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.

Wednesday, March 23, 2016

Kosovo - Arrival - 22 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.)

It is rare that I find myself truly “off the grid” but indeed, this is where I have found myself in Prishtina, Kosovo. After 13 or so hours in the air, I had an overall uneventful trip to Prishtina International Airport Adem Jahari. At Passport Control, my passport was stamped and I was told “welcome.” No questions asked. I was able to access the internet for 15 minutes to let my parents and Michael know that I arrived. My bag arrived also uneventfully, I put it through a security scanner and when I walked out of the baggage claim, Angel from the Macedonia Project HOPE headquarters was here to pick me up. I slept horribly (as usual) on the plane ride over and so was hoping today would not be a long day. We drove to the University Hospital and spent at least 20 minutes looking for a place to park. Hard to believe, but this parking situation may even be worse than Lot 1. 

We first walked to the cafe and had a macchiato. Kosovo is known to have good coffee, and I was not disappointed. We then proceeded to the gynecology building where we were to meet with the nursing director. She was not there. Apparently Kosovo time is a bit similar to my experience with Uganda time - the time is more like a suggestion and you can expect people to be late. We then walked up to the apartment where I will be staying the next four weeks. It is at the end of the maternity ward and quite adequate. There is a pull-out couch that serves as a bed, a private bathroom with shower, a couple of small dressers (with some stuff in them perhaps from prior volunteers?) and a television that does not work. There is a desk and another small couch. The WiFi does not work which is unfortunate.

The remainder of the day was spent in a series of meetings. I never had time to change out of my plane clothes so spent the entire day wandering around in day-old plane clothes consisting of black Fabletics pants, a Reebok t-shirt with the phrase “we can work it out” on the front, and a Reebok jacket. Way to keep it classy, B. Angel comes to Kosovo about once a week and tries to meet with all the people he needs to on the days he is here to ensure that Project HOPE’s projects are functioning smoothly and to troubleshoot on the ground. Part of Project HOPE’s mission in Kosovo is with supplying essential medications. The health care workers in Kosovo assess what medications they need and have difficulty obtaining and Project HOPE works to get these medications for them. Most of the medications are chemotherapeutic agents for a variety of cancers. They are also working on a project for a medication to treat cystic fibrosis. 

The interesting thing about Kosovo is that it is a new nation (independence 17 February 2008), has the youngest population in Europe (average age in the mid 20s with approximately 70% of the population < 27 years), and is working on building infrastructure form within. Prior to independence, it was run by the United Nations, and prior to that, it had experienced years and years of war and was part of a larger nation (Yugoslavia) that ran the infrastructure. One of Kosovo’s current struggles is that it is not uniformly recognized as an independent nation. Major changes are happening in health care policy such as revamping health insurance so that all people will have access to care and that care will be able to be provided. Providing care requires revenue and in the current system, enough revenue is not generated to sustain the health care system. 

Things I have learned:
  • Turkish Airlines is nice. Good food served with real silverware (even in economy class), and they give you a little toiletry kit with slippers, socks, eye mask, toothbrush, toothpaste, and lip balm! They are receiving advertising from the new Batman v Superman movie so all of this came in a batman/superman case. Amazing.
  • There is a reason people dress reasonably well on planes, you may end up meeting with the Minister of Health Financing, and if you happened to wear “athleisure,” you may feel particularly underdressed…
  • People are very friendly and even if they do not know you, they will refer to you as “my friend” by the end of a conversation. Everyone at leasts shakes hands if not hugs upon greeting and parting. I was offered a coffee at every meeting Angel and I attended today (4-5 total).
  • Kosovo is pro-American - there is a street that runs through the center of the city named after Bill Clinton with his picture plastered on the side of a building and a statue of him just to the side of the road by a flying American flag. Kosovaars are grateful to the United States for their support in the war in 1999 and in supporting Kosovo’s independence.
  • My sense of direction when I am really tired is truly awful. We went past a cafe with WiFi that shouldn’t be too far from where I am staying, but I couldn’t find it when left to myself this afternoon. Perhaps when I am more rested tomorrow, I will venture around more to try and find it. The hospital complex is a series of separate buildings, and I am not quite sure where the road is that the cafe is located on.
  • I need to turn on the hot water heater at least an hour prior to wanting to take a shower if I want any semblance of warm.
Sorry for the lack of pictures. More to come as I start to learn my way around.

Monday, March 21, 2016

A New Adventure

It has been a few years since my last post on the blog. Since graduating medical school, I matched into residency at the University of Rochester in Rochester, NY in Ob/Gyn. I have been a busy worker bee working 80ish hours a week with 4 weeks of vacation a year. I spend my vacations traveling, mostly to Germany to spend time with my fiance Michael. I have finally reached my third (of 4 total) year of residency and have an awesome 4-week rotation called "elective." My journey to create my elective experience was arduous and frustrating, but finally worked out. I am working with a group called Project HOPE (all opinions are my own and not those of the organization) and on my way to Prishtina, Kosovo to teach and mentor in the Ob/Gyn department at the University Hospital. I am not really sure what my day to day will look like, but I am ready for a new adventure!

I tried to prepare by doing some reading about Kosovo's history and learning a little Albanian. I can say good day (mirë dita), my name is (unë quhem), and goodbye (mirupafshim). I'm not as prepared as I would like to be, but I will learn as I go. I worked up until the day I left and ready to have a change in scenery. I have a long travel ahead - ROC --> JFK --> IST --> PRN and will arrive Tuesday morning at 0830. See you in Kosovo!