Sunday, April 29, 2012

The First Three Weeks - Ob/Gyn at Mulago Hospital

Olyotya! (Lugandan greeting). It's hard to believe I have already been in Uganda for three weeks. I just finished my last day of my Ob/Gyn rotation on Friday and will move on to the Casualty Ward (Emergency Medicine) next week. It has been an incredible experience so far and I am absolutely enjoying every day.

I spent the three weeks of my Ob rotation on the high risk labor and delivery ward. At the end of my time, I delivered 9 babies - most of them I did solo and learned how to repair second degree tears. The labor ward at Mulago Hospital has the most deliveries per capita in all of Africa. With the Ugandan fertility rate being 6.7, the hospital delivers on average 80-85 babies per day. The main labor ward of the high risk unit contains around 25 beds. On most days, all of these beds are filled and often there are mats laid out on the floor with another 3-10 laboring women lying on those as well. Most of the women end up delivering when they are on a bed, but on the busiest days, there are a few that end up delivering their babies on the floor. There is no privacy within this ward. Not even curtains or dividers to separate the beds. No one is allowed to come into the ward with the woman - not the father of the baby or family members or friends. It is overcrowded as it is and so no one is allowed inside except for the laboring mothers, a few midwives, a few nurses, the international students posted to the ward, and the doctors, interns, and residents during the rounds. The day typically starts at 8:30am with the morning report. It is really interesting as they report daily the events from the previous 24 hours. For the labor ward, they report how many deliveries, both vaginal and cesareans, complications from the deliveries (stillbirths, maternal deaths, multiple births, breech deliveries, etc.), and go over the pending cesarean cases. There is a lot of discussion that takes place after the report and it is really encouraging because the Ugandan Ob/Gyn doctors, midwives, and nurses are very proactive to try to identify major problems and discuss ways to resolve these problems. The maternal mortality rate is unfortunately high in Uganda and despite the lack of resources and inadequate staff, there is a strong motivation to find whatever way they can to try and reduce this using the resources and the staffing that they have.

Following the morning report, we head off to our respective ward rooms for rounds. On rounds in the main labor suite, there is a senior house officer (a resident), 1-3 junior house officers (interns), the international medical students, occasionally a consultant and occasionally Ugandan medical students. We go through every patient in the main labor suite - review their case, do an exam, and discuss the complications. The primary purpose of the ward rounds seems to be to make the prioritization of cases for cesarean section for the day. There are always more patients that need cesareans that will get them before they deliver vaginally so it is really important to prioritize the cases from the most urgent to the least urgent. This is difficult in and of itself, but unfortunately on a regular basis, there are patients that seem equally needy for cesarean. One day in particular, there were three women who had all had two previous cesarean sections (meaning that there chance of rupturing their uterus is unacceptably high). One was dilated to 7cm, one to 6cm but with a multiple pregnancy, and one only at 4cm but with signs of possible rupture occurring at that moment. When rounds are finished - often after a few hours and often interrupted by anywhere from 1-6 deliveries - the doctors all leave. Some go to admissions, some to the operating room to start on the list of cesareans, some to the pre-eclampsia/eclampsia ward, and some to the high dependency unit. After this, the only people left in the main labor suite to take care of the 25+ near-delivery mothers are 1-3 midwives and the international students. At times things are quite quiet but it seems that as soon as one delivers and that baby lets out its first cry, then several start to deliver. Some of the women yell (typically you hear cries of "Musawo!" which means doctor in Luganda) as they realize they are about to deliver while others are pretty quiet and I have often found myself turning around only to see a woman on her back with her legs flexed and the head of her baby starting to crown. I throw on my gloves, if I have time (as in the head is just at the introitus and retreats when the mother is not pushing), I will gather the supplies needed for the delivery - a syringe of 10 IU oxytocin, two elastic cuffs from gloves to use to tie off the umbilical cord, and a blade to cut the cord. If I really have time, then I will try to find the blanket that the woman brought to have her baby wiped down with and get the cotton ready. The women have to bring their own supplies for the deliveries - they are supposed to bring cotton to clean themselves with, two plastic sheets to lie on to try and keep the bed clean, bleach to wipe the bed down with after delivery, as well as sterile gloves for the person doing the delivery and for their vaginal exams prior to delivery.

I was a little terrified with the first baby I delivered in Uganda. The head was crowning and because another international medical student and I were standing at the bedside, the midwives assumed that we were fine and did not need them. Besides, there was a lot more work to be done elsewhere so if we were not in need of help, then they had a lot of other things to be doing. As the mother was pushing, I realized that head seemed to be too big to fit through the vaginal opening. We don't routinely cut episiotomies in the US, but it seemed in this case that one was needed. I had never cut an episiotomy before in my life and did not feel comfortable experimenting without supervision on a Ugandan woman and had to ask the midwife twice to come over and cut it for me before she finally came over and did it. As I delivered the head, I felt for a nuchal cord which there was one wrapped twice around the baby's neck. I couldn't get it reduced and so stuck my fingers between the cord and the neck to try to protect the baby from suffocating and finished the delivery. Everything turned out fine - the baby was healthy and had a good cry. The mother was so grateful for my help in delivering her baby and kept telling me "thank you, thank you" over and over again. It was a great feeling. After that first delivery turned out well, I no longer felt terrified of the imminently delivering mother. In addition to delivering several babies on my own, I also helped some of the other international students deliver babies as well. Several of them had never delivered a baby before and a few had not even had Ob/Gyn at home yet. It was fun to do some teaching and get some incredible practical experience as well.

Unfortunately not all the deliveries turned out as well as my first one. Everyday I saw at least one stillbirth and participated in three of those deliveries myself - one that I did solo. Sometimes the mothers seem to know when they are going to delivery a stillborn and other times, it comes as a surprise. There are also times when the baby comes out not breathing and due to a lack of a well equipped NICU, many of these babies don't make it despite our best resuscitative efforts with the resources we have. The worst stillbirth experience for me was with a mother who knew she was giving birth to a stillborn. The baby was in a breech position and when I walked onto the ward that morning, I saw the woman lying on the bed with the baby half out. She had stopped having contractions and had been stuck like that for I'm not sure how long. I alerted the doctors doing rounds to her predicament and was told to start an IV with 10 IU of oxytocin to try and get her to contract. I did this and as I was standing there, she asked me if she was going to die. I told her no, that she was going to be fine. She asked me if I would stay by her and not leave and I of course said yes, that I would stay with her until she delivered. After about 30 minutes of the IVF running and still no contractions, I again alerted the doctors who told me to add another 10 IU to her IV. They said that when she had her next contraction, I should deliver her baby. I have never done a breech delivery in my life and even though the baby wasn't alive, I certainly did not feel comfortable tackling this one on my own. Again, no one would come to help. The midwives told me to leave her be and she would deliver on her own, but I had promised her that I would not leave her so that was not an option. When the mother seemed to have a contraction, I instructed her to try to push. The baby was completely stuck. At this point it had been about an hour since I had started that IV and beyond this one weak contraction, the mother was not having any. I again asked the midwives to help. They told me to just wait. I asked the doctors to help and they said that they would come back to her when they finished their rounds. I kept pleading and finally a visiting resident from Canada came over and assessed the situation. She agreed with me that this baby was not going to deliver on its own and was able to recruit the Ugandan consultant and intern to come and help with the delivery. Turns out I was right. In order to deliver this baby, the consultant had to dislocate both shoulders, broke one arm and finally got the arms delivered (which had been up above the baby's head). After delivering the arms, the consultant realized that the baby seemed to have hydrocephalus and so the head was way to big to deliver. So, they had to manually drain CSF from the baby's skull in order to shrink the head to get the baby out. Nearly 2.5 hours after I first saw this woman, she had finally delivered her stillborn. Thankfully she seemed stable after this traumatic labor and delivery experience. In the US, breech is an indication for cesarean but here, there is not enough OR space to section all the breech babies so many of them end up delivering vaginally. Of the 4 breech deliveries that I saw and helped with, only one lived through the delivery.

The other really traumatic delivery I helped with was for a woman with severe eclampsia who had major mental status changes because of her eclampsia. She was agitated, anxious, and almost seemed to be in a psychotic state. Her baby was stuck and because there was no space for her in the OR, the decision was made to try a vacuum delivery. A third year resident from the UK that I had been working with for two of the weeks I was on the ward took charge of this delivery. This resident was the best part of my Ob rotation - she was an incredible teacher and provided the perfect amount of supervision and autonomy. She really cared about each and every one of the patients and we teamed up on many deliveries which I think made the whole process go much more efficiently and better overall for the mothers we delivered. Anyway, this particular mother due to her eclampsia and her mental state was aggressively uncooperative. We sedated her with diazepam and it still took four of us holding her down to be able to deliver her baby by vacuum. Thankfully, the baby came out alive but needed immediate resuscitation and so the resident and two of the other international students left to work on that. The Ugandan midwife and doctor who had also been helping disappeared and so I stayed with the mother who was lying in a pool of blood from the episiotomy that had to be cut to deliver her by vacuum. She was continuing to bleed and I was concerned about her stability since she was bleeding and had been given sedation. I watched her respiratory rate and kept checking her pulse and watching her bleeding. One of the midwives stopped by and looked at the patient, shook her head saying "that was not the right way to cut an episiotomy - what a mess" and walked away. The UK resident returned and between her and the three of us international students, we tried to hold her down to repair her episiotomy. The mother was still fighting us despite her sedation and we asked the midwife to come and help hold her down. It seemed like all she really had to contribute was criticism - for the episiotomy and the "slowness" of the repair and for the fact that I was leaning over the patient, trying to hold her down and subsequently was getting blood on my clothes. I said that I could wash the blood out of my clothes later and the resident told her that she should show her how to do a fast repair. The whole scene just felt wrong - four people holding down this poor woman while someone tried to suture her and stop the bleeding. It was a sloppy job, but it seemed to work to stop the bleeding. At the morning meeting the next day, I found out that the patient and the baby were both stable and the mother was in a better mental state than the previous day.

Every day was a complete adventure on the labor ward and if I wrote all the stories I had to tell about my experiences, it would be a short novel. It was incredibly hard and difficult but also equally rewarding. I felt like I was learning so much and at the same time was able to give back and help others. Even though at times it seemed like people didn't care or moved too slowly when you needed something NOW, they really do an amazing job with the resources that they have and for every person that seems to not care when something terrible happens, there are at least two that really do care. I was also so inspired by the motivation of the staff to identify problems and try to brainstorm ways to fix them to decrease their maternal and neonatal morbidity and mortality rates. I am sad that my time on Ob is over, but I am excited to start something new - Emergency Medicine!

Location:Kampala, Uganda

Tuesday, April 10, 2012

The Beginning of the End - Arriving in Kampala

So I may get back to my India blogging, but then again, now that I am in Uganda, I may just forget writing about the rest of India and just move on to my last and final location of my world wide medical student tour.

I flew out of Minneapolis on Friday, April 6 at about 3 in the afternoon. My mom and sister brought me to the airport after we stopped and had lunch with my brother in St. Paul. When I got to the airport, my one checked bag was 6lbs overweight. Even though I was given 2 free check bags each 50lbs which means I should have gotten 100lbs of weight to bring, Delta was going to charge me $90 for my 6lbs overweight bag. I refused to pay that and I didn't have another bag to check, so I unloaded my shampoo and conditioner and some other liquid things that I had planned to bring and got my bag down to 50lbs. Going through security was a breeze and I sat at my gate for a little over an hour before we boarded the plane for Amsterdam. The flight to Amsterdam was entirely uneventful as all good flights are. I ended up sitting next to a girl around my age who works for the CDC and was also headed to Uganda for 4 weeks to do a project here. The slightly less than 8 hour flight went by relatively quickly and we made it to Amsterdam. I didn't sleep at all on the flight and was quite tired by the time we arrived in Amsterdam. The airport is not very conducive for sleeping, but as I was tired, I still managed to sleep for an hour on the tiled floor.
I boarded the plane to Kampala with a stop over in Kigali, Rwanda and the flight was relatively empty so I ended up with a row to myself. The guy sitting in the row next to me was a really nice guy from Texas who was going to Uganda for the second time to do some military training for the Ugandan soldiers. He has been to Africa several times and has loved all of his trips. It was great to get a bit of insight prior to my arrival especially with regard to trips to take on the weekends! This flight was also uneventful and I made it to Kigali and then to Kampala without problem. On this flight I only slept for about an hour as well.

Once I arrived in Entebbe (about 35km south of Kampala and the location of Uganda's international airport), I was quickly able to retrieve my bag and get my Ugandan visa ($50). The whole thing went so smoothly and as I walked out of the baggage claim area, I saw a man with a sign with my name on it who I presumed was the person sent from the school to pick me up. He and his wife welcomed me warmly to Uganda and we got into the Makerere University van. It was unfortunate that it was night (10:30 or so) when I arrived so that I couldn't see the scenery on my ride from Entebbe to Kampala. But I was quite tired and ended up falling asleep on the ride to Kampala. I was brought to my housing - the Edge House - on the Makerere campus and was greeted again very warmly by Lucy and Nasser who run the house. None of my housemates were around as the Easter weekend provided for a long holiday weekend so everyone was gone. I was okay with that as I was really tired and after unloading my things, I fell asleep and slept until nearly 11am on Sunday morning.
Sunday was a very relaxing day. I wrote my blog about Goa, did some reading, took a nap on the outside porch, went shopping for some groceries and the toiletry items I was forced to leave behind in Minneapolis, and enjoyed being in my new home. One of my housemates, Cecilia from Sweden, returned from her weekend trip with her boyfriend and it was really nice to meet the both of them. Cecilia has already been here for 4 weeks and will be here for another 2 months so we will get to know each other quite well I think by the time she leaves at the beginning of June. Sunday night Nasser took me to get a SIM card for my phone and also get some data so I can connect my phone to the internet. It was so easy - we just asked for a SIM card and got it. Then I bought the airtime and it worked. So easy.
Monday morning I slept in quite late again and was woken up by Lucy when a Makerere medical student arrived to take me on my orientation tour. I had to quickly get ready and then headed for my tour. Along with me were two other medical students from UCLA who had also just arrived. We first met with the international student coordinator, Susan who was very friendly. Then we took a tour of Mulago Hospital where we will do our clinical rotations. Finally, our orientation ended with a tour of Kampala itself - the city center and downtown. It was really cool to see some more of the city and kind of get some idea of the layout. Kampala is a much cleaner city than Bangalore and the sidewalks are actually walkable. It's definitely not as crowded nor is the traffic anywhere near the level it was in Bangalore. So far, I am really loving it here. The only bad thing that happened on our tour was that near the taxi park in downtown, a man tried to steal the necklace off of one of the other medical student's neck. He did not succeed and she was okay, but it definitely raised all of our heart rates a bit and made us keep a little tighter hold on our bags.
When I returned to Edge House late that afternoon, I met the rest of my housemates and my roommates. The group is fairly international although the majority of students are either from the US or England. We have one from Sweden and one from Holland. It was one of the American's birthday on Monday so 12 of us that are living in the house went out for dinner together to celebrate. Everyone has been so friendly and welcoming and I feel like I am at home already. I am so happy to be hear and think that this will for sure be the overall best of my experiences yet.
I am writing this on Tuesday after my first official day at Mulago but I will save the going-on of today for the end of the week when I can recap my first week of Ob/Gyn at Mulago.

Location:Kampala, Uganda

Sunday, April 8, 2012

Goa (Feb. 24-28)

The weekend before I started Ob/Gyn, Kim and I talked about taking a trip to Goa. She had been to Palolem Beach with Michael, Carina, and Carina's boyfriend Noti the weekend of my birthday but had heard about a beach party happening at Morjim Beach in north Goa that she really wanted to go to. I just wanted to go to Goa so we decided to try and make that happen the following weekend. During the week, our group going to Goa grew - it started out just Kim and me and then Carina, Sonja, and Julia all decided to join us as well. The problem was that we tried to buy our bus tickets very last minute. We went to the travel agency on Wednesday afternoon to buy bus tickets for the weekend. We had decided to go for a long weekend and leave on Thursday night. We had a horrible time trying to get bus tickets. We spent around 2 hours at the travel agency with no luck. There were tickets showing up on the website, but for some reason we were unable to book them. Then we each tried to buy tickets online on our own computers but were again unable to book bus tickets. This was the only time during my time in Bangalore that the bus ticket websites (we tried several) would not accept my American credit card. Just when we thought there was no way we were going to be able to make it Goa, our magic friend Mahesh came through for us. He got on the phone with someone and suddenly we had bus tickets for all of us on a sleeper bus leaving Thursday night for Goa. Unfortunately, we could not get bus tickets to return on Monday morning so we ended up having to change our return to Tuesday morning.

Thursday night we headed to the bus pickup point and made it on our bus with our handwritten paper tickets. We were not confident these tickets were valid since none of us had had handwritten tickets before this. Thankfully, they worked without a problem and we boarded our bus to Goa. The difficult thing about being on a sleeper bus with 5 people is that often the beds are shared between two people. Since Julia was the last person to decide to join us on the trip, she ended up sharing a bed with a stranger. This actually worked out to our advantage. The guy Josi was an ex-pat living in Morjim Beach. He knew a guy with a car that would be able to pick us all up from our bus drop off point and bring us the rest of the way to Morjim Beach (about an hour away) for a very cheap price - 700Rs for all 6 of us (about $2 per person). He also knew the owners of a group of beach huts and was able to get us a great deal on our accommodation as well. We paid 450Rs per room per night which split between two people was less than $5 per night. They were clean huts with a great location. There was a common shower and toilet that everyone used, but for $5 per night, none of us could complain.

After arriving at our huts, rearranging our bags, showering, and changing into our beach wear, the 5 of us headed out for breakfast on the beach. The place we went to - Fish and Feni - ended up being our breakfast place for the duration of our stay. The food was delicious, the service great, and the prices very, very reasonable. The fresh fruit and the fresh fruit juices were amazing as were the omlettes. After breakfast, we headed down to the beach and began our weekend of relaxation - napping on the beach, reading, swimming in the ocean, and of course eating. Late afternoon on Friday we decided to head over to this party that Kim had found and have lunch in that area before checking it out. We went to this Italian place on the beach. The food was good but it took 2 hours for us to get it. To make up for their incredibly slow service, they brought us two pitchers of sangria. Even though we didn't have anywhere we needed to be, we were all starving and a little frustrated at having to wait so long for our food. We finally did eat and then headed to the party next door.

I have never been to anything like this party. The music was loud and the place was packed with people - mostly Europeans - who were all dancing, sometimes very crazily, to the beat of the music. I think a lot of the people were on some kind of drug but it was great for people watching. Julia left to meet up with Josi and Carina and Sonja left soon after because of the crowdedness of the place. Kim wanted to stay and although I am sure she would have been fine on her own, I didn't really want to leave her by herself so I stayed as well. After a couple hours of dancing and a ton of sweating, we walked out of the party to get some fresh air. It was a little after 8pm and the sun had set. We still had our swimsuits on and so to cool off, we decided to jump into the ocean. We set our stuff a little ways down the beach - our clothes, flip flops and put our wallets, phones, and my camera buried within the clothes. We jumped into the ocean and played around in the surf for no more than 10 minutes and when we got out and went back to our stuff, it was gone. After searching up and down the beach area and asking anyone nearby if they had seen our stuff, we headed back to our huts in our bikinis to put on more clothes and get a flashlight to look for our things. We were sure it was stolen, but as the clothes really had no value, we were hoping to at least find those thrown somewhere. When we returned to the huts we had an additional problem. I had used my own personal padlock instead of the one provided to us by the hut to lock everything up and the key had been inside my wallet and the spare key in Kim's wallet. We had to have the staff break into our room my removing the bolt on the door (which definitely needed replacing anyway) and replacing it. We got dressed, grabbed our flashlights and as we were heading back down the beach to the party, we ran into Carina and Sonja. We told them what happened and both tried calling our cell phones from Carina's phone. They had both been turned off. We did not find anything when we returned to the party to search for our stuff. We told the bartender at the party about our stolen stuff and asked if anyone turned anything in, if he would let us know. We walked back to our hut and decided to call it a night. Thankfully the flip flops were cheap and I had other sandals, the sarong I had on I bought in India which was no great loss, I didn't have any ID or credit cards in my wallet although I did have all the cash that I brought with me to Goa in that wallet (stupid, I know...), the camera was several years old and actually the back-up camera that I brought and only had pictures from that night on it, and the phone was cheap. The bad thing about losing the phone is that getting a SIM card in India was such a pain and now I would have to go and get another one.

Saturday morning I woke up early and couldn't get back to sleep. I decided to go for a run along the beach to burn off some of my frustrations of getting my stuff stolen and to also look in the daylight to see if any of our things of no value had been ditched. I ran back to the location of the party and did find both of our pairs of flip flops but nothing else. It was a beautiful morning so I decided to bring the shoes back to our hut and continue my run along the beach. On my way back to the hut, a young-looking Indian man in a white running outfit whom I had seen on my run to the party beach ran up to me and started running next to me. He asked me what I was doing and I said "running." He asked if he could join me and I said "No. I want to run alone." Then he asked where I was staying and I responded vaguely "On the beach." He then asked if he could go to the place I was staying with me. And again, more forcefully I said "No." As if somehow he thought I was not getting his intention, he then reached over and grabbed my crotch. Completely startled, I stopped pushed his hand away and yelled "Don't do that!" Thankfully at that point he turned and ran away. I continued running toward my hut and before I turned in, I checked to make sure he was not around before going in. I brought our sandals back and told Kim what had happened. I still wanted to continue running as now I had even more frustration to burn off and so Kim got dressed and went with me. After my second run with Kim, we went back to the huts and saw Carina. Carina had wanted to go for a run as well so I went on a third run with her. After all of my runs, I went back to the hut, rinsed off, changed into my beach stuff and went to the beach. Julia wasn't feeling well that morning and so didn't join us at our breakfast place for breakfast.

The rest of the weekend was much improved from the first 24 hours. I finally had a chance to relax and enjoy the weekend with great friends. We laid on the beach, swam in the ocean, ate good food, read (I finally finished the book Curry: A Tale of Cooks and Conquerors and read a great book that I highly recommend especially if traveling to India called The White Tiger), slept, and had great conversations. I'm so glad that I was there with such great friends since the weekend would have been a miserable disaster if all that had happened and I had been alone. I am very thankful that nothing worse happened with that guy on the beach and that I had good friends to help me out and make sure the rest of my trip was enjoyable. Monday night came all too quickly and soon we found ourselves back on a sleeper bus and heading back to Bangalore.

Location:Morjim Beach, Goa, India

Saturday, April 7, 2012

Ob/Gyn (Feb. 17 - 24)

After finishing my two weeks in Emergency Medicine, I spent the weekend in Bangalore. A few of my German friends who had been spending the last several weeks traveling were going to stick around for a weekend in Bangalore. Unmotivated to go traveling somewhere by myself, I opted to stay in Bangalore as well. On Friday evening, I went out with my friends Kim and Ruby and we met up with one of our Indian friends Prash and several of his international friends out at the Skyye Bar (Skye Bar is spelled with two k's, y's, or e's but I can never remember which letter they double...). The bar is really cool and like most of bars/clubs I visited while in Bangalore, was really upscale and per usual, I felt terribly underdressed. The bar is located on the top floor (14th I think) in UB City - a shopping center with all designer label stores. The best part is that the bar is partially on the rooftop and outside with a really cool view of Bangalore below. I think this is the best view of Bangalore I saw while in India and from the rooftop of the bar, it doesn't look like such a dirty, crowded city like it does from the streets. We had a great time that night with old and new friends and at 11:30 when the bar closed, went back to the Annex 3 satisfied with our evening and all of us looking forward to not having to get up the next morning.

Saturday I slept in then spent some of the afternoon shopping on Commercial Street with Kim. Commercial Street is one of the major shopping areas of Bangalore and is nothing more than a main street and several side streets with a variety of stores including some Western-style stores and Western brands of clothing and shoes as well as stands along the sidewalks of the streets selling all sorts of clothing, shoes, jewelry, and bags. After returning from shopping, Kim, Michael, and I went out again with Prash, this time to the Ice Bar. This bar was of course upscale as well and was built up by a hotel and surrounding a swimming pool. A group of Swedish students who arrived during my last week of emergency medicine and were doing their pathology course at St. John's also met up with us at the bar. We had a good time although I think both Kim and I agreed that the previous night at the Skyye Bar was more fun. Sunday was again spent relaxing and gearing up for the week ahead.

For the start of my second half of my time at St. John's, I decided to spend a week on Ob/Gyn. I decided to only post myself there for a week and see how it was and if I liked it, I would stay for another week, otherwise I would switch to a different service. I brought my posting letter to the department office and was instructed to wait in the labor and delivery room for the head of the department. I introduced myself to the interns on labor and delivery and asked if they could tell me when the head of the department arrived. The only problem was that they had all just started on the service and none of them knew who the head of the department was. Within the first hour of sitting in the labor and delivery room, I saw my first vaginal delivery in India. It was fairly traumatic for me as an observer which means that for the pregnant woman delivering, it was probably even more traumatic. The non-private labor room had about 10 beds for pregnant women. When a woman seems ready to deliver, she is brought back to the delivery room where she is transferred to a delivery bed and her feet placed in stirrups. The first traumatic thing I learned was that in India it is common practice to cut episiotomies on all women. I was told that this is because the pelvis of Indian women is typically unfavorable for delivery even though Indian babies tend to weigh less than American babies. Regardless, this was the first episiotomy I have seen cut and although I have nothing to compare it to, it seemed to be quite a large episiotomy. After the episiotomy, one of the consultants and one of the residents both climbed up on the bed with the patient and started pushing down on her abdomen. It didn't seem like they gave her much of a chance to push at all before they decided to help physically push the baby out from up above. Again - I don't know the history of this patient and it may very well be that they had a good reason to start pushing so hard down on her abdomen, but I have never seen anything like this either. The baby was delivered successfully and seemed to be a healthy newborn. I floated between watching the pediatricians do their newborn exam and watching the resident deliver the placenta. Not long after the placenta was delivered and the baby was cleaned up, the baby was brought to the mother and placed on her breast to try and start breast latching to facilitate breastfeeding immediately. This seems to be a common practice as well.

Unfortunately the excitement of this first hour was the highlight of the day. I had high hopes for this posting after such an exciting start but found the rotation to be overall disappointing. Sometime during the delivery, the head of the department had shown up but I missed her. After the delivery, I was told to go look for her on rounds and I searched all of the obstetrics wards as well as the gynecology wards. I found only one group of consultants and residents that were doing rounds and the head of the department was not among them. I did finally find her after all the rounds were done and the first thing she said to me was that she wished I would have found her earlier so that I could have joined her rounding team that morning. I explained that I had been waiting in the labor and delivery room and saw the delivery which is why I hadn't found her sooner. She then told me to go observe in the labor and delivery room and then left. That was the first and only time I saw her during my time on Ob/Gyn. I got very little other instruction as to what I was supposed to do during that week - where I should report, what clinic I should observe - actually, I got no instruction for what I should spend my week doing. After spending the morning on a search mission, I returned to the labor room and read for a while. After nearly 2 hours of reading and only 1 patient in the labor room in latent labor, I decided my time would be better spend outside the hospital and I left.

I returned Tuesday morning to the labor and delivery room and started my day of waiting. I rounded with the Ob docs on labor rounds and after they were through, I went to the operating room and saw a cesarean section for a patient with pre-eclampsia. The C-section was very similar to ones I have seen in the US. After the C-section, I stuck around in the OR and watched part of a hysterectomy and then left after about an hour of not really being able to see much of anything of the procedure. I went back to labor and delivery and again there were no patients in active labor so I decided to go get some lunch and do some independent learning outside of the hospital.

On Wednesday I reported to labor and delivery and found out that it was the clinic day for the labor rounding team. I spent the day in clinic with one of the senior residents. Her clinic was a little slower paced than that of the consultants. I didn't see as many patients as I would have seen with the consultants, but the major bonus to being with the resident is that there was time to talk about the patients between their visits and this was by far the best learning day I had on the whole rotation. I learned that the Ob/Gyn residency is only 3 years long and there is not any sub-specialization within the field after residency. I learned that at least at St. John's, the consultants will not perform speculum exams or bimanual exams in unmarried women. If a patient comes in with a complaint of a white vaginal discharge, she is treated with a cocktail of medications to treat any of the possible causes - Chlamydia, Gonorrhea, Candida, and bacterial vaginosis - without having any cultures or lab tests to find the cause. In clinic, I did see my first patient with leprosy. She was in the Ob/Gyn clinic for other reasons, but as this was my first time ever seeing leprosy, I found that to be the most interesting part of her history. One of the more disturbing patients that came into clinic was a first time pregnant woman who was married to an HIV positive man. There have been a few HIV negative women married to HIV positive men that I have seen in the hospital. The disturbing question that I have is since arranged marriage is very common in India, are any of these women knowingly married off to HIV positive men? I really hope that this is not the case...

Thursday I saw my second vaginal delivery on the rotation. An episiotomy was again cut but at least no one jumped on the bed to push the baby out for this delivery. There was a large audience for the delivery, however. A group of 8-10 medical students on their Ob/Gyn course stood around and watched the delivery of the baby and the placenta and the suturing of the tear and episiotomy. The rest of my time that day I spend looking through the large birth registry that they keep at the hospital. Every delivery is recorded with detailed information about the mother and father including age of the mother, occupation, level of education achieved, literacy, number of previous children, and number of years the couple has been married. These logs were really interesting to look through. The majority of women had "housewife" listed for their occupation and those that were not most often had the same occupation as their husbands. Also, I noticed that many of the women were quite young (18-21) when married and when having their first children.

Overall, my week on Ob/Gyn was not the greatest. It seemed pretty disorganized, and I very much felt like absolutely no one cared that I was there and wanted to learn. I saw a couple of vaginal deliveries and felt that the experience I had that week were enough to get a sense of Ob/Gyn in India. I decided the rotation was not a high enough yield learning experience to spend more than one week posted there and made the decision to spend the next two weeks with pediatrics.

Location:Bangalore, India

Sunday, April 1, 2012

Emergency Medicine (Feb. 6 - 17)

It has been a long time since I have blogged, and I am sorry for my readers that follow and have been waiting in anticipation for the next installment of my great epic tale of my adventures abroad. Now I am writing this weeks after the fact sitting and enjoying US comforts with my friends and family. India was such a mix of experiences - there were times when I really loved it and at least an equal number of times where I really hated it. Overall, it was a great learning experience and I came away with a lot of amazing new friends. It was difficult to blog while there for several reasons: 1 - bad internet connectivity (it's difficult to get connected and when you are, the connection is not always great) 2 - social life (this was a good reason for not blogging - I was busy spending time with my new friends instead of sitting in front of my computer writing) 3 - it's difficult to write about a difficult situation when you are in the middle of it. So - this is why it has been nearly 2 months since my last post and I will do my best now to catch you up on what happened in India.

My second two weeks at St. John's I spent in the Emergency Medicine Department. The ED is a busy place that sees a whole range of complaints a day including trauma. I saw a lot of things in the ED that I had never seen before and are uncommon in the US including 2 patients with snake bites, tuberculosis of nearly every region of the body, fulminant hepatic failure resulting from a hepatitis A infection, a patient with unretractable seizures, and a pregnant woman with previously undiagnosed rheumatic heart disease. I also saw things that I have seen or will see in the US although I think the approach to the care of these patients is very different on the opposite ends of the world.

The emergency department was a great learning experience for me. Out of all of my rotations at St. John's, it is probably the place where I was able to do the most as a medical student. Since the ED was busy and oftentimes the staff and residents had their hands full with patients which meant that I was able to do more to help out. This mainly came in the form of placing patients on heart rate/blood pressure/O2 saturation monitors and periodically checking on them to make sure that they remained stable. The emergency department had fairly new monitoring equipment which is great except for the fact that a lot of the staff did not know how to or were comfortable using these monitors. For stable patients, this wasn't really a big deal. Unfortunately, this was a very scary situation for patients that were unstable including the many trauma patients that came through the ED. Kim (one of the German medical students who was in the ED with me during my first week) and I took it upon ourselves to hook these patients up to monitors and to watch them and alert the staff if the patients' vital signs took a turn for the worst. In addition to keeping track of patient vital signs, I was also allowed to help with some minor procedures - the highlight of which occurred on my birthday when I got to suture a scalp laceration.

The emergency department was also the place where I saw three of the worst things I have ever seen in my life. These three experiences are probably the main reason why I stopped blogging when I did and are also part of the reason that I have made the decision to specialize in Emergency Medicine when I finish medical school. The first of these experiences occurred on my first day in the emergency department. At least in our area of Bangalore, burn patients are brought to the ED. I'm not sure if specialty burn centers exist, but if they do, not all patients are brought to them. This patient had extensive superficial and deep second degree thermal burns on his face, upper body, and arms from a gasoline fire that occurred at his place of work. Since burn patients are brought to burn units in the US, I had never seen a burn patient before. The burns themselves looked painful and uncomfortable, but the worst part was not just looking at the patient. The worst part came when one of the ED residents took the patient back to the minor operating theatre in the ED and started to peel the blistered skin off of the patient's body before administering any pain medication. These are the first screams that have haunted my thoughts since. Kim and I asked and soon after begged the emergency resident to wait until the patient had adequate pain control before continuing but we were ignored. The resident told us that he "didn't have time" to wait for the patient to receive pain medication. Lesson #1: the most important things at the hospital in decreasing order of importance are COST, then EFFICIENCY, then the patient. Until that point, that was the worst thing I had ever seen.

In between my first and second weeks in the emergency department, I decided I needed to get out of the Annex I since it was my birthday and I refused to spend the night of my birthday in with the cockroaches. I booked myself a room at a nice hotel in Bangalore with a pool and a fitness center and a free continental breakfast buffet. The night of my birthday after having a great day in the ED after suturing up a scalp, I went out to dinner at The Chocolate Room with my German friends that were still in town for the weekend. Several of my German friends had headed to Goa for the weekend the day before so it was a small group to celebrate my birthday. We had a delicious dinner and it was a great continuation of my birthday until about 10 minutes before I had arranged for a taxi to pick me up from St. John's and take me to my hotel. I received a text message saying that due to some technical error, my taxi would not be coming to pick me up. Irate - because this is so typical India - I started to cry and complaining about all of the infuriating things about India. Thankfully, one of our Indian friends Mahesh - a psychiatrist at St. John's that I really believe may have magical Indian powers - called someone he knew and taxi was there in 30 minutes to take me to my hotel. Along the way to the hotel, Mahesh kept calling to driver to check on my progress and to make sure that I made it to the hotel okay. Once I arrived, I was given a fresh juice and my things were brought up to my room. Soon after settling in, I received a phone call from the front desk wishing me a happy birthday. They asked if I liked wine, and if so, could they bring me a bottle in honor of my birthday, complimentary from the hotel? Of course I said yes. After the taxi fiasco, it was a great way to end the night of my birthday. The weekend was exactly what I wanted it to be - I was able to work out in the fitness center, swim, eat some good food, sleep in a clean and comfortable bed and returned to check into the Annex 3 on Sunday totally recharged.

My second week in the emergency department brought the second and third worst things I have ever seen with each one being worse than the first worst thing I ever saw in my first week in the emergency department. The second worse thing I ever saw was a trauma patient - he had been hit by a truck and when I saw him in the ED, I saw the entire anatomy of the bottom 2/3 of his right leg. His knee was completely disarticulated and he had an open tibia/fibula fracture near his ankle. The muscle and bone were exposed. Miraculously, his vasculature to his foot was still intact so it looked like the patient had a chance to keep his leg despite the severity of his injuries. Like the burn patient, it wasn't the injury itself that made this the new WORST thing I have ever seen. No, it was the treatment that made this the new worst. The same resident that had managed the burn patient was in charge of this trauma patient and with no regard for patient comfort, the resident began washing out this huge open wound with saline in the emergency department before the patient had received adequate pain medication. The patient had received some, but it was clearly not enough as again the patient was screaming with the aggressive washing out that this oblivious resident was doing. At least this patient was in the main emergency ward room and so the senior consultants stopped him and made him wait for more pain medication before continuing. After washing out the wound, the resident was going to change the dressings underneath the patient's injured leg. If I had not stopped him, he would have lifted the leg (which was in three separate pieces - above the knee, the knee to the distal tib/fib fracture, and the foot/ankle) by himself holding the foot and the thigh and leaving the middle piece free. The middle piece with sharp broken bone fragments and a tenuous blood supply that was barely palpable left free to move about. I actually yelled at the resident at this point and directed him to lift holding the foot and the distal end of the middle piece while I held the proximal part of the middle piece and the thigh and counted to lift and to set the leg down. It took 4 hours from this patient's arrival in the emergency department for him to be taken up to the orthopedic ward. And I'm not sure how long after that he was able to go to surgery. The following day I switched to the afternoon shift to avoid working with this resident and to try and give myself a little break from seeing the WORST things I had ever seen.

The third worst thing I had ever seen which definitely tops the charts in WORST things actually didn't happen with my least favorite resident in the emergency department. This was another trauma patient who had been crossing the street when she was hit by a car and the car drove off. She was brought to the emergency department unconscious and bleeding from her chest. The emergency department was very busy that day and I became involved in her care when I noticed that someone had put the person that brought her into the hospital in charge of bag ventilating her. There are no ventilators in the emergency department so since she was intubated and not immediately brought to surgery or to an ICU, she had to be manually ventilated in the emergency department. I will never forget seeing the man's face who was put in charge of her breathing. He looked scared - I saw his mouth move - one, two, three - then his hand squeezed the bag - one, two, three, squeeze. I went over to him and told him that I could take over. Relieved, he handed over the bag and so began my 1.5 hours of breathing for this patient. As I breathed for her, I watched her shaky vitals signs. I watched her saturation levels drop to the 70s% and watched as I told the consultants and nothing happened. I watched her heart rate rising then falling. I watched her blood pressure start to fall. I watched the jar attached to the chest tube fill up with the blood draining out of her chest. I told the consultants and nothing happened. I went with the patient to have a CT scan of her head and her chest and stood with a falling apart lead apron covering me and no protection for my thyroid and continued to breathe for her. Finally, 1.5 hours later, the head of the department of emergency became aware of this patient and her tenuous status and brought her to the emergency ICU where she was finally attached to a mechanical ventilator. Her hemoglobin was finally measured - it was down to 2.9 from all the bleeding from her chest. The cardiothoracic surgeon was called. There is only one at St. John's and he was in surgery and he is the only person who can open up a chest and stop a bleeding pulmonary artery. Even though she and her family had the money to pay for the surgery, she couldn't have the surgery she needed to save her life. So my patient, a young woman who just moved to Bangalore for a new job, the woman I breathed for for 1.5 hours, bled out of her chest and died that afternoon. That was the worst thing I have ever seen.

Location:Bangalore, India