Tuesday, April 12, 2016

The practice of reflection is integral to fully realize the experience.

I am a volunteer for 4 weeks with Project HOPE. All opinions expressed are my own and do not represent the positions, strategies, or opinions or Project HOPE.

The end of last week added some additional learning experiences on top of the work I have been doing at the hospital. Last post, I talked about how I have worked on teaching the internship students and medical students while at the hospital. After a day in the hospital, one of the internship students asked if I would like to go out and have a coffee or lunch somewhere in the city. It was a gorgeous sunny day and in the 70s (global warming…) and we went to a large national park within the city of Pristina called Germia. We took a bus which cost 0.40 euros to the park. At the park entrance was a bike rental, tennis courts, and an enormous outdoor swimming pool that is filled and opens in June. We walked through the park along a path that threaded through fields where children were playing soccer and on playground equipment. It was spring break here in Pristina, so the children and their families were taking advantage of the warm weather. On the other side of the path was a large hill with flowering trees and trees starting to bud. We walked along this path and stopped at a bench to enjoy the outdoor weather, drank at the fountain with reportedly some of the best water in Kosovo (at least in the city of Pristina!), and talked all along the way. Some teenagers that we passed shouted out a greeting and asked “Where do you come from?” I responded “New York.” He shouted back “I love America! I was just in New York.” We continued our walk to the end of the path where a large restaurant sits amidst the trees and the playgrounds and had a traditional local lunch of peppers in cream sauce with cornbread and garlic bread to dip as well as fresh salads of cucumbers, tomatoes, onions, olives, and cheese. My friend and I talked about everything - current TV shows and movies, hopes and plans for the future. I asked if she would mind telling me about her experience during the war. She said of course - it is one thing that friends don’t talk about much in Kosovo. Many people suffer from PTSD, and now that the war is over, want to put the past behind them. She says she knows everything about many of her friends, except where they were during the war. 

My friend was living in Pristina with her family. She was 11 when the NATO bombing started in 1999. They were initially told the bombing wouldn’t last for more than one week. After 10 days with no end in sight, her family fled south to Macedonia. They spent 5 days sleeping outside at the Macedonian border in a neutral zone then entered into a refugee camp inside Macedonia where they lived for 3 months before being able to return home. She remembers life in the camp to be well organized and structured. They did not worry for food or shelter. The biggest concern she remembers is that her sister was 5 months old at the time they fled Pristina and due to shortages of food, her parents were constantly worried that her sister would not survive. Her sister now has scholarships to study abroad in prestigious universities in the field of her choice. When they returned home, their house was still intact although there had been looting of some of their possessions. They had left everything behind except essential items and passports when they fled for the Macedonian border. I think about the current refugees and migrants sitting along the border in Greece where they are being sent in boats back to Turkey. So many people I have met who were in a similar crisis situation leaving their war-torn country only 17 years ago have been some of the most inspirational people I have met. They are people determined to advance their education and use that education to help improve this new independent nation that the war was fought in order to achieve. 

Later that evening I went to the local mall with one of my other friends. There is a 5-D “60’s” cinema that you can pick two short movies to watch. In addition to 3-D glasses, the chairs move so that you feel as though you are in the movie. When it rains in the movie, you get rained on in the theater. It was pretty entertaining. 

Due to some scheduling conflicts, plans to revisit the refugee transit center in Macedonia were postpones. Instead, my colleague and I decided to explore the immediate surrounding area of Pristina. We had a fantastic guide, Alban Rafuna (www.beinkosovo.com) who brought along his extraordinarily bright 7-year-old daughter Noliana with him. We visited the predominantly Serbian populated village of Gracanica where one of the best preserved Serbian Orthodox Churches/Monasteries is located. Like many Serbian churches, this one is surrounded by a high brick wall with barbed wire on top of it. The Monastery is still in active use by the Orthodox nuns and is beautifully preserved. We were not allowed to take pictures within the church, but the frescoes inside were breathtaking. It is hard to believe that they are the original frescoes from the 1300s when the church was build by the ruling leader of the time. After this, we headed to an archeological site, the old city of Ulpiana which dates back to the time of the Illyrians - the original predecessors of modern Albanians. Three areas have been excavated within a large area of farmland outside the city. It was picturesque with flowering apple tree orchards dotting the countryside around it. Here we met a beautiful stray dog who fed our scraps of food and spare water to. We traveled a bit father out in the countryside up to Novobrdo Fortress which is in process of renovation. The village below was filled with flowering trees surrounding an old mosque and the ruins of a church that have been many years without use. We had lunch at a restaurant atop an adjacent hill with views of cows and sheep grazing on the green grassland below. We took our leftovers from the meal and revisited the stray dog to feed her our scraps. 

Sadly, one of many stray animals in Kosovo

Prizren at night
That evening on a whim, I went on a drive back to Prizren with some friends in order to see the city at night from the top of the fortress. I hadn’t been feeling all that well the past few days after eating far too much of a milk cake that I think was likely going bad (unfortunately discovered post-consumption in the GI ailment that followed and persisted for days). But, sick or not, I did not want to miss this opportunity! I was not disappointed. The city of Prizren is even more magical at night. 

Friday brought along with it another enriching encounter with an inspiring Kosovar who is the executive director of an NGO called Action for Mothers and Children (www.amchealth.org). I was connected with the director through one of the internship students I met who was on the previous rotation through labor and delivery. This foundation has connections to Dartmouth in the US and she connected with them while spending 3 months studying electronic medical record systems at Dartmouth as part of an exchange program. AMC was originally founded in 2009 in conjunction with USAID with grant money. In 2012, that grant money ran out, but determined to continue the work of the foundation, it became a locally run NGO. Its emphasis is on women’s and children’s health with the original mission to reduce maternal and child mortality rates in Kosovo which was one of the highest in Europe. The statistics are mostly unofficial as there is not a system in place for keeping track. They have multiple projects with the primary aim of education. There are 5 educational resource centers throughout Kosovo which offer classes to women and their partners. Most of the classes are aimed to prepare women for labor and delivery and in prenatal care (nutrition, smoking and alcohol cessation). They also have classes on newborn care. Currently, they are working to establish a national screening program for cervical cancer and to create a national transportation system for babies to be transferred to the only Level III NICU in the country in Pristina when a higher level of care is required (currently, the babies are transported privately by car). The aim of AMC is to provide research and evidence-based information to the people of Kosovo and also to use that information to advocate for policy changes. Some of the advocacy is being done for the health insurance system in development to ensure that prenatal care is included as part of the health insurance package. Prior to AMC’s lobbying efforts, this was not included in the original plans. The main office has 5 employees who all take on a number of projects. They are a group of highly motivated people dedicated to the improvement of health outcomes for the people of their country. 

Thursday, April 7, 2016

Finding my niche

I am a volunteer for 4 weeks with Project HOPE. All opinions expressed are my own and do not represent the positions, strategies, or opinions or Project HOPE.

This past weekend, my fiancé Michael came to visit me from Germany. It was his first time in Kosovo. Unfortunately, he started not feeling well the day he left and continued to not feel well the whole weekend. Despite having to take it easy and not being as ambitious in our plans as we had hoped, we still had a great weekend!

Stone Bridge of Prizren
On Saturday, we took the bus to the city of Prizren. Prizren was the original capital city of the region in the era of the Ottoman Turks. It is strategically placed along a river and within a valley of beautiful mountains. In Kosovo, it is one of the areas where Turkish heritage is best preserved - Turkish is still taught in a lot of the schools and the local cuisine tends to have more Turkish influence than in other parts of Kosovo. The bus ride took approximately two hours and en route, Michael slept and I read about the city and formulated a plan for the day of things we may want to try and see while there. We took a walking tour along the river up to a fortress dating back as early as the 6th century overlooking the city. En route up the steep hill to the fortress, we passed by the ruins of a Serbian Orthodox Church - St. Savior. It is completely enclosed within a metal gate topped with barbed wire and is watched over by a caretaker. This Church was destroyed during riots in March 2004 and is in process of restoration. The church itself was built in the 1300s and some of the frescoes on the wall can still be made out - those that weren’t destroyed in 2004. While wandering through the inside of the now open air church, one can imagine the beauty of it when it was complete. Continuing up the steep hill, we reached the fortress and the view was spectacular. We could see the entire city below and the surrounding mountains. Standing on top, we stood quietly and listened as the call to prayer rang out across the mosques in the city below. We grabbed lunch at a place along the river specializing in Albanian cuisine and happened to be present when a large entourage of political figures came to dine at the same restaurant. The roads were blocked off by police cars. After lunch, we continued our walk through the city. We walked past many of the city’s highlights including the League of Prizren which is considered the original group advocating a nationalist movement for Albanians in Kosovo since the middle ages. We saw multiple mosques and another Serbian Orthodox church destroyed in 2004 and now in process of restoration. Sunday, we took a walking tour of Pristina before Michael headed back to Germany.

Serbian Orthodox Church - St. Savior. Destroyed in 2004.
I feel as though I am getting into my niche at the hospital. I have had multiple students, residents, and specialists ask me if I have done any deliveries/episiotomies/c-sections and I said, no, but that wasn’t really my primary focus for being here. This is true, and I really do feel like I have an alternate purpose in being at the University Hospital. As I mentioned in a previous post, I am working towards providing educational resources for the faculty (residents, students, midwives, nurses, specialists - whomever!) to have on hand on labor and delivery so that when there is some down time, they can look at evidence-based guidelines and try to make the University Hospital up to international standards of care. I have emailed some PDF files to one of the residents and provided the residents with a brief textbook of Ob/Gyn so that there is at least something to start from.

Kids playing outside in a public fountain on a warm spring day in downtown Pristina
I have discovered two additional roles for myself that have certainly provided me with a sense of purpose, and I hope have contributed positively to the experience of the others I am with on a daily basis. There are many medical students that rotate through labor and delivery. Medical education is difficult. There are many more students than there are positions available to them after the finish their studies. If you are not at the top of the class, the chances you will find a residency program and especially a program that will pay is limited. After completing 6 years of medical studies (this is a bachelors/masters degree), they do a 6 month internship. Afterwards, they must work for 1-2 years as a general practitioner and then can apply to residency. The number of spots are limited within specialties so there is a chance that the specialty one is interested in may not have an available spot at the time you are ready to start residency. A choice is made to start residency in another specialty or to wait. Residency positions within the university or public hospital system are paid but not a living wage (I’ve hear anywhere between 500-700 euros per year) and private residency training is not only unpaid, but requires the resident to pay for the job and training. For Ob/Gyn, residency is 5 years. After that, many physicians do not make a living wage working in the public hospital system and so have private practices on the side. Because of these limited opportunities in training, many students and residents will leave to complete or do further training abroad, many with plans to not return to Kosovo given the limited opportunities here for work. If such highly educated people are not paid a living wage for their work, I worry that an educational drain will exist in Kosovo whereby everyone who can leave, will leave. 

Medical students very much take on the role of observer when doing their practical part of training (during medical school and during the internship). They are sometimes engaged by the specialists but there is not a lot of teaching that happens at the bedside. Some of the this is the hierarchical culture of the training system but some is just a lack of time - with 10,000-12,000 deliveries per year, there is not a lot of down time on labor and delivery for teaching. I have tried to personally fill in this gap by engaging the medical students and trying to teach things that are applicable to the clinical situation they are observing or to answer any other Ob/Gyn related questions. This is one role I have been trained to do as both a medical student and a resident and I am happy to be able to fill the role of a teacher while I am here.

The other role I have made for myself is being the support person for the woman in labor. Since family members are not allowed on labor and delivery, the first time moms seem the most nervous and unsure. Although I do not speak Albanian, the effect of holding a hand or rubbing someone’s shoulder, head or back when they are in pain gives the support I am unable to provide with words. In my normal day-to-day residency work, I often have too much to do to be able to provide this one-on-one support for the patient in labor. In the US, many of them have family members or friends who come to support them and also have awesome labor nurses who are their support people. It has been nice to take that place for the women who deliver at the University Hospital in Kosovo. For me, this role as part of the care of the patient has been invaluable, and I think more meaningful for the patient than if I were the one sitting on the other side delivering the baby. 

Monday, April 4, 2016

The Halfway Mark

I am a volunteer for 4 weeks in Pristina, Kosovo with Project HOPE. All opinions are my own and do not represent the positions, strategies, or opinions of Project HOPE.

Those who know me well know that I tend to operate a little more on the glass half empty side of things. When I find that the glass is half full, it is positive; whereas, if my expectations are met, I am no worse for wear. 

Kosovar medical students and me after a rousing game of Uno
I would like to approach this moment in my time in Kosovo as a glass half full. Of course, I am amazed that already two weeks have gone by that I have been here, but I am pleased to still have two more weeks to take part as a visiting member of this lovely society in Kosovo. My colleague and I have some working plans for Project HOPE and are looking forward to the implementation phase of our plans. I am getting more comfortable in my physical environment. For example, when I first arrived, the overhead light in the bedroom of the apartment did not work. It still doesn’t work. However, there was a lamp on the desk that does work. The problem is with having enough outlets to charge my electronics. I have a computer that needs charging every night, my personal USA cell phone that I use when I am in a WiFi network that needs charging, my local phone that needs charging, and occasionally a camera battery, iPad, Kindle, portable bluetooth speaker, or iPod. (I realize I’m a bit of an electronics junkie although I will not claim to be an aficionado in anything electronic). When I wanted to go to bed and read, there was no light to use if I wanted my phone to charge, so I read with the backlight of my kindle which often made me very tired and prone to falling asleep prior to 9PM when I first arrived. After a few days in one of the desk drawers, I found an American power strip. This helped the charging problem for all of my electronics except my local phone (which has a European plug) and the lamp. So I could either have a working local phone, or light when it became dark outside. Finally, after two weeks of living here, I happened to wander past and notice the European power strips at the supermarket! So now, I have light AND a charging phone. It’s the small things that can create a lot of joy.

Albanian Flag outside the League of Prizren Museum
The other issue I have had living physically in the hospital at the end of a patient ward is entering the building and getting to my apartment. I am on the fourth floor at the end of the postpartum unit. There is no way for me to enter or exit the building without going through a patient ward. This isn’t so much the problem as the fact that the front doors of the building are locked sometime between 7-8PM and you have to go through a side entrance. This is also not so much of a problem except for the past two weeks, I have had to literally break into the hospital in order to get to the area to go up the four flights of stairs to get to the postpartum unit and walk through that and show my badge and get to my room at the end of the unit. There is a set of double doors and U-shaped iron bar is placed over the handles to create a lock. With some of the doors, you can open them wide enough to squeeze a small hand through and remove this bar. In one of the sets of doors, this is not possible and I had to knock and wake a sleeping patient or visitor (not sure which) that was lying on the bench on the inside and have her open the door for me so I could enter. Well, when I got back tonight (at 8:40 PM) from dinner with friends, I went through the side entrance, through the doors that miraculously did not have the U lock on them, but found that the other set of doors that I was unable to open wide enough to remove the U lock had the lock on. I happened to see that another visitor who I noticed enter the building behind me entered through a corridor that opened into the main area of the hospital. So I backtracked and discovered this open corridor. My life in the evening has just become 1000x easier. Let me tell you, I have so much more appreciation for freedom of movement in so many aspects of life then I did before. From the limited movement available to Kosovaars with the Visa Problem to my difficulties getting to my apartment where I live, I have a new appreciation for the freedom I have in my life to move from one place to another and would number that as something that should be considered a human right. 

Outside the Parliament Building in Pristina
I have thought about this a lot as I have read about the history of the region - I read a book by Robert Kaplan called Balkan Ghosts that discusses the entire Balkan region and its utterly fascinating history filled with conflict and various authoritarian powers and limits placed on the movement of people within the region. It is also something that was in the forefront of my experience visiting the refugee transit center. The whole reason for its existence being limitations of the freedom of movement. It is something I have only given thought to in passing such as thinking about my most important physical possession - which for me is my passport because it allows me the freedom of movement. All of our human ancestors dating back to the start of the species were nomadic - prior to the advent of agriculture, we all came from hunter/gatherer societies that depended on the freedom of movement for survival. Limitations in the freedom of movement has impacted survival.

Speaking of movement, Michael was visiting this weekend and we went on a day trip to Prizren, Kosovo. Unfortunately, he was feeling quite sick after he got here so our trip was not as full as either one of us had hoped it would be, but we still had a great time visiting a new place. 

Thursday, March 31, 2016

Through our conversations we can change the world for the better.

The best part of traveling is the people that I meet. My favorite part of the past two weeks has been having conversations with people who were born in a different time, a different place, speaking a different mother tongue, practicing a different religion. Our commonality is that we are meeting in this place and in this time and it is through this shared experience that we both learn more about each other and through each other, learn more about the world that we live in. 

Last night I spent the evening with a friend of mine that I met the first day I arrived in Kosovo and had spent Sunday/Monday with in Skopje. We had dinner at a thai restaurant in downtown Pristina, very appropriately named “Thai Restaurant.” We met up with some of her friends including both locals and internationals and sent an evening on the town. I hope to be so inclusive when someone new comes to the place where I live. I was immediately a member of the group and had a great time dancing salsa at the Cuban restaurant (my second salsa dancing at a Cuban restaurant/bar in the Balkans!), talking, and enjoying a beautiful evening out in the city. I’m usually the underdressed person of the group, but this group really put me to shame despite my efforts with the limited clothing I brought with me. It didn’t matter. There was zero judgement. 

Dancing salsa at a Cuban restaurant/bar.

The end of my day today, there was a new group of medical students that had arrived on labor and delivery. They were there for a 12 hour shift that they do once every 2 weeks. One medical student in particular immediately started talking to me and asking me questions about where I was from and what brought me to the University Hospital in Pristina. Soon, there was a group of three students an myself discussing what brought us to the field of medicine, how one chooses a specialty, various methods for learning (textbooks, online), and plans and goals for the future. Many of them hope to go abroad to do their residency training. Their English is excellent and many of them are currently studying German as Germany is the place that the majority would like to go to for training. 

One of the students was born in Germany. His family is from Kosovo but moved during the war the moved back to Kosovo two years after the war ended. He is doing his medical school here but would like to return to Germany for his residency and hopes to live and work there. He went to medical school for a love of science and a fascination for how the human body works.

Another female medical student was born in Kosovo and has “never left Kosovo.” Her mother is a doctor and she became interested in medicine because of what she witnessed of her mother’s work and her mother’s satisfaction with her work. She has never thought about doing anything else. She was in Kosovo during the war at the age of 6 and although she was so young, she remembers the time and the fear that gripped her country. She also hopes to go to Germany for her residency training but definitely wants to return to Kosovo. She says that she wants to go to Germany to have better experience and better training so that she can bring that back to the people of Kosovo. There are more doctors being trained here than there are training spots. She has a lot of hope for her country and is thinking about pursuing a career in gynecologic endocrinology or pediatrics.

A third student was talking about how she is fighting some of the traditions of her family. She says that families are proud to have a son become a doctor as he has job security and can provide for the family. Some of her more traditional family members don’t encourage her studies because her role is to get married, take care of the home, and have children. Her response, “I don’t want to do that.” She is one of so many fiercely independent women I have met in my brief time in Pristina.

After talking about our careers and futures, they invited me to their medical student room to hang out. They all pulled out various salty and sweet snacks and we played several rounds of the card game Uno. As has been my consistent experience, they spoke English for my benefit even if it was limited or unsure about words. It was a wonderful way to spend an afternoon.

I have met two other medical students during my time here. One has spent time in the US on an exchange program where she was working with electronic medical record systems. She was offered a scholarship to do a combined MD/MBA program but wants some more life experience before committing to further school. During the war, her family were refugees in Albania and were taken in by an Albanian family. The male of the household was a physician. They were treated with kindness by strangers who saw their needs and took them in, provided them with safe shelter and food.

Another medical student did not have the freedom to leave during the war. Her family stayed. They were isolated with other ethnic Albanians and forced to live in the top floors of apartment buildings during the NATO bombings of 1999. Though she was 9 years old at the time, she vividly remembers the stress and the fear that they lived in through that time. 

One of the residents also hopes to bring her family to Germany for more training for herself and also to stay there for hopes for a better life for her daughter. She told me of the challenges of being a working woman with a family and the pressure she is under from her husband’s family to do more at home and that her primary job is to “look beautiful.” 

Another resident spoke of the difficulty they have in Kosovo to travel. She wants to see the world but “the problem is the visa.” Since Kosovo is not internationally recognized as an independent country or a part of the UN, it can be difficult for people to obtain visas to travel. There are many barriers - some of which she has overcome as both she and her husband are employed with stable jobs. Some of the countries require a savings of anywhere from 6000-10,000 euros in order to obtain a visa. It is prohibitive for those who want to take a vacation in another part of the world, to widen their global perspective.

After the events in Brussels, I had a conversation with another resident. She spoke of her Muslim religious faith. She was horrified by the events of Brussels and the implications this may have for people who share her religious traditions and faith. She said, this is not Islam. What these people do is not Islam. She also spoke of the Kosovar love for America and Americans the gratitude they have for ending the war and supporting their independence. Every day we have a  coffee together and one of these days, we will have one together “outside - out of work.” She is one of the only colleagues I have had that greets me everyday with a handshake or a hug and always when she sees me (even if it is only 15 minutes since I last saw her) how I am doing.

I love a good story and the people of Kosovo are filled with good stories and the courage to share them. I have learned much about the country and its people in my short time I have had here. My most valuable learning has not been of obstetrics and gynecology, it has been learning about this country with all its turbulent history and its perpetually inspiring people. 

Wednesday, March 30, 2016

Back at work.

I am a volunteer in Pristina, Kosovo for 4 weeks with Project HOPE. All opinions stated are my own and do not represent the positions, strategies, or opinions of Project HOPE.

I mentioned at the end of last week that I had some ideas for what to do in terms of my work for Project HOPE. One goal listed online for the work at the University Clinical Center was to train all nurses, residents, and doctors in basic life support (CPR). When I arrived, it seemed this was not a very helpful goal for the current situation in the Obstetrics and Gynecology department. For one, there is no equipment to use to help train people. There are no projectors for powerpoint presentations or even any computers at all on labor and delivery. There are computers in many of the offices and internet (although it requires a username and password), but nothing really available for the teaching of BLS. In addition, many people don’t speak enough English to be able to ask questions. Many people understand English but don’t speak it well enough to ensure that the teaching was understood and therefore effective. Also, there are no mannequins to practice CPR on and their are no non-rebreather masks to use to practice safe CPR. Also, BLS teaches about the use of defibrillation which when you have access to it, is what makes CPR most likely to succeed in saving a life. I have not seen any defribillators on the unit. And, most people who require CPR will likely need a higher level of care following resuscitation - higher level of care meaning an ICU. Although I am certain there is an ICU within the University hospital, the hospital is a series of separate buildings and there is not an adult ICU in the obstetrics and gynecology division. I am not sure where it is or how patients would be able to move from here to there in a timely fashion. The only patients who seem to be able to receive higher level of care quickly are the neonates as the NICU is on the same floor as labor and delivery. 

The sterilization equipment on labor and delivery.
All record keeping is done on paper and there are no computers on the labor and delivery unit. Computers are not just helpful for documentation in an electronic record, they are also helpful as a source of information and learning for residents, midwives, and staff here at the hospital. Without a computer and without any textbooks, there is a deficiency in resources available for the staff to learn from. There is a lot of teaching that goes on especially from midwives to residents and the specialists to the residents and midwives and medical students, but there are no resources available while at the hospital to refer to for management questions or even just for learning to enhance knowledge. Many of the residents are learning German in hopes of going to Germany for further training and possibly to live. There are not as many opportunities here for them. I hope to at least help change the availability of education resources for them, and this is what I plan to work on through my time with Project HOPE. I have started by emailing some PDF files to one of the residents who speaks English. She has been very thankful for these and asked if it would be possible for me to send her more to learn from. Michael is hopefully going to be able to bring a textbook of obstetrics and gynecology for the residents to have to keep in the hospital. One of the residents owns a pocket manual of ob/gyn and another resident owns a book geared toward medical student education published in the UK in 1988. My co-Project HOPE volunteer and I are going to work on a proposal to get a computer on the labor and delivery unit which can be used for education. If they have a computer, PDF files and online textbooks could be accessed by all. We live in an era where so much information is available online and if people are guided where to look for good information, there is so much that can be learned. I hope to help provide some of these resources. 

In terms of practical experience, those who work at the University hospital are not lacking in deliveries. As I mentioned before, during the slow time of year, this hospital averages around 40 deliveries per day and up to 80+ during the busy time of year. They keep a record in a large ledger book of all the deliveries done during the day. Here are the numbers from the past week: 3/23: 40. 3/24: 42 (7 c-sections). 3/25: 21. 3/26: 15 (really slow day). 3/27: 15. 3/28: 25. 3/29: 36. 3/30 by 2PM: 25 (14 of which were c-section deliveries). 

The empty 4th floor operating room on L&D
Yesterday, I observed my first c-section delivery at the hospital. It was an urgent c-section for non-reassuring fetal heart tracing. The patient was fully dilated but the head was still high and there is not a lot of access/options for operative vaginal deliveries. She was taken for an “urgent” c-section. I’m not sure that an emergency c-section can really happen in an emergent manner here. Labor and delivery is on the 4th floor. The operating rooms are on the 2nd floor. There is an operating room on the 4th floor but there is no equipment or bed in the OR so it is basically non functional. Anesthesia was via spinal. Reusable cloth drapes are used. The glove sizes available are 7.0, 7.5, or 8.0. The technical parts of the c-section were the same as how we do it in the US. The most interesting part about the whole experience was that the operating rooms are adjacent to each other and all the doors were open - the door between our OR and the neighboring one (which also had a surgery going on simultaneously) as well as the door into the hallway. Betadine is used for skin prep prior to surgery and is used liberally. It is also poured on the dressing before it is applied at the conclusion of the surgery. The patient helps to move herself onto a transfer bed after surgery by pulling on a triangle attached to the top of the bed while the anesthesiologist and resident help pull the patient’s body (on a cloth placed beneath the patient prior to surgery) and legs. Per one of the residents, the infection rate is “high” after surgery. I’m not exactly sure what that translates to in terms of percentages. It was interesting for me to see the flow and see how everyone performs their job in a surgical setting. 

Cutting and folding bandages
My typical role during a delivery here in Kosovo is to provide support for the mother. As I have mentioned before, no family members are allowed on labor and delivery. I hold her hand, provide water to drink and a wet cloth for the forehead if desired, and talk to her. Even if she doesn’t understand what I am saying, I think she understands my tone of voice and a smile can go a long way. It is a different role than I typically have in the US, but a valuable one and one that helps me feel that I can contribute to the birthing experience for the women here in Pristina. I also helped fold gauze sponges today. Instead of having individually wrapped gauze, they have a large role that gets cut by hand into smaller squares than folded into individually wrapped pieces that are used in the delivery room. We filled two large metal containers with them to prepare for the upcoming deliveries. It was a good day’s work. 

Tuesday, March 29, 2016

New Country, New Friends, New Life Experiences

(I am a volunteer for Project HOPE for 4 weeks in Pristina, Kosovo. All opinions stated are my own and do not represent the positions, strategies, or opinions of Project HOPE.)

Stone Bridge: Skopje, Macedonia
On Sunday I took the bus to Skopje, Macedonia. My travel companion was a lovely woman from Kosovo who has worked very closely with Project HOPE as part of her job in Pristina. She is my sister’s age - born at a time of conflict and war in Kosovo and was once a refugee herself. She was interested in visiting the refugee transit center in Macedonia and so we traveled together. In the 1990s, when Kosovo was wracked with war, many Kosovaars fled the country and headed south to Macedonia and Albania. Many of them were resettled in western Europe, the US, Australia, New Zealand. Some of them have returned. My travel companion hadn’t thought of coming back to live permanently here but was visiting on a holiday, got a job, became invested in the work she was doing and a year later, she is still here working very hard to help improve the lives of the people of Kosovo. Much of her work has ties to the University Hospital which is how she came to work with Project HOPE and how I came to meet her. 

One of the many statues of Skopje

Mother Teresa
The bus ride through southern Kosovo was stunning - we drove through winding roads through mountains and valleys and small villages. I imagine that when spring comes into full bloom, the hillsides are breathtaking. It was even without the green of spring. It took about two hours to get to Skopje and we were picked up by one of our colleagues from Project HOPE at the bus station. We toured the city - it is a lovely old city with the Kale Fortress overlooking the city that dates back to the 6th century, a stone bridge from the 15th century, and a 66-meter high cross on the highest hill surrounding the city. The city itself is full of statues of famous revolutionaries from Macedonia’s history as well as depicting other historic events of the country. There are also a multitude of memorials for Mother Teresa who was born in Skopje. Fitting to spend Easter at the birthplace of such an iconic figure within the Christian faith. A Turkish bazaar was reminiscent of bazaars in Istanbul. We had a whirlwind walking tour of the city complete with coffee on a touristic boat sitting in the river. This was followed by a spectacular dinner with bread and garlic and pepper dipping sauces, fish soup, rakia, local wine, and entrees of beef, pork, and chicken that tasted even better than they looked. The rest of the Project HOPE team joined us for dinner then afterwards, we headed to a Cuban bar and danced salsa throughout the evening. The apartment we stayed at overlooked the stadium and had an amazing view.

Refugee Transit Center
On Monday, my co-Project HOPE volunteer here in Pristina met us in Skopje. We went to the Project HOPE office, had breakfast, then headed out to the refugee transit center in Tabanovtse. There are currently 1500 refugees that are living at the transit center and have been there for approximately one month. The refugees are a combination of Syrian, Afghani, and Iraqi people. Both Farsi and Arabic are spoken in the transit center. The people usually do not stay for as long as they have but due to border closings within western Europe, the cascade effect has been people stuck wherever they made it to at the time of the border closings. The most recent agreement between the EU and Turkey is that any refugees that land in Greece will be sent back to Turkey and Turkey will take them in return for a better relationship and financial incentives with the EU. It is unclear to me what will happen to the people in the transit center. A particular date was set as part of the agreement that anyone who was in Europe prior to that date would be placed in western Europe and anyone arriving afterwards would be sent back to Turkey. The people who are in Macedonia do not wish to settle there. Macedonia, like much of the Balkans, has considerable economic hardship. With a near 25% unemployment rate, refugees are uninterested in competing for an already limited number of jobs. The infrastructures is not strong enough to support the influx of people they have experienced over the past year in transit, let alone to take them in. And the refugees are stuck - they left war and violence and insecurity in the hope for a better life for themselves and for their children. The current refugee population has changed as well. Initially, it was primarily men making the arduous journey and now it is many women, children, and elderly. It is only by fortune that I was born in a place where I have stability and safety in my life and they were not. We are all one human community and we have an ethical and moral responsibility to care for our fellow brothers and sisters in their time of need. The news is filled with horrible stories of terrorists and terror attacks - the refugees are refugees because of the terrorists and terror attacks. They are not leaving their homes, leaving all their possessions, and risking their lives to instill terror. They are leaving to try and save their lives and the lives of their children. 

Project HOPE Clinic
In the transit center, there is a red cross clinic that sees patients and serves as a sort of medical triage. Patients that need more advanced care are sent to the Project HOPE clinic - a one room makeshift clinic with basic medical supplies. One doctor, one nurse, and one logistician work in alternating 12 hours shifts with another team to care for the 1500 people in the camp. They see about 60 patients per 12 hour shift. Most of what they see lately has been children with fevers. It has been a long, cold winter for many of the people living here and they are fighting off disease from living in crowded conditions in a harsh environment. There are between 40-60 pregnant women within the transit center. A local gynecologist comes daily from 3-6 to see these women and provide them with prenatal care.

Single Family Housing Units
The transit center was well organized and clean. There are multiple single family housing units as well as some larger tent/buildings that house multiple people. Many people were outside - doing the washing, the kids were playing soccer and volleyball and catch. People were talking to each other and to us. I didn’t know what to expect when I went, but I left impressed with the organization and inspired by the people who are working there. There are cleaning groups that come three times a day to remove garbage and clean the camp. People bring meals several times a day to feed all 1500 people. Various organizations have set up children’s centers with toys to play with and to play on. There is currently no school system set up, but as it is unclear how long any of the people will be staying there, it probably will not be set up. The people working there are there for the right reasons - they have been moved by this terrible crisis that has displaced millions from their homes and they are contributing the skills that they have to try and help make the lives of their fellow humankind just a little easier on the way to a better life. 

These two guys asked me to take their picture. It is a picture that could be any two guys anywhere in the world. We are all one human community.

Our visit was short, but powerful and a lasting experience for all of us who came and saw. 

3 friends + 2 passports = stuck at the border
Our trip back to Pristina was more adventurous than expected - one of our group left her passport in the Project HOPE car in Skopje and was not allowed to cross the border from Macedonia back into Kosovo. The three of us travel companions got off the bus and waited at the border crossing for our friends from Project HOPE to come and rescue us - they had found the passport and delivered it. Not knowing if we would be able to catch another bus to Pristina at the border, we went back to the bus station in Skopje and bought tickets for another bus trip back. We made it back, about 3.5 hours later than planned but we made it safe and sound ready to sleep and to start another day.

Saturday, March 26, 2016

When I'm not at work

The beautiful thing about an elective is that you don’t have to spend 80 hours a week on average working in the hospital. This would have been true if I stayed in Rochester for my elective or elsewhere in the US. However, if I am able to travel, travel I will. I think it is only when you take yourself outside of the familiar and the routine that you learn the most about yourself. 

I spent the week getting oriented at UCCK (University Clinical Center - Kosovo) and starting to understand how labor and delivery works at the university hospital. The first few nights I was here, I was incredibly tired from traveling, being recently sick with a cold, and jet lagged that I went to bed by 8PM or earlier every night except Thursday night. 

Thursday, I met my Project HOPE counterpart who has already been in Kosovo for the past 6 or so weeks working in the hospital. She had taken a holiday in Tirana and we met after she returned to Pristina. I saw the essentials - where the grocery store is, where I can buy shampoo, the good restaurants near the hospital, and where to get a SIM card. Now I had coffee, a phone, and items for daily living! She also invited me out for dinner with another friend of hers living in the city - a guy named George who is from Hawaii but whose parents are both physicians that trained at the University of Rochester - small world. We went out for some traditional Albanian food at a restaurant in downtown Pristina. The food was good although more expensive than my usual meal (although I can’t complain about a fancy restaurant charging 7 Euros for an entrée) and then we went to a bar owned by a Scottish ex-pat where trivia is hosted on Thursday nights. We didn’t stay for the whole thing, but enjoyed the time we did have and overall did pretty well as a team. We were certainly contending for the championship with 3 rounds to go. 

Today, I spent the morning walking through downtown Pristina and seeing some of the free signs of the city. I saw the Newborn sculpture - a sculpture created after independence in 2008. It is repainted every year on Independence Day (17 February) and over the year becomes covered in graffiti until it is repainted again in a different color scheme. This year it is a blue sky with clouds and barbed wire. Across from the Newborn sculpture is the newest memorial of the war. It is the face of a woman made up of a mosaic of coins that each depict this woman. The word “Heroinat” is at the bottom right (Albanian for heroines). This woman represents all the women who suffered atrocities during war. It is a powerful and beautiful memorial. I had to meet someone at noon so I started to head back towards the hospital. On my way, I took a detour down Bill Klinton Boulevard (yes, Clinton spelled with a “K”) named for Bill Clinton. At the bottom of the hill, there is a statue of Bill Clinton next to an American flag and the building behind it with a large picture of Bill Clinton saying “Welcome.” Around the corner is a store called “Hillary” named in honor of Hillary Clinton. 

For lunch, I stopped at a bakery and had a traditional Albanian pastry filled with meat that was delicious and cheap (0.70 Euros). Tomorrow I will take the bus to Skopje, Macedonia. Skopje is the birthplace of Mother Teresa which is a good way to celebrate Easter Sunday. I am heading to Skopje to stop over on my way to a refugee transit center on the Macedonia-Serbia border on Monday. 

Living in Kosovo for the past week has been enjoyable and very easy. People are friendly, the food is delicious and cheap (most days I spend less than 5 Euros on food eating out for most meals), and it is a safe place to walk around. Today walking through downtown, the streets were full of people walking together or alone, shopping, eating, drinking coffee. There are a number of stray dogs wandering the streets although fewer than I experienced in either India or Uganda. Smoking is very common in Kosovo and unfortunately the idea of indoor spaces being entirely “non-smoking” is not a reality. Even non-smoking areas are adjacent to smoking areas and the smell has permeated some of my clothing. Most of the people I have met have commented on how young I look. I hear this in the US as well, but not as frequently as I do here. When I tell them that I am 31, they are surprised and say they would not think me older than my early 20s. I have been fortunate to be born in a country that has not gone through recent war on its own soil, where pollution is limited, and it helps that I don’t smoke. 

I probably won’t post for a few days as I will not have my computer with me in Skopje and I anticipate a late return Monday night or Tuesday morning. Until then!

Friday, March 25, 2016

Learning the Flow when Giving Birth at the University Hospital in Pristina (24-25 March 2016)

(I am a volunteer for Project HOPE for 4 weeks in Pristina, Kosovo. All opinions stated are my own and do not represent the positions, strategies, or opinions of Project HOPE.)

I am always amazed every time I travel to a new place how welcoming and friendly people are. I don’t speak Albanian, I am an outsider coming in to learn and to find ways to help “improve” the provision of care, and I ask a lot of questions. I feel fully embraced by the staff that I have met in the Labor and Delivery department at the University Hospital and am so blessed to add them to my circle of friends. Sometimes when I get bogged down in the drudgery of my day to day work as a resident in Rochester, NY, I forget why I went into the field of medicine in the first place. Over the past three days, I am starting to remember again why I chose this profession and why I chose Ob/Gyn in particular. I am inspired by the women and men I have met here, their dedication to patient care, and their passion for learning. 

The Obstetrics and Gynecology Clinic is 4 floors with each floor having its own area of focus. Pregnant women who plan to deliver at the University Hospital can come up to two weeks ahead of their due date to wait for the onset of labor. There is a ward in the clinic for these women to stay. There are also wards for gynecology, oncology, and “pathology” - the women who have complicated pregnancies (hypertension, pre-eclampsia, diabetes, etc.). 

"Labor Corral"
When any of the pregnant women go into labor, they stay on their respective floors until they reach at least 5cm dilation and +/- broken water. At this time, they are moved to the top floor to the labor and delivery unit. There is series of three rooms with two beds per room that I call the “labor corral.” Women are here until it is time for them to start pushing. The labor corral is a cluster of three, three-walled rooms with large windows encompassing the majority of the wall between them, sort of like a fish bowl. The staff room is adjacent to these rooms and all the labor rooms are visible through the large windows. Sometimes there are more laboring women then there are beds available. The women are here alone - no family or friends are allowed on the labor and delivery unit. They bring a bag of supplies with them including clothes for during labor and afterwards, water and other drinks, wet wipes to clean themselves after delivery and for the cleaning of the bed, and clothes and blankets for the baby. The women are each other’s support throughout the labor process. There is a fetal monitor in each of the rooms and doptones are intermittently obtained. 

Exam Chair
There is a specialist who checks the cervical dilation of each of the patients at prescribed times throughout the day. The women are walked to a nearby room with small steps leading up to a half table with stirrups. One by one, the women sit at the edge of the table and are examined. The resident sits at the desk to the side and records the exams on a labor curve and also records the plan (continue “passive” labor, stimulation of labor with oxytocin…). The other residents, nurse midwives, other specialists, medical students, and techs are all present for the examinations - sometimes as many as 15 people are in the room for each of the examinations. Once a woman has her cervical exam, fetal heart rate is obtained with a fetoscope and documented, she gets up and walks back to the labor corral. The tech removes the dirtied cloth and places a fresh one down on the table for the next patient.

Delivery Room
Patients are not just checked at the time of the specialist examination. While in the labor corral, the residents will also periodically check the patients. When a patient reaches full dilation, a resident and midwife bring the patient to a delivery room. The delivery room is already prepared for delivery with the bed broken in half and stirrups up. Pushing never seems to last for very long - the midwives are very active in helping the patient move towards delivery. For most women who are pregnant with their first child, an episiotomy is cut without local anesthesia during one of her contractions. The fetal heart rate monitor is brought into the room, if one is available, for doptones between pushing. If no fetal heart rate monitor is available, the fetoscope is used to assess fetal heart rate between pushes. After delivery of the baby, baby is immediately placed on mom for skin to skin. The cord is clamped and cut and an additional person in the room brings the baby to the scale and weighs it. Afterwards, the baby is wrapped in a series of blankets ending with a thick fleece blanket and either left on the warmer or given back to mom. In the meantime, the midwife administers 10 units IM oxytocin, delivers the placenta, and examines for lacerations. The resident is documenting throughout. After placental delivery, the resident brings up a stool and a light and repairs the episiotomy. 1% lidocaine is used for local anesthesia (approximately 4-5cc). There is only one size suture available for repairs, size 0 braided dissolvable suture. The episiotomy is repaired, the woman is cleaned off with the wet wipes she provided, the foot of the bed is replaced, and she stays with her baby in this room for approximately 2 hours. 

Standard Delivery Cart: Top left jar with hand cut and folded mic pads, far left container with scissors for episiotomy, next to that is container with sterile forceps and needle driver, top right fetoscope 
At the public university hospital, epidurals are not available. There are no options for pain management during labor. Although women have been delivering babies for centuries without analgesia, this is so removed from my usual day to day experience in the United States that I find myself in awe of the strength of these women as they deliver their babies with only the support of each other during labor and the support of the health care workers during delivery. 

Over the past two days, nearly 90 women have delivered their babies at the University Hospital. This is the slow time of year.

The big question for me is how do I take the observations and experiences of the past few days and use them to contribute to improving the system to provide better care for patients, better health care administration, and better education? I have some thoughts on this, but for now, it is Friday and I am looking forward to exploring my new home. 
Delivery room supply cabinet with medications, sutures, syringes, needles

Fetal heart monitor and reusable monitoring straps

Thursday, March 24, 2016

A Day in the Life on Labor and Delivery - 23 March 2016

(I am volunteering for 4 weeks with Project HOPE at the University Hospital in Prishtina, Kosovo. All opinions stated are my own and do not represent the positions, strategies, or opinions of Project HOPE.)

Obstetrics and Gynecology Clinic
Despite going to bed at 6:30 last night, I still woke up to my alarm at 6:30 feeling tired. I attribute that to the jet lag. I met with the head of the nursing department at 8AM this morning and also met with one of the Gynecology staff. I was brought up to the “normal” labor and delivery unit which is on the same floor where my apartment is. This hospital is quite busy as one would expect given that the average age of the population is in the 20s and >70% of Kosovaars are less than 27. They average 40-50 deliveries per day in the “slow” winter time and more than 80 per day in the “busy” summer time for a total of more than 10,000 births per year. There are 6 resident physicians who work here during the day (7AM - 2PM). They do three 24-hour call shifts (I think per week although this wasn’t clear) and at night, there are three residents present and three specialists. Once finishing high school, medical school lasts for 6 years after which they spend 1-2 years as general practitioners before they can specialize. Ob/Gyn is a 4 year training. There is not a specific training program per se but instead 4 years of training. They spend about 3 months in a department at a time. 

The view of my department
The first delivery of the day was a bit of a throwback to my very first day of residency. The woman was lovely. Women have to be at least 5cm dilated and have their water broken before they can be brought to the labor ward. Once there, they stay in a “labor” room with two patients per room and no curtains to separate them. Sometimes they have cervical exams in this labor room and sometimes they are moved to a separate checking room which has a half-bed and stirrups. Once a patient reaches fully dilated and is ready to push, she is brought to a labor room. These rooms are individual. No family is allowed in any part of the labor department. The labor bed is prepared for delivery by already being broken down with stirrups up. A bucket sits below the half bed to catch fluid and the placenta after delivery. The woman pushes, most often an episiotomy is cut, and she delivers her baby. This woman pushed like a champ and her baby came quickly and was placed on her abdomen until the pediatric nurses arrived. The pediatric nurses will dry the baby and weigh it and then wrap it in a series of blankets. In the meantime, the episiotomy is repaired. Epidurals are only available at the private hospitals for laboring women and are not available at this university hospital for normal labors. They do provide lidocaine prior to the repair. I held the woman’s hand as she pushed and watched her face light up with joy after her baby girl was placed on her abdomen. As the episiotomy was being repaired, I started to feel quite light-headed and really wishing I had figured out how to eat breakfast prior to starting my day. I let go of the woman’s hand, grabbed my coat, and walked to the end of the hallway where there was an open window and sat down. Shortly thereafter, several nurses and residents approached me and asked if I was okay. I was, just embarrassed. I sat for a while in one of the nurse’s rooms and received a very kindly lecture on how I just need to tell someone if I don’t feel well as they are more than happy to help me. 

I met several residents and went to their resident call room where we paused for a breakfast. One of the residents ordered breakfast for me from a local place which was delivered. We had our coffee, I had a chicken sandwich, and we had a leisurely breakfast. Then back to work.

The “specialist” (attending) does the checking of the patients at various points throughout the day. Nurse midwives do the deliveries and the residents do the repairs. They do not have enough fetal monitors for all the patients so most women have intermittent monitoring during the labor process. Some will have monitoring if they are complicated or demonstrate non-reassuring fetal status. The records are all kept on paper and like in the US, the residents are primarily responsible for the documentation. They also keep a large book with all of the deliveries from the hospital. They have between 4-6 scheduled c-sections per day and approximately 4-6 unscheduled c-sections. The c-section rate for the country is about 30%. One laboring woman was taken urgently for a c-section for a fetal bradycardia. There were no bells, no obstetrics team, just nurses and residents working very quickly to get the patient in a wheelchair to be wheeled down to the operating theater on the floor below. 

Many people are in and out of the room during the labor process and each has their set role. After delivery of the placenta, someone comes to mop the floor and replace the placenta bucket. The repair is completed, the foot of the bed is added, and the woman has two hours with her baby in this room before being moved elsewhere.

My Breakfast, Lunch, and Dinner with WiFi
I ventured out and found the cafe owned by a friendly man who spend several years in Britain. The food is delicious and cheap (2 Euros for a lovely greek salad, 0.50 Euros for a Turkish coffee, and 0.50 Euros for sparkling water) and the WiFi is excellent. The best part is that it is open from 0600-2200 every day except Saturday which means I have a place to grab breakfast in the morning!


My apartment in the hospital is the closest door on the left. The door to antepartum is on the right.
My room on the inside.