In the last week or so I’ve done a whole bunch of maternity work. Last Thursday I spent most of the afternoon working the clinic MHC (maternal Health clinic) which happens twice a month. This is basically a way for pregnant women to get health check-ups that they wouldn’t otherwise be able to receive. The clinic is run by this old mid-wife named Shiraz. She is one of those women who is somewhere between the 40 and 70, and I imagine has looked that way for at least the last century or so. She is a big woman, and she moves with a sort of, slow, deliberate gait that is impossible to entirely associate with anything else. She had me help her complete a series of checks on both the condition of the women and the conditions of the unborn children. There is no technology involved in this, no ultrasounds or lab tests, it is all done by touch and sound. First she would palpate the woman’s entire stomach, looking for any signs of organs being displaced or infected, than she would locate the child’s head, and from there feel out the whole rest of it’s anatomy. There is a trick to knowing how far along a woman is. The space from a woman’s belly button to the head of the child (located near the waist) is about 20 weeks, and every finger width above the belly button that the child goes is another 2 weeks of gestation that have already occurred. After this extensive hands on exam, Shiraz would get out this old, worn metal thing that looks like a funnel and place it on the woman’s belly, she would move it around slowly, massaging the child’s until it would move into a position for her to listen to the fetal heart beat. Sometimes she would find it in a matter of seconds, and sometimes she would spend minutes slowly moving this thing around. For the most part I felt like I was totally out of place and had no clue what I was doing, but I surprised both Shiraz and myself when I correctly identified a breach baby. There is nothing to do about that here, they just try to get the woman to agree to have the baby in the hospital, where an emergency C-section can be done if needed.
The topic of pregnancy related surgery gets me up to two days ago, when a team from Marie Stopes came through. Marie Stopes is a UK NGO that works on family planning and birth control issues in developing worlds. Population control is a huge issue in Uganda. It’s this vicious cycle where male success and vitality is very much judged culturally by the number of children you can produce, but few families have the resources to support 6, 8, sometimes even 10 or 12 children. Birth control pills are widely panned here, I think for several reasons. There is definitely a stigma about birth control, but the governments HUGE effort to emphasize the need for family planning and birth-rate control has at least somewhat impacted that positively. The bigger problem is that the birth control pills offered here are way out of date by western standards and have very common, really unfortunate side effects (about 60% of women who use the pills complain of vomiting, diarrhea, other nasty things). Instead, many women opt for this thing called “Injectaplan” which is a birth control shot that lasts for 3 months. We probably do about 10 or so of these injections a day at the clinic. That is not what Marie Stopes does though, they offer permanent birth control solutions. And by permanent I mean surgical. Which is how I spent my day. Basically, a team of four workers from Maris Stopes came and set up a make-shift OR in our education pavilion (Musa gets kicked out of his office like twice a week because the pavilion is the only space we have outside of the clinic building itself where people wouldn’t get soaked). The team consisted of a surgeon, a surgical nurse, and two assistants people who did patient prep and clean up. The procedure they performed is called a tubul ligation, which is basically the equivalent of a vasectomy for women. It’s an outpatient procedure, and takes about 5 minutes to perform. Essentially, the abdomen is numbed with a local anesthetic, and then a small incision (maybe 4 inches) is made in the abdomen. The fallopian tubes are then pulled out of the incision with this big hook looking thing and each one is tied off and then severed. The process is permanent and non-reversible, and most of the women who got it had already had 5 or 6 children (one had just given birth to her 12th). The surgeon performed 11 of these procedures while he was here, which is actually a bit of a light load for him. He said he’d done 42 in one stop the week before. Watching the first one (which was the most complicated because the woman’s tubes were small and slightly out of place) made me definitely a little queasy (broken bones, gaping flesh wounds, maggot-infest burns I can deal with, watching a woman watching a surgeon dig around in her stomach with a 12 inch metal hook, not so used to that). After the first one though I was good to go. It was fascinating to watch, and there was surprisingly little in the way of bleeding or complications. All in all it made for a fascinating day.
I do think I should follow-up with that potentially off-putting visual with a fun story. We had a 3-year old boy in a few days ago who had fallen and broken his wrist. (This is based off Viola and my diagnosis, not any definitive X-Ray or anything. That said, sometimes those are easy to spot). Anyway, we needed to send the kid to Bududa hospital to get X-rayed and plastered, but didn’t want to put him on the back of a boda with his broken wrist unsupported, so we wanted to splint his hand. We don’t have any splints though, so we ended up having to make one out of cardboard, wrapped in medical tape and gauze. Given how jenky it was, it actually worked really well, Rogers and I were very pleased with our work, but in order to get it fit to the right size and shape we had to be moving the kids wrist around a bit more than we wanted to. By the time it got to the stage of actually splinting and slinging his arm, the kid was so unhappy (understandably so) that he wouldn’t let us near his arm without beginning to scream and flail. We decided we should give him an injected pain killer on top of the oral one we’d given him about a half hour before, so Rogers stood him up between his mothers legs and stripped him in order to inject the pain killer in his butt. The kid didn’t entirely get what was going on until Rogers stuck him in the ass with a needle, and then he went absolutely off-the-walls ape shit. He spun around, screamed full out in Rogers’ face, then ran off with the needle still stuck in his bum. I probably should have tried to help, but the visual of Rogers and this Ugandan woman all wrapped in her flowing local garb chasing after this toddler wearing nothing but a cardboard splint and a needle in his backside was too much for me and I spent a solid 30 seconds sitting on the floor cracking up.
I bought a football in Mbale on Tuesday, which has made me instantly the most popular Muzungu male “doctor” around.(The fact that I’m the only Muzungu male “doctor” around probably helps with that too). I found out my first day here that trying to explain that I wasn’t a doctor to anyone who wasn’t also a medical worker was totally pointless. As one of the teachers at the school told me, “You are white, you are a man, you are wearing a stethoscope, you are a doctor”. The kids all call me Doctor Nate, which, I’m not gonna lie, I’m definitely getting used to. That’s all for now.
Oh except I have….PHOTOS!