Final Day: Forgiveness
AK is 23 years old. Aged and experienced in ways a young woman should not understand. It is not her story as such that is most deeply painful. Rather an avoidable suffering that degrades too many.
Happy to be pregnant, AK regularly attended her prenatal appointments with the encouragement of her husband. Unlike many women in sub-Saharan Africa she had access to healthcare. She understood the symptoms of labor. And the warning signs of potential complications.
After nearly two full days of regular, searing contractions and two attempts at being admitted to a hospital, AK returned to the hospital in pain, sure that something was wrong. No fetal heart tones could be heard. Another doctor was called. He could only confirm an intrauterine fetal death. Stillbirth.
Labor was induced. 14 hours of agony. No medication to relieve the pain. She never saw her child. Four hours later she was sent home.
AK was unable to leave her home for weeks. Fearful that others would mark her as the cause of a tragedy she had done everything in her power to avoid.
Over the next several weeks, AK noticed a constant sense of wetness between her legs. The death of her child sprouting uncontrollable nightmares. She was never given any explanation. AK assumed she had done something wrong. An older neighbor told her she was drinking too much water. AK stopped drinking water. The leaking continued. Another neighbor convinced her this happens to women who are promiscuous. She had never known any man except her husband. Yet accepted responsibility for her fate.
About a month later AK noticed an advertisement for women with vesico-vaginal fistula. She mustered the courage to inquire. After an initial appointment with a health worker, AK was referred to CCBRT, an amazing rehabilitation hospital in Dar that does miraculous work including treatment for women with fistula. After seeing a doctor at CCBRT, AK was properly evaluated and her underlying condition clearly explained. It had nothing to do with water. And certainly was not the result of some imagined past sin.
A compassionate team guided AK and her supportive husband through the process of healing and repair.
The fistula was likely caused by prolonged labor. AK had a hole in her bladder leaking urine into her vagina repaired early one Tuesday morning. After a week of recovery in the hospital she returned home. Whole in a certain way for the first time in many months.
AK even took a new job. Her afternoons were spent counseling other women with fistula at CCBRT. She spoke with conviction about the possibilities of healing. From the inside out. Physically. Psychologically. She worked with women in the hope that their husbands’ would not abandon them as is too often the custom for women with fistula. Outcasts. Placed in an eternal isolation. She gave these other women hope that life could be different. She praised their initiative. She honored their taking control of their own lives. She dignified their every effort.
Seven months later AK missed her first period. She immediately saw a doctor. An early pregnancy was confirmed. An uneventful pregnancy unfolded until late one night around 28 weeks’ gestation. A little blood. Some abdominal pain. Rhythmic tightening just above her pelvic bone.
AK contacted an amazing doctor at CCBRT. Doctor Brenda met her late one night at the national hospital, Muhimbili. She was admitted. Worked-up. Medications given to stop her contractions. Every doctor at Muhimbili knew her history. A story of loss. A story of repair.
Days passed. The contractions waned. The bleeding subsided. AK went home to rest. She lay in bed. Reduced her activity. Kept her prenatal appointments. And time passed.
At about 35 weeks, AK felt a gush of fluid one morning. The floor below her feet wet. She contacted Dr. Brenda. Plans were made. Admission to Muhimbili arranged.
On an airless, January morning, AK was brought to the operating theater. She knew well in advance that delivery would be by Cesarean section. Every effort made to avoid any trauma to the bladder. To the vaginal tissue. To the suffering buried deep inside her.
A live male infant was delivered. Healthy. Shortly after the surgery, Her newborn son was placed on her chest. He instinctively found a nipple. His lips moving like the paws of a cat clawing at play. AK smiled. Tears on her cheeks.
Before AK left the hospital Dr Brenda asked her about the past year and a half. She looked up from a chair. Looked beyond the doctor, beyond her pain and she said something I will always remember. “I will never forget [what happened]. But I have forgiven. My husband did not leave me despite the fistula. I now have a beautiful child. I am a mother. My life begins now.”
Another Day: Initiation
Accessibility. The traffic in Dar begins about 6am. All roads leading toward the city center are clogged by 8am with the backflow stretching many miles along some paths. The return trip becomes bumper to bumper starting around 3pm and remains at a near-standstill until early evening. Like Los Angeles most cars have only one passenger. Starch-white clad police direct the intersections. Fortunately my 15 min trip each day is against traffic. This little trip each morning and evening does make it clear why accessing health care is so difficult. Besides the high cost of hiring a taxi or even renting someone to carry you on a bike, it is a long journey even within the city and an exhausting voyage for women coming from the rural communities.
We begin morning rounds at 8am. Our meeting place is outside, under the shade of a Baobab tree. The purpose today is to review the case of a 29 year-old woman who died early Sunday morning, 6 hours after arriving at the hospital. Anna was 22 weeks’ pregnant with her 7th child. She came to Amana complaining of headache, abdominal pain, vaginal bleeding and vomiting. Her blood pressure was 200/110. Although the admitting assistant medical officer recognized the likelihood of severe preeclampsia, there was no quick acting anti-hypertensive medication available at the hospital. After her first seizure this young healthcare provider went from ward to ward trying to borrow a few doses of this medication from other patients. And though he started magnesium sulfate to prevent recurrent seizures, she continued convulsing.
That evening there were more than 20 women in labor at Amana. The operating theater packed with cesarean deliveries. At 11pm he was called away from Anna to evaluate a woman in active labor with signs of a uterine rupture. By the time he returned at 12:30 am, Anna was dead.
Under the Baobab tree I was trying to make sense of all this. Over the past 25 days, 31 women have presented to Amana with severe preeclampsia. Hypertensive disease is the second leading cause of maternal mortality in Tanzania. Amana does almost 30,000 deliveries each year. How is it possible that the few medications needed to treat this disease and prevent death are not available?
After rounding on the 8 women in the post-C/S ward and spending an hour organizing the work flow on the labor unit we moved toward the primary focus for the day. It is known as the “sorting room”. Unlike a Harry Potter story, there is little magic to behold. It is overwhelming. Every minute of every day.
The gravest obstacle is the lack of staffing. The entire healthcare system in Dar was designed for a population of 750,000. The head count today is about 4.4 million. And while the number of deliveries at Amana has dramatically risen over the past decade, the staffing levels have not increased to keep pace. At one point I counted 3 nurses, 41 women in labor. The frustration and burnout is overwhelming.
When we arrived, 32 women were in various stages of “sorting”: Active labor, early labor, special attention or discharge. It is a dizzying sensation. All these women in their brightly colored khangas. Some lying on a mattress. Some lying together on the same mattress. Several grasping the walls or floor during contractions. Some moaning. The sounds muffled by so many other moans. It is impossible to have any clear idea what to do first.
No one speaks to the other though many are lying on the same single mattress. There is a harrowing blank stare. This is not a happy experience for them.
We triaged about 70 women in labor today. The “special attention” pile was always twice the size of the normal labor pile. Severe preeclampisa, undiagnosed twins, prolonged labor measured in days not hours and 3 cases of “impending uterine rupture”. When we left the ward, the sun was beginning to set. The sole operating theater was occupied with a ruptured ectopic and two women in labor were being given blood while awaiting a vacancy. Those 3 impending ruptured uteri were awaiting transfer to another hospital.
Anna made it to the hospital. She did not get stuck in traffic. She was fortunate enough to have a relative with a car. And she died. On our watch. That is the thing about it. The indigestible portion. The part that gets stuck in the throat. This was not a failure of Amana. And surely not a failure of one individual on-call that evening. This was a monumental failure of the system. And we are all part of that global, interconnected system. So yeah, we failed Anna.
Amana. Second largest district hospital in Dar es Salaam. 29,000 deliveries each year. Do the math. Teeming with births. Just 6 birthing beds. Not actually birthing beds. Metal tables with a hole at one end. Fresh blood dripping through. A bucket underneath. No full-time OBGYN. No full-time anesthesiologist. No air conditioning. 92 degrees outside. Hotter inside.
This is where we start. High maternal mortality rate. High full-term neonatal death rate. The intent was to spend the afternoon teaching the basics of eclampsia management. Recognizing the risk factors, eliciting a good history, making quick, simple observations, taking blood pressure, and recording pulse. Assessing that the fetus is still alive. At Amana that means putting your ear up to the belly and listening for fetal heart tones. An art lost several decades ago in the West. Now we let our electronic dopplers perform this ancient exam.
The challenge is not practicing good obstetrics. The challenge is practicing better obstetrics with limited resources. The high technology wrongly considered essential nowadays for the modern practice of obstetrics is simply unavailable in the developing world. When it comes to saving a life, one can do far more with a single unit of blood than an ultrasound machine.
Basics. History and physical. The idea is to standardize the triage process. Ask the right questions every time. Follow the best evidence available for detecting a problem.
Most of the serious clinical problems that besiege the health worker here are preventable. Although disastrous complications such as rupture of the uterus, vesicovaginal fistula or malaria causing anemic heart failure in pregnancy can be treated when they occur. Their elimination is the challenge that cannot be neglected.
Next comes management. IV lines. Hematocrit. Anti-hypertensive medications. Magnesium sulfate to prevent seizures. We are working on creating an eclampsia kit. A drawer that will contain these things. A drawer that is hopefully stocked more times than not.
But the kit cannot act on its own. Even simple things like correct doses of medications seem to be part of a lost narrative. We will make some posters that outline the basic management steps. Put it in a simple, 5-step checklist. Plaster it all over the hospital.
Not so simple. The head of the hospital told me this might create clutter. He took great pride in telling me that Amana is doing a 5S project. I did not have the heart to tell him that 5S is not a housekeeping tool. It is intended to remove waste so that the essential items are available. A poster on the wall outlining how to save a life should certainly qualify.
In the middle of all this the strangest thing happened. I had been introduced as Professor Yoni. ”Professor” puts you on par with the angels. There was an emergency in labor and delivery. A woman needed an urgent C/S. The head of the hospital asked if I would please run over to the operating theater and do the C/S.
I was given a pair of surgical scrubs. I think they once belonged to the fattest man in Tanzania. We needed to find a piece of rope just to keep me from operating in my underwear. And a pair of rain boots. White rain boots. The room was incredibly hot. Hot even before I put on what looked like a rubber butcher’s apron. Between the boots and that apron I really felt like we should be going to a fish market.
My assistant began his training 6 months ago as a general medical officer. This was his 3rd C/S. I might have been concerned about the sweat dripping from my forehead into the surgical field, but I was more worried about what I would do if one of those flies landed on my nose once the sterile gloves were on.
So here I am. Standing over a Tanzanian woman’s belly with a scalpel in my hand. None of the usual instruments available. No electrocautery. No hemostatic gauze. Blunt scissors. A pick-up whose ends don’t quite approximate. And suture material that looks like it was just cut and dried from a dead cat. Much too thick. Probably gonna cause as much bleeding as it stops.
And of course there is an audience standing outside looking in through the window. All the credibility of 25 years bet on one hand. As I made that first incision I truly wondered how I ended up here. At Amana. In 92 degree heat. Wearing rain boots and a pair of surgical scrubs about to fall to the ground. Flies buzzing around. A scalpel in my hand. And at that moment no one else in the room who could make a difference.
Skin. Subcutaneous fat. Muscle. Fascia. Peritoneum. Uterus.
Thick meconium. My hand now inside the womb. Gentle. Lift the head out. Slowly. Now the shoulders. Focus. Clear away the meconium from the mouth and nose. Concentrate. Cut the cord. Healthy baby. And a mom who will be able to care for this new child.
There is much to be done here. Training. Supervision. Continual reinforcement. A commitment to quality care. With more than 80 deliveries each day at Amana, there is little time to look back. Under the sweltering Tanzanian sun, we move on to the next patient.