing.

One of those new young things was on my prenatal bed this week. She was two months pregnant and suffering from a long history of venereal symptoms. She was wife number five. Her last pregnancy ended in a miscarriage at 3 months which was most likely due to this infection.

Investigating further, she explained that three of the other wives were infertile. Even after years of marriage, they have never carried a child to term. So, I explained to her the role STDs play in infertility and miscarriage. Surprised but happy to learn this lesson early, she promised to take her medicines carefully and encourage the others to come for treatment as well.

This man, no doubt desperate for children, married five times. Did he know he was the problem? Probably not. Will he come for treatment? I don’t know. Will he allow his other wives to come? I hope so. I hope he gets a clue before it’s too late.


You probably didn’t think this post would entail me ranting and raving on the rate of STDs among the Sudanese. Ha! But there you have it. That is what you get from this exhausted midwife. Rants!

Pray for me to find socially acceptable ways to teach these families about STD prevention. I think some of the women will listen, but what about the men? There seems to be some kind of stigma; some men equate STDs with AIDS. They are ignorant that a few drugs can mean the difference between healthy children and pain free sex!

The good thing about all of this is... my translator gets it. I can safely say at least one Dinka man has learned this lesson well. Now for the rest of them!

Saturday, January 29, 2011

Hands off!

I’ve been thinking a lot about birth and midwifery ideals lately. (Some of it was sparked after the hands on breech birth I had this last week but it’s been a long time coming actually.) Too often, I resort to med-wifing to hurry my labors along. Too often, I strip membranes and augment labors with oxytocin. The women here seem fine with it all because it get results. I’ve been fine with it too because I’m often tired and (Yikes! Can I admit it?) impatient. However, each time I mettle, a little piece of my midwifery innocence dies.

I want gentle, unhurried births. I want tender moments and relaxed atmospheres. I want to offer these women a joyful experience... as much as is realistically possible; I want be hands-off.

So, out of protest (of what? of my wrong thinking and silliness!) I’ve decided to practice ‘intentional inaction’ with all my future births. The joy of this resolve has been overwhelming.

Let me explain.

The other day, when Anyang waddled in with contractions every 3 minutes, I knew she was close. I forbid myself from doing an ‘admission’ vaginal exam. Instead, I reassured her that she and her baby were doing famously and that the birth would be soon. Would she be interested in walking around a bit?

She was and immediately marched off. I joined her in her journey not wanting her to be alone. I was there just as an observer. She chose to circle the clinic grounds, stopping every few meters to kneel for a contraction. I kept pace with her, though at times it was difficult; she walked so fast!

On the last leg of her trek, while kneeling in the dirt she began to grunt and push. I asked her if it was time and she nodded. Together we hurried back to the birth-room. She crawled on the bed, even though I assured her she could deliver in any position she wanted. After pushing once of twice on her back, she decided that wasn’t what she wanted after all.

Moving to the kneeling position on the floor, her friend behind her and me in front, she pushed determinedly. Her baby was happy and so was I. Practicing my ‘Hands-off’ approach, I didn’t even tell her when or how to push and strictly forbid anyone else the room to do so as well.

Minutes later a tight ball of beautifulness was birthed! Everything about it was simple and intimate. There was no yelling, no chaos, no hurrying here and there. It was just like I hoped for her. Afterward, she smiled so sweetly while holding her baby to her breast. I loved it. 

Her birth was the most fun I’ve had midwifing in ages!

Don’t get me wrong, there is a place for vaginal exams and labor induction. There is a place for fundal pressure and vacuum extraction. There is also a place for cesareans. My point is that just because they have their place in some births, they don’t need to be a standard in every birth.

Does that make me a radical? To some perhaps, but I doubt it means that to everyone. I feel a bit more mature as a midwife today-- sort of like, I got my training wheels off. I feel free-- Free to trust women’s bodies in this miracle called birth.

I’m sure I haven’t mastered this lesson yet but I hope to one day make it my own. Pray for me to be wise enough to know when NOT to act and mature enough to BEND when necessary. May my determination be for each woman’s best-- not what her family wants or how it might effect me.  Thanks!

Determined to help her live~

Two days ago, a young girl (perhaps 6 years old) was admitted with a history of seizures, aspiration and fevers due to a case of severe malaria. Dr. Tom, tired of watching these little ones die, treated her with all the meds at his disposal, but nothing seemed to stop her seizures. She continued to have them hourly despite regular doses of diazepam and Phenobarbital. It didn’t look good. You could see the worry etched across his face.

Each time a child dies in his care, it tears him to pieces. This time he was ready to give up sleep and comfort to make sure it didn’t happen again. He stayed up with her and her father all night, dosing her with medications and clearing the secretions from her mouth each time she seized. Apparently, that meant sleeping on her bed and waking every 45 minutes or so.

By 3 am, he started to see results; her seizures calmed a bit and her breathing improved. The next morning, he and her father were knackered but she was alive. Hallelujah! She continued to improve the following day but it was only this morning that she looked somewhat normal. She’s able to keep food down now and her malarial symptoms are greatly improved. Most importantly, her seizures are gone. Tom tells me she’ll be discharged this afternoon.

There is no doubt in my mind that this little girl is alive today because of his sleeplessness and concern. Thank God with me for this precious life saved. Thank God with me that me have people working here that care so much!

Breech Births Rock!

She came in saying her water broke about an hour before, releasing copious, thick, green meconium stained fluid. It was hard not to miss since it stained everything she wore. Not good.

She also explained her contractions had been going strong, but once her membranes ruptured, they petered out. As I palpated her belly, things were out of place. Instead of finding a hard globular ball wedged deep in her pelvis, I found tiny fetal movements. Heart tones confirmed it as well; her baby was breech.

(A few months before, her baby had been a solid breech but we thought we had turned him with special exercises. Her last visit, I was confident he was cephalic (or head down), but either I was really wrong or this little guy was quite the gymnast!)

The vaginal exam confirmed my suspicions. For a moment, I thought it could be a hand, but once I found the scrotum all doubt disappeared. Not only was he a breech -- he was a footling breech! Yikes. Tickling his toes, my mind wandered back to a teacher I had in school. She loved to tell the story of her ‘nightmare breech’ which also happened to be a footling.

The way she told it --arms flapping with high-pitched tones for dramatic emphasis-- would have made the most daring of students take pause. She described a long labor, two little feet, a trapped head, a freaked midwife and one floppy baby. His resuscitation was challenging, but he lived. She vowed never to do it again and transferred any potential breeches quickly (which was required by law where we worked.... but still.)

Pulling my thoughts back to my patient, I finished her vaginal exam. She was six centimeters dilated which meant there was enough time for her to get to Wau for a cesarean if she was willing. I explained that there were risks involved with breech births (prolapsed cord, low apgars, etc.) and told her it might be safer for her to go to the hospital... just in case. She refused.

She would have unlikely gotten a cesarean for a breech in Wau, now that I think of it. It was silly of me to even suggest it, but I couldn’t help it. Years of training, dozens of so-called research articles, and all those horror stories of breeches gone bad, weighed heavy on my heart.

The real question was: Did I believe breech births were safe? I was sad to admit that I didn’t-- Shocked even. Why else would I suggest an unnecessary (and risky) surgery? What was I thinking? I hate those moments when I am forced to admit my biases and prejudices. This was definitely one of them.

Setting up for the birth was the easy part. I notified Dr. Tom and asked him to be my resuscitation  man if they baby needed it. I also informed Dennis and asked if he’d assist me by doing the suprapubic pressure for the delivery of the head. They were happy to lend a hand. It felt good knowing I wouldn’t have to do this birth alone.

Her contractions were no longer effective, so I augmented with oxytocin. Her baby had a short episode of fetal distress before induction, so we took it slow. He handled the contractions well and she progressed to fully in no time.

Once fully, she labored her baby down in the kneeling position, but when it came time to push she wanted to be on the bed. I figured it couldn’t hurt, so long as she was on the edge. Plus, that way Dennis could do suprapubic pressure easily. Both Tom and Dennis were called as the foot emerged, bringing with them noise and tension. I tried to settle the room down a bit, but failed. So, I ignored them and focused on her pushing. She was doing great!

Watching his little foot push its way into the world shook me a bit. All that I’m accustom to --hairy heads, fontanels and sutures-- was missing. Instead, I was assaulted with toes, testes and bluish buttocks. It was a trip!

One arm slipped out easily but the other got trapped behind his head. I had to reach in and pull it free, then his whole body fell out effortlessly. Tom kept trying to help me maneuver him, but his helpfulness was unsettling. He pushed one way while I pushed the other. (Note to self: Never let two ‘midwives’ grab a breech! What a gong show!)

Fortunately, it didn’t last long, and his head was born. Tom stepped in to do suctioning while Dennis and I held him tight. He was cyanotic and limp (with a 1 min apgar of 5) but perked up quickly. Not long after, he was breastfeeding like a champ!

All in all, it was a memorable birth that taught me many lessons.

As I think back on this birth, I’m confronted with my fears and biases. I thought I was pro-breech until I heard myself recommending a c-section. I would have argued the statistics in favor of breech vehemently, thinking I was a true advocate, but this week, I learned I was just a big faker. I don’t know about you, but it sucks when I realize I’m a hypocrite.

Mulling over my hypocrisy this week, I revisited the research papers and looked back over my textbooks, and yes, I even talked back to my teacher (in my mind). I can now say, without any doubt, that I trust birth -- even the footling breech. I trust it not because this particular birth went well, or because of some midwifery honor code of which I feel obliged to uphold. I trust it because... well... because I trust life.

I trust life in its many infinite forms. I trust the miracle-ness of it all (and yes, I just made that word up!), but think about it, babies have been ‘backing out’ since the dawn of creation. They will do that from time to time. It is our job as midwives (or as women, or doctors, or random people reading this blog) to be prepared and trust.

Lesson for the day: Breech births rock!

Thank you all for cheering me on through these adventures. It helps me get through these tests with a touch of grace. And thank you even more for your precious prayers, I know I’m able to do what I do, in large part, because of you!

Thursday, January 27, 2011

Five in three!

This week I got to deliver five babies in three days! They were all special in one way or another.

The first one didn’t even know she was in labor when she came in. Her husband brought her in because she had unrelenting belly pain but she insisted it was NOT labor. I didn’t argue with her, I just got out my doppler and watched. The thing was, her baby was in distress with heart tones in the 70s each contraction. 

The woman insisted on going home to deliver, but I cautioned her husband that it was not safe. There was likely a cord problem and the baby might not do well at home. He made the executive decision to stay, and we set up for the birth. She was fully and despite crazy-low heart tones each push, she was a rock star and delivered quickly.

Her little girl was born with a tight double cord coil around her neck and body. Plus, the cord was so short, it was tearing away from the insertion area on the placenta. I showed them the tear/weak insertion and they all smiled in relief. Catastrophe averted. I am so glad she stayed.

The next morning, I woke to another labor who had been waiting for first light. This was her fourth time down this path of pain, and she knew it was close. She told me she wanted to deliver in the kneeling position, so I set up the room with the underpad on the floor. (I love it when they deliver like this! It makes me actually feel like a midwife.)

She pushed like a pro but progress was slow. Between contractions, she rocked back on her heels and groaned rhythmically. I didn’t want to touch her, lest I break her concentration. It was magic. One huge splash, two grunts and a squawk later and a five pound seven ounced miracle slip into home! I definitely needed a mitt!
Mom #2 breastfeeding her little girl!
But the placenta wasn’t even cold when another lady came in saying it was time for her too! Fortunately, she wasn’t fully yet and chose to do a duck-waddle around the clinic while we cleaned up.

An hour (exactly) after arriving, she delivered a testosterone coated chunkster into my happy hands. He was born on his due date, meaning exactly at 40 weeks GA. I say that tongue in cheek because due dates are more of an art than a science in these parts! I must confess, I’ve gotten pretty good at guessing gestational age by fundal heights and palpation, but sometimes I’m WAY off. Ha!
Mom #3 and her boy!
The fourth baby arrived the next morning. Her mother is one of my favorite prenatal girls-- a true force to be reckoned with! When she arrived, she was going on and on about how she was dying. Her friends just laughed at her saying she was a big faker. She played it up though and in a few minutes had us all in stitches -- even my translator.

It was funny only because this culture is so quiet in labor. And when I say quiet, I mean SILENT.
I breathe louder than they do in transition! So when a woman starts complaining in labor... sometimes they are teased.

Anyway, her friends stopped laughing when I told them she was ready to deliver any minute. They seemed surprised and excited. I asked her to stand for a contraction or two to help the baby settle lower in her pelvis. She was happy to comply but instantly needed to push.

Baring down once, the head was almost born in mid squat. This freaked her out and she crawled awkwardly back on the bed. It surprised me too. I barely had time to glove up when her precious packet of estrogen tumbled out. All her friends where there to watch because as she pushed she screamed bloody murder bringing them running in panic.

They giggled and applauded and I joined in. It was perma-grins galore!
Check out those grins. What a fun birth!
I’ll stop there for the moment. I have one more birth to tell... it happened later that day. But this post is already too long, and frankly this other birth deserves its own space. It’s the story of my first footling breech.

To be continued...

Bullet Explosion!

Late one afternoon, as the clinic was closing down for the day, a boy walked up with his hand wrapped in a bloody towel. He and his parents had traveled from a far village by car. Normally, it would have taken a day to walk the distance, but this time, they drove. They explained his hand was all cut up after a ‘bullet explosion’. (Huh?)

Unwrapping his hand, we all cringed to see the mutilated fingers hanging limp and dead. The story fell together piece by piece as we prepared to suture. As a goat herder, he stumbled upon a bullet while wandering the fields and picked it up. Curious as any nine year old boy would be, he decided to see what would happen if he beat it with a stick. I am not sure how long he hit it, but eventually it exploded, taking several fingers with it. There was even charred residue glued to his skin. It was bad. Fortunately, by the time he reached us most of the bleeding had stopped.

Once his hand was properly numb, Dennis (our clinical officer) removed a finger which barely hung by sinew and muscle. He left the main bone sticking out, saying it would die and eventually fall off. The other fingers were then stitched and wrapped tightly in gauze.

As he sutured, the boy’s mother, kept peeking at the carnage and mourning her son’s pain. She was a wreck. In fact, the boy kept comforting her: “Don’t worry mom, it doesn’t hurt at all. I promise.” It was really quite sweet.

I asked him if he was ever going to play with bullets again, and he shook his head emphatically. This lesson was costly but effective. I told him to tell his friends to stay away from bullets too, and reminded him that he was fortunate he only lost a few fingers. The realization of this truth stopped us all up short, and together we thanked God it was not worse.

Today, he came in for wound dressings. I’m happy to report that it is healing nicely. Pray for a full recovery. Perhaps one day, he’ll warn his son the dangers of playing with bullets... I hope so. 

For those who are squeamish, I am putting the pictures after the story. I don’t want to spoil anyones breakfast (Achem... I mean yours Robin! ha ha!).

Tuesday, January 18, 2011

Updates on a few stories.

For those of you who've been following along in these adventures for some time, I have a number of updates to share with you.

Yar: The young girl with the bone sticking out of her arm, in need of surgery (read her story here), has had a 'break through' of sorts. We have been dressing her arm for weeks, trying to keep infection from setting in while we look into flights and raise funds for her surgery. Last week, a piece of gauze got stuck on the bone. While trying to remove it, the bone came out as well! Now all she has is a wound that is healing nicely. She can move her arm without much pain. There are still limitations, and we still need to get an x-ray, but it's looking up. Woohoo!

Achok: The woman with the outrageously engorged breast (read her story here) came in for another prenatal today. She is open to having surgery on it if we are able to help her. I'm told there is a surgeon coming in a few months for a short-term trip and/or she might be taken to Kenya. All this is a bit speculative but I remain hopeful. Pray for her. Twelve years is a long time to wait for relief.

Veronica: The young girl I prayed for last year after finding out she was pregnant out of wedlock at 15 years old (read her story here), returned for a prenatal today. We were just finishing up, when it occurred to me that she was the brokenhearted little thing, weeping her eyes out just a few months back, but I wasn't sure. So, I asked her and she smiled sheepishly, apparently happy to be remembered. Relieved to see her again, I asked her for an update: Was her brother understanding? Did she have to drop out of school? Was the father of the child honorable? She explained that she was able to stay in school (at least this year), her brother didn't beat her and the father of the child is helping support her. She looks great. Praise God!

Saturday, January 15, 2011

Waiting to die...

Preparing the vehicle to transport her.
I have a story but I don’t want to tell it. I’m afraid if I write it down, it will somehow become real to me. It is true though and that’s why I don’t want to tell it. But the not telling is starting to make me sick. So here goes...

Monica was a regular prenatal patient. Each time she came, I stressed the importance of delivering with us. She also knew not to push longer than two hours at home for I taught it many times. But as a 19 year old Dinka girl expecting her first child, she was at the mercy of her family when it came to how she’d deliver... not her midwife.

When her labor started, her family chose to keep her at home calling for a TBA (Traditional Birth Attendant) to watch her through the night. By morning, even though she was fully dilated, the TBA wasn’t able to get the baby to come down. She pushed for hours causing the baby’s head to swell as well as her labia. The TBA did all she could but eventually gave up.

Precious time lost.

But instead of coming to us next, they gathered their money and took her to a witch doctor, where (I’m told) he massaged herbs on her belly and proclaimed that ‘Now, the knots were untied and the baby could be born.’ Realizing he had nothing left to offer, they finally brought her to us.

More time lost.

When she arrived, I estimated she had been fully dilated for at least 6 hours, possibly longer. Her contractions were still strong but there was absolutely no progress. She lay exhausted, writhing in silent pain as her family explained all they had done. 

As I did a vaginal exam, I knew immediately she required a cesarean. There were too many signs of obstructed labor. This couldn’t be fixed by binding her belly. This wouldn’t progress if I stretched her and forced her to push. This appeared to be a case of deep transverse arrest (when the fetal head gets stuck in the mid-pelvis, restricting the mechanisms of labor). So I told her family she needed a cesarean. They didn’t seem surprised.

Fortunately, both Monica and child where doing fairly well. All we had to do was get her to Wau and they could be saved. There was just one catch, night was falling. Buses don’t travel at night. However, even if it were broad daylight, they’d be out of luck. With all the voting this week, the buses were booked solid. Even if the family paid twice the fare, there were no seats available. So I went to Sabet and asked if we could drive her.

He was happy to comply but we had to find our diver first. It’s dangerous to drive at night but sometimes if he is in the right mood, and you ask him nicely he will take that risk. We sent people to find him.

More waiting.

The family paced the floor while she writhed in pain. I went back to Sabet an hour later asking if we found our driver. He explained he couldn’t locate him and that we’d have to wait until morning. But even then, they wouldn’t leave at first light since the truck would need to be fueled first.

Meanwhile, the family told me they had arranged for a motor bike to take her home. What? I was confused. “How will she get to Wau if they went home?” I asked naively. Only then did it occur to me that they were giving me an out. They wanted to take her home to die.

The last time I had this conversation I kept telling the family that the patient (a multigravida with  IUFD and potential placenta abruptio. Her story here. And here.) needed to get to Wau or she’d die any minute, thinking that pressuring them would get her there faster. It didn’t. It just made them insist she go home and die there instead. The family gave up because I painted such a dark picture.

So this time, I played my cards differently. I reminded them that Sabet had promised transportation at sun-up. All they had to do was get through the night and we’d drive them to Wau. I explained that both she and the baby were alive and they shouldn’t give up hope.

They were glad for the news. But it meant more waiting.

My stomach churned as I considered how long she’d have to endure. Already, she had suffered so much. I couldn’t help but marvel at how she handled the pain. But her silence wasn’t courageous resolve for her eyes betrayed her. They darted from face to face in panic. Fear had it’s grip on her. So I prayed.

I prayed she would be able to handle the pain, that the contractions would stop, or that miraculously the baby would be born. I prayed that if not, she’d make it to Wau and both would be saved. I entrusted her to God and went to sleep. The on-duty health worker would check on her in the night and alert me if there was a problem.

Tossing and turning all night, I got up early to check on her. I needed to be reassured. I arrived as the health worker was unsuccessfully trying to find heart tones. It was apparent Monica hadn’t slept at all.

I shooed away the onlookers as I searched for heart tones myself. Nothing. Her abdomen was taut and tender to the touch. How long had she been like this? The health worker explained he never checked on her in the night. What? I wanted to scream it but didn’t want to cause a scene.

“What do you mean you never checked on her? You were suppose to check her every two hours. I left very clear instructions.” He stammered something about not having been told, refusing to look me in the eye.

I was kicking myself for not waking the guard to let me out of the compound that night to check on her. I should have been more persistent. I shouldn’t have trusted our health worker with something so important. I was mad at him... myself... and the situation.

She was in shock. Her blood pressure was bottoming out. It wasn’t good. On top of it all, her baby was dead. I couldn’t find a heartbeat anywhere. I called for Dennis to help me get an IV started as her veins were collapsed. He got it on the third try. Then I went to wake Sabet.

I explained that the baby had died in the night and the laboring mom couldn’t wait any longer. She was in shock. We needed to go now or she’d be dead too. He immediately got on it, saying he didn’t realized she was at such a risk. An hour later they were on the road.

In my head I imagined they’d drive up to the hospital, rush her through the doors and take her directly to surgery. She’d be saved.                       But I was wrong.

Our driver returned in good spirits saying she got ‘a picture taken of her baby on the inside’ (ultrasound?) and it was still alive. (Really the baby was alive? How?) He added that the ‘doctor lady’ said Monica would be observed for another 8 hours. If she didn’t deliver in that time then they’d do a c-section that night. (What? She is being made to wait another 8 hours! $#@%$#!) I wanted to scream.

I bit my tongue instead and smiled as he gave me this ‘great news’. My gratitude was genuine. I was thankful he was willing to go, for Sabet’s generosity in sending the vehicle, for the family’s continued hope. I trusted that the doctors in Wau knew what they were doing. I trusted God with her life. It didn’t make sense to wait. She had waited long enough but it wasn’t up to me. (By the time she arrived in Wau, she was fully for over 24 hour.)

So I waited and prayed. More time lost.

The next day I learned that she got the cesarean after failing to progress in Wau. She waited 7 hours before they took her in. The baby was born dead (not a surprise) and an hour post-op, she joined him. I don’t know why.

I think it was all the waiting. 

Her death surprised me -- not because dying in childbirth isn’t possible but because it was completely avoidable. I know it’s foolish to play the ‘what if’ game but I can’t help it.

What if she came to the clinic earlier?
What if they hadn’t wasted time pushing so long?
What if they bypassed the witch doctor?
What if they arrived before sunset?
What if our driver was found and took her to Wau that night?
What if the hospital rushed her to surgery immediately?
What if... What if....

Thursday, January 13, 2011

Witch doctor charlatanism!

The other day, a woman was carried into the clinic acting very strange and fighting her care takers. She foamed (literally) at the mouth and walked in stilted, jerky motions. It took her family a number of minutes to even get her in the door.

Such behavior is common for severe malarial patients and she was no exception. The doctors worked to get her the medicine she needed and monitored her all afternoon. As she recovered on our back porch -- Achem. I mean our in-patient room-- her family explained they first sought help from the local witch doctor.

Under his care, she didn’t improve even though he “removed” a shard of coal, a sliver of black wood and a dead beetle from her body. They even had proof. Untying her “sickness” from a plastic bag, her brother didn’t seem the least bit flustered as he showed us what they took out of her. Did he really believe that was what caused her malaria? I couldn’t tell.

The beetle, coal and wood.
When they told us how much it cost to get these things “removed” from her, I was simultaneously shocked and horrified. It cost them a weeks salary-- or 60 Sudanese pounds ($25). Charlatans!

My horror makes sense only when I explain that we charge our patients 2 pounds. The money they pay is just a one-time fee for a patient book.  All medicine and consultations are free. Knowing this, why go to the witch doctor first? I just can’t understand. I just can’t.

By that evening, she started acting normal again. And by the next morning, she was sitting up and brushing her teeth as I passed. Sane. She even smiled shyly in my direction. Not long after, we sent her home to the relief of her family. Healed.

I overheard Dennis (our clinical officer) encouraging them ‘to save their money next time and just come here.’ Her husband and brothers nodded in agreement, evidently pleased. I don’t want to speak ill of any of the witch doctors here. I don’t know any to speak ill of them. I just can’t help but wonder what they do when they get malaria....

Hopefully they take their own medicine and die!
Brother holding "sickness", sister behind him.

Tuesday, January 11, 2011

Update: 8 1/2 fingers... left.

The other day I ran into the worker who lost his fingers in our brick making machine. (Read his story here.) I got pictures of how it's healing and thought you might be interested to see. He says one finger has a bit of the bone protruding but flexibility is better. I'm happy to see his pinkie is healing up well. What is more, he doesn't seem the least bit bitter about the whole thing. Do you think fingers are just fashion accessories here? 

Too old for this?

Last year, the first day we opened the clinic after the holidays we were slammed. They said that it was a mass chaos, so I prepared myself mentally for anything. But this year, with everyone at the polls we found ourselves blissfully quiet instead. It was really quite relaxing.

Preggos filtered in all morning and I spent lots of time caring for them. It was fun catching up with faces I hadn’t seen in weeks. I even got a visit from a baby I delivered in September. She was all sparkly-eyed and smiles. It was a good morning.

But at noon a labor came in to stir things up. Martha, my labor, appeared bone tired, making her look much older than her years. Had you told me she was 50, I would have believed it. She never came for any prenatal care, so I had to get her story on the go. She was 39 years old and expecting her 6th child. Labor started three days before but something was wrong.

Her husband carried a large wooden cross everywhere he went, much like a very short walking stick or an incredibly large good-luck-charm. He held it tight while answering my questions about her history. Yes, there had been a lot of blood. No, it has never taken this long before. The worry, love and concern in his eyes clouded his face and sobered his voice.

As I assessed her, I was excited to find her in good health, despite her exhaustion. Her baby was in a good position, contractions were effective and labor was progressing well. I had to reassure her husband that she’d deliver within the hour at least three times before he believed me.... and even then I’m not so sure he did.

So I prayed for them all, tied her belly (which was lax and possibly causing some of the delay) and got her in some good positions. Twenty minutes later she was asking to push. Four solid pushes after that... and he was born.

Once he was out, he instantly started peeing a fountain of urine for all the world to see. It made my translator laugh and clap for joy, saying “This is very good. Very good!” over and over again. I think he was more excited the baby was peeing than the fact he was even born!

The husband was overjoyed as well, and repeatedly thanked me. Personally, I don’t think I did anything but remind them that God is in control. But I guess that was enough to make his day. 

I, too, was encouraged though. I’m not sure if it was the big wooden cross, the peeing bambino or the fact that this strong Dinka woman would have a little boy to comfort her in her old age. Perhaps all three.

Before discharging them I asked to take pictures and pray. The father was happy to have me blessing his family and stood over us, glowing in satisfied pleasure. Beside him was a pregnant girl. She seemed wide eyed and innocent... and very young. I asked if she was a second wife (as having young wives for very old men is not uncommon), but they laughed and explained she was his daughter-in-law.

Only then did it hit me. Her oldest child was married and expecting a baby of his own! Ha! Their son and future grandson will grow up as best friends, no doubt. A happy time indeed.
Husband, Daughter-in-law, Martha and Bambino.

Sunday, January 9, 2011

Voting Begins on the Sudanese Referendum~

This morning I woke to the sound of drums beating out a steady rhythm, waking the world with the good news. It was time to vote.

At church we spent the service in prayer for this nation’s leaders and especially for peace. It’s a historic moment. I’m glad I get to be a part of it.

This afternoon, I was able to visit the voting stations and see history unfold for myself. In spite of the afternoon heat, dozens queued happily for their chance at the blue inked ballot. Since most of the Southerners are illiterate, they are casting their vote by putting a fingerprint beside one of two images. If they want to stay a part of the North, they must choose two hands clasped together in unity. If they want independence, they must put their mark beside the hand waving goodbye. And as they leave the polling station, they must dip their finger in permanent blue dye, to prevent them from voting over and over again.

Snapping off a few pictures of the crowds, I could feel excitement and hope hanging in the air. The day had finally come....and it only took 55 years.
Polling station at neighborhood school.
As we drove from one polling station to another, Sabet, our Sudanese director, explained the history of his home country and why today was so special. Fifty-five years is a long time to wait for independence. Many had to die for this day to come.

He explained that the Southern Sudanese wanted independence in the 1950s but it was denied them. In 1955, a group by the name of “Anyanya” (Rebellion in Dinka) declared war and started fighting the North for freedom. War continued until 1972, when a peace agreement was brokered.

In that agreement, the South was awarded semi-autonomy and a budget to run its own affairs. For this concession, they agreed to remain a part of Sudan and not insist on secession anymore. However, it only lasted 10 years.
Women waiting in line to vote.
By 1983, Sudan was miserably in debt and could no longer afford to let the South govern itself. The nation’s leaders reneged on their agreement and war broke out again. This is when the “Rebellion” resurfaced, calling themselves the SPLA (Sudanese People Liberation Army). Years of bloody skirmishes tore the South apart, leaving generations of widows and orphans. It was ugly.

In 2005, a powerful and well educated SPLA director, John Garang negotiated another peace agreement with the North. But this time the South refused to settle for autonomy. Independence and nothing but independence would do. They would put it to a vote -- thus today’s referendum.
Excited to cast their votes in this historic event.
Garang became Southern Sudan’s first president. Six months later he was killed when his helicopter crashed. The investigation into his death was officially declared an accident, but if you ask anyone in the South they’ll laugh at the thought. It’s widely believed he was assassinated for his political clout and radical ideas.

I’m told he was not asking for independence as we see it today. He was pushing for Sudan to remain one country but with a new constitution that protected religious freedom. He no longer wanted Sudan to be considered a ‘Muslim’ country; but one where even a Christian could be president.
Hanging around after the vote, holding registration cards.
Many believe that had he lived, the South would be in control of hotly disputed lands; The blue Nile region, Abeyie and the Nuba mountains. Had he lived, I wonder if Sudan would be splitting like this. I wonder if the North would be threatening to adopt Sha’rai law. I wonder...

A nation’s hopes, fears and future rest on what happens this week in the polls. Everyone believes independence is assured, so long as Bashir keeps his word. Pray that he does. Also pray that with independence strong, godly leaders will carry this neonate of a nation toward peace. May it one day be called a Christian nation.

Here is an inside peak at the voting process...
Police guard monitoring that voting goes unmolested.
After voting, he dipped his finger in blue dye.
Evidence that his vote is cast.

Saturday, January 8, 2011

Scorpions Suck!

Not the original offender, he died. Ha!
Last week I was asleep under my mosquito net when suddenly two sharp pains shot through my right index finger. I moved my hand away in aching surprise and rummaged for my flashlight. It reminded me of the searing pain I had when stung my hornets... earlier this year. (I was stung 4 times in less than a half hour. It was awful.)

Unfortunately, hornets were the least of my concern. Instead, my flashlight revealed a brown scorpion, 3 inches long, furiously trying to get out of my net. He had somehow squeezed his way inside (since my net is tucked in at night) and was spitting mad he was trapped. But he couldn’t have been more mad than I was at that moment of realization.

I slowly pushed him to the side, slid out of my bed and then wacked him till he convulsed into a pile of brown mush on my floor. Stupid scorpion. I wanted to squish him even further... and who knows maybe light him on fire, but the throbbing in my hand distracted me.

Instead, I dressed and rushed across the compound for Dr. Tom’s help. It was two in the morning but I had to wake him. Tears of pain trickled down my face as I explained I was stung by a scorpion. Twice.

He jumped up, awake in seconds but just stood there looking at me bent in pain outside his door.
-- “Umm. What do you do to treat a scorpion bite?” He asked. “I’ve not seen one yet.”
-- “Lidocaine!” I almost screamed. The pain radiated to my shoulder. I couldn’t help but worry I’d die of anaphylactic shock from an allergic reaction. “Numb my finger with lidocaine!”
-- “Ok. You got it kiddo. You are gonna be okay. I have some in my bag right here.”

The few minutes it took him to fill the syringe and jab me with lidocaine, I spent on the floor bent in frustrated pain. It was intense. I thought I was a toughy until this. Wowzeers.

Within minutes my hand was numb; I couldn’t feel it at all. What bliss! But the radiating pain persisted in my arm. I thanked Tom behind embarrassed tears and quickly rushed away. I didn’t want to appear to be the sissy that I was. Imagine that. Crying over a stupid scorpion bite.
I guess I’d live after all.

Once back in my room, I took a paracetamol and Benadryl cocktail and was able to fall asleep within the hour. The next morning, my hand was stiff and very tender but by the end of the day was working just fine.

Conclusion: Scorpions suck.

Picture taken from this website.

Friday, January 7, 2011

Update: Blood Transfusion?

A few weeks ago, I wrote about an 18 year old pregnant woman who had a hemoglobin of 4.4 after a case of severe malaria. We attempted to do a direct blood transfusion to improve her condition. (Read her story here.) But we failed. We just aren't set up for this kind of thing.

In fact, after several hours and many 'learning curve' situations, we were only able to infuse about 30-40 ccs of blood. She spent the night at the clinic and we discharged her to Wau the next day, so she could get a transfusion there.

Well. Today I learned she died.

I was surprised to think a grown woman could die for something so preventable, let alone a pregnant one. What happened? What went wrong? Didn't she go to Wau? Didn't she get the blood transfused?

One of our translators, Wilson, (who happens to be her cousin) told me the rest of her story today. She was too weak to travel so he (Wilson) went to Wau instead and inquired if there was any blood available. He was told they had no B+ blood but if someone came in to donate they'd do the transfusion. He came back, told his family the news and together they stopped trying.

She died two days later. (Three days after our attempt at a transfusion.)

I asked him why the two men (that we cross matched to her in our lab), didn't just go and give their blood; They still had plenty. He looked at me confused and said, "But they had no blood. Don't you remember? We couldn't get any from them."

Instantly my heart sank. Yes, I remembered. But I remembered it much differently than he did. We couldn't get blood from them because we didn't have the correct materials -- not because they were out of blood. (!#$%!@!)

I asked him if he remembered learning in class that a person has over 5 liters of blood in their body on average. He nodded and said he remembered. "Well, if a person has 5 liters, don't you think that they can give much more than 30 ccs?" He just cocked his head to the side and looked at me sadly. He didn't appear to understand.

"Wilson, your friends still had blood to give. She could have gotten the transfusion with their blood." I struggled to keep the incrimination out of my voice. He explained that the 'Fathers' decided that they shouldn't give anymore since they had tried and failed...

I tried to teach him more about how blood transfusions are (normally) done and how much can be given. I didn't want him to feel bad, just to know so this didn't happen again. But I cut my lecture short, seeing he wasn't listening.

He was tired. He was sad. He had done all he could... all he thought best in fact. So, I shut up and started lecturing myself instead. "He did everything he knew to do... He was trying by going to Wau, by talking to the 'Fathers'. He was fighting for her life and failed... just like we did."

The conversation moved on but my heart sank further down. What more could I say? I failed.

I failed to explain to them that a person cannot 'run out of blood'. I've failed because... this isn't the first time I've heard this excuse. I just never thought it could hurt anyone.

Generally when someone says they have 'no blood', I ignore them. I don't try to explain to them that it's impossible to live without blood, that we have liters and liters of the stuff... yada yada. I just move on with a prenatal or check-up or whatever. But now I see the damage this ignorance can do.

Another face of maternal mortality. Another needless death. Lord please don't ever let this happen again. May her death teach me to teach them better. May I never forget this lesson. Amen.

Recent Article on Sudanese IDPs and Referendum.

I was interviewed this week by a French journalist for Observer24, an online news journal, about my recent post A nation in Flux: IDPs and the Sudanese Referendum.

Here is a link to her article. Millions of exiles head to Southern Sudan for Referendum. And for those who are French speaking click here. (Achem... Oui, ca veux dire vous D & R! Finalement, j'ai mis quelque chose en Francais uniquement pour vous. :- )

Wednesday, January 5, 2011

Won't my baby drown?

 Yesterday, Rosa came into the clinic saying the baby was on its way. This is her third baby and I believed her. She didn’t need to push yet, but she assured me it would be soon.

As we worked to set up the birthroom and check her vitals she writhed a bit on the bed. I went through all the basics; When did they contractions start? Any water come out? How about blood?

Focused intently on her pain, she shut her eyes with each contraction and softly answer our questions. Her contractions were just minutes apart. Heart tones were good, so I asked if I could do a vaginal exam.

She was fully with the head at a + 2 station while membrane bulged at the introitus. I asked if I could rupture her membranes to prevent a big splash, explaining that the baby would be born very soon.

She looked at me worried and a little confused so I reassured her that it would not hurt her or the baby at all. She still looked concerned so I told her that the membranes would break on their own in a few minutes anyway... but if she didn’t want me to do it, I most certainly wouldn’t.

Only then did she explain what was on her mind.
-- “But if you break the water, won’t my baby drown in the water?”
Huh? Drown? I made my translator repeat her question.
-- “Oh, you are worried the baby will drown?”
-- “Yes.”
-- “Your baby is living in that water and has not started breathing yet. I promise, your baby will not drown if I break it.”
Sighing in relieved pain, she agreed.

Her baby was born 5 minutes later -- A beautiful bundle of estrogen!

As I cared for her afterward, I couldn’t help but mull over her question. It actually makes sense. I can see why she would think it possible for her baby to drown. Perhaps that is one of the reasons they believe babies die in childbirth. I’ll have to ask more questions about this when I do the community outreaches.

Anyway, rejoice with me that another little blessings was born-- healthy and strong.

Saturday, January 1, 2011

A Nation in Flux: IDPs and the Sudanese Referendum

January 9th voting begins. That’s in exactly one week. That means in one week this nation’s future is going to be decided. We might not know the results of these votes for months... but the whole course of this nation will have been decided.

Pray. Pray. Pray.

In anticipation of this historic event, and as a consequence as well, the leaders of Tonj have been preparing for an influx of people. People are on the move.

The referendum has Northerners fleeing south in hopes of security and a chance at a new start. Buses headed for Rumbeck (a town 5 hours south of us) passed through last week. It was quite the sight to see; buses lined the main square for blocks, loaded down with baskets and bundles.

An exodus of sorts.

Tonj is expecting 700 internally displaced people (IDPs) in the next few days. They are already en route. That’s 700 mouths to feed and bodies to bed. The town leaders have been preparing schools and fixing outdated wells. They have begun discussing latrines and water rights in anticipation of the chaos. Much has to be sorted before they arrive.

I’m told they will be supported and housed for 3 months by the Southern Sudanese Government. During that time, they will be required to reconnect with relatives and/or find lodging and land. Then they are on their own.

Change is coming and with it potential-- Potential laced with a hint of fear and a lot of the unknown. Pray for this nation. Pray that God’s perfect will would be done among the leaders and in this nation. Thanks.