“Slice of Dar Day 1” – Story from the field by Dr. Yoni Barnhard
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.