It is hot! It’s not unusual for it to hit 120 degrees (49°C) or more some days. We have hot days in Arkansas, I know, but the way we survive them is usually by finding a pool of water or by jumping from air-conditioned room to air-conditioned car to air-conditioned room.
There’s a little respite around 3 am when the temperature drops low enough that you can turn the fan from high speed to low speed. The mornings start out relatively cool (the worst time, I should add, to take a cold shower) but by 11 am I’m already starting to feel scorched and the feeling of being an underwatered plant just progresses throughout the day. By the time I get home from the hospital, covered with dust and looking pretty grimy, nothing sounds better than a cold shower.
I’ve spent most of the week getting over jet lag. The doctor I’m replacing just finished his assignment and is going to be a tough act to follow. I met him the evening I arrived while assisting him with a difficult Cesarean section and have really grown to like him. He was supposed to fly out on Thursday but his flight got cancelled so he’s not leaving until Monday.
As a result we’ve had plenty of time to do an in-depth handover. He quit taking call on Tuesday, the day before he was supposed to leave, and my first three nights on call were all busy but it was just as well since I was waking up at 1 am every day wide awake. The sun rises and sets at pretty much the same time every day, coming up between 6:30 am and 7:00 am, and setting completely by about 7:30 pm. I try to be in bed by 8 pm so most nights I get some sleep on the front end even if I get called in later in the night.
The days usually start at the hospital at about 8:30 am and if things are under control we usually head home by 5 or 5:30 pm. The daytime hours don’t seem so bad but I never feel guilty about leaving when it’s relatively quiet because I know there’s a good chance I’ll be back up there within a few hours. Already I’ve seen stuff that I’ve never seen before. On my second night here we had a set of triplets who delivered vaginally. The patient showed up in labor and the first baby delivered without any problem. The patient didn’t know she had multiples until the second baby, a breech, started to deliver but then the head wouldn’t come out. That’s because it’s head was pointing skyward and had locked chins with the third triplet who was coming down head first.
I was in bed when I got the call that a breech delivery was stuck (the message I got was that there were conjoined twins who were stuck which, fortunately, wasn’t the case). The doctor I’m replacing was still here so we went in together. When we got to the hospital we were able to push the third triplet upwards, unlocking the chins, and then deliver the second baby by placing a finger near the second baby’s nose and bring its chin down in order to deliver the head. Not surprisingly, considering the amount of time that had passed from the time the baby became stuck to the time we were able to get it out, the baby didn’t do well. It had a heartbeat when it was born but did not breathe on it’s own. It eventually established some respirations but died later in the week. There is no mechanical ventilation of babies here. If the baby doesn’t breathe on its own then it is allowed to die. The third baby also didn’t do well. It had a very slow heart rate by the time it was born and also died later in the week.
I have two patients with abnormal blood clotting, both presenting with nosebleeds. We have limited blood tests available here but the old tube of blood taped to the bed trick pretty much confirmed that the problem was their ability to form normal blood clots. Neither of them formed clots over 15 minutes. One of them has a huge spleen so it might be some autoimmune disease. The other has a fever so it could be typhoid. It would be nice to order some proper lab tests but we’re trying steroids on one and antibiotics on the other. They’ve both received five units of blood each and the blood bank has already let us know that they’re almost out unless we can get family members to donate.
Every day I order blood transfusions on anywhere from three to six patients. Because the supply of blood is almost completely dependent on family members who donate (and people do not donate for anyone but their family members) we have to take what we can get. Today I needed two units for a patient who was so severely anemic that she couldn’t stand on her own.
I think yesterday was the first day I actually starting feeling at home here. The first few days were tough because of the jet lag and the hours and the heat but I feel like I’m falling into a normal rhythm again. The patients are always grateful. They seem so acquainted with death that they never flinch when you tell them that their baby has died. They will sometimes want to see the baby after it is born but often they do not.
The emphasis here is on saving the mother even at the baby’s expense since she can have more children but a scar on her uterus might kill her with the next pregnancy. So it’s not unusual to just watch a baby die in labor in order to save the mom from a Cesarean. I’ve had to do one Cesarean so far and it was because the mom had pushed for 12 hours and was unable to bring the baby down to the point where we could’ve helped her with forceps or a vacuum-extractor (which, again, would have been done for the sake of the mother’s health and not, necessarily, to save the baby). It’s a whole different way of approaching obstetrics but I think it’s the right one in this area.
We still monitor the baby’s heartbeat during labor but even if the heart rate is low we will probably not intervene with a Cesarean. The only time the information might be useful is when the baby is close to birth and we might be able to speed up the process with forceps or vacuum. There are exceptions, of course, but on of our primary goals is to minimize the risks to the mother in future pregnancies. If, however, the mother has indicated she wants a tubal ligation, a sterilization procedure, I have a lower threshold for proceeding to a Cesarean delivery.
So that’s been my introduction to Aweil in South Sudan. The hardest part of the day is not the complicated cases at the hospital but just adjusting to the heat. I’m drinking more water in one day than I usually drink in a week and still not having to visit the bathroom very often. Overall, though, the adjustment seems to be going well. I can tell that being here is going to be a good experience in spite of all the suffering and sadness. I’ll keep you updated.