Sunday, October 4, 2009

3 Highs

Elias here. It's just after midnight and I just got home from the hospital. I got a ride back with the hospital truck and a bunch of other hospital folks. Even though it's only 2 blocks the other midwives didn't want me to walk, so I went along with them.

I'm hiding in the bathroom so as not to wake Molly (though I desperately need to shower which may wake her anyway, and for that I apologize -- sorry Molly!) but need to write because I'm so totally stoked.

You know it's going to be a good day when the little boys in the neighborhood actually talk to you. I was walking down the street towards the hospital and they were shooting at birds with slingshots. Aside from machetes, slingshots seem to be the weapon of choice of this neighborhood. Our security guy, for example, can occasionally be found with his own slingshot and pile of rocks. I have no doubt of their efficacy. I said hello, what's up, to the boys and one of them asked where I was from, so I told him, and then asked his name and introduced myself. (I also asked him where he was from, and he patiently explained that he was ni-Vanuatu, from Vanuatu.) Then I asked the name of the bird they were shooting at. Basically I am getting better at asking questions in Bislama, but like my ability to ask the location of the facilities in Japanese, I am completely unable to comprehend the response. Regardless! A connection! We chatted a little more (where are you going? the hospital?) and then parted ways. I was tremendously cheered by this interaction! It's a little odd having this quite nice studio apartment surrounded by corrugated tin shacks. Over the wall, of course.

I got to the hospital in time for the shift change just before 4pm. There were two preterm labors in progress, one that had been effectively stopped and who was just waiting to complete her course of steroids (to mature the baby's lungs in case the labor couldn't be stopped) and the other who was plowing ahead.

She'd had a CTG (fetal monitoring strip) done a little while before that had showed some decelerations (possibly a sign the baby wasn't handling the labor well), so we were going to repeat it at 4:30pm. I repeated it and it looked good, but she said she wanted to 'sit-sit' so I checked her cervix. The last check two hours prior she'd been 3 cm, and now it was gone! Baby right there! We all hustled across the hall to the delivery theatre. This baby was 34 weeks and 4 days and quite small. Her membranes had reportedly ruptured last Friday, but when the baby's head approached, he was still within the bag, so the other midwife picked a hole quickly with tweezers.

The baby delivered quickly -- little dude was little, after all -- but the placenta came at the same time. This has the potential to be super bad news -- the baby needs the placenta to be attached while he's being born so he can keep receiving oxygenated blood, and the placenta usually separates 5 or 10 minutes after delivery. Had she not birthed him when she did, and had the placenta still separated when it did, he could have died. He was incredibly small and not breathing. (When I was guiding him out, I was shocked to feel his shoulder blades so clearly -- he didn't have much in the way of fat layers.) We took him over to the warmer and I stimulated him, but it wasn't enough so we gave him positive pressure ventilation breaths (rescue breathing with a bag/mask). It took 4 or 5 puffs for him to start, and another couple to get him really going, but he did okay. We left the mask on him with oxygen. I asked if we could use the pulse-ox to see how well he was oxygenating, so we put it on his foot. Under the hood (a little lucite box that fits over the baby's head) with oxygen up pretty high he had great saturation, but whenever we lowered it it went down, so we left it flowing. I'm still in awe of how calm and unflustered the midwives here stay. No fuss, just doing what needs to be done. And no alarms, either. Can you imagine an American hospital without audible alarms?

Meanwhile the midwives were trying to track down the pediatrician (the one who was supposed to be on call was sick) and I checked the mom for tears (none) and tried to do a little informal check on the baby to check his maturity. He was 1.320 kg (around 2.9 lbs) and working very hard to breathe. He was transferred to an incubator in the nursery, where the pediatrician checked him and ultimately started him on glucose (and probably antibiotics? maybe more steroids?).

The next baby came quickly after that. This one ended up having a tight cord around his neck. I couldn't get it over his head and didn't think I could get his body through it, so I ended up clamping the cord and cutting it while his body was still inside. This is a high-stakes choice because if you can't get the body out, you're in a similar situation to the above -- the baby has no oxygen supply. Luckily we got the rest out of him out promptly, and he started breathing quickly and well. Compared to the preemie this guy was huge!

Ministry of Health
We had a lull then, and I sat in the tearoom with the midwives and watched first some Australian old-school revival/crusade, and then the international news (an aggravatingly Ireland- and sports-focused newscast, first in English, then in French), and then a great local show (a collaboration between AusAid, NZAid, and Wan Smol Bag Theater) called Love Patrol, a health-focused soap opera! It's fantastic! This episode was about HIV, being HIV-positive, how people should react and not be afraid. The sisters shared their dinner with me. At first I was going to decline (I'd scarfed a Clif bar a little earlier), but then I took them up on it, and was very great I did -- a rich chicken-vegetable soup with cabbage and carrots, and also the oxytocin-enabled glow of sharing food! We'd been talking a lot, and again, I felt an actual connection, the kind that comes when you can make jokes. They coached me on my Bislama and attempted to fill me in on the backstory in each of the 17 story lines on Love Patrol. I admitted knowing nothing about the Lisbon Treaty, which was the only thing besides tennis and racing covered by the news. I asked a lot of questions about what food is good to get, plant protein sources, all that good stuff. There are apparently local beans (in addition to green beans) and now I have a rough idea of what they look like at the market.

Then we had a bunch more admissions and another baby. This one also had a tight cord around his neck, but I'm wondering if maybe I could have gotten him through it (somersaulted) instead of cutting it, but at the time, I couldn't get it over his head, and the midwife couldn't get much slack out of it, so we cut it again. Luckily this one was also born fairly easily (with some insistent traction) and breathed well. She had a tear, and I decided I wanted to see how they sutured before I bungled another job, so I watched and tended the baby, then took the baby to be weighed and immunized. They have this great, massive scale with a dial reading the size of my abdomen (and I have substantial girth). The baby goes on top in a welded holder that is actually shaped like a baby, keeping them semi-upright (unlike our scales where the babies are fully supine). Then baby goes back to the changing pad on the counter while I draw up Hep B, Vitamin K, and BCG (if it's open). Last year they ran out of BCG (an immunization against TB that isn't used in the US, in part because it gives you a positive reading on the PPD skin-prick TB test that we use) so they're being extremely cautious with their supplies and only opening a vial if there are enough babies to use the whole thing. Any babies who don't get it at birth get lined up for when the vial is opened -- clearly this appeals to my logistics obsession. The vitamin K they're using is an oil, which is torture if you're used to a water-soluble preparation. The oil takes forever to draw up because it's so viscous, forever to inject for the same reason, and 1 mL of oil seems like a lot to put in a little baby thigh! (Though they actually seem to cry less with the vitamin K injection than with the Hep B injection. I wonder if the Hep B stings. Probably.)

There were some other folks still working through their labors when we wrapped up, including a woman who seemed to have some fused cervical vertebrae. She wasn't progressing as quickly as they would have liked, but I think she'll keep progressing slowly and hopefully have her baby before morning.

At shift change I finally got to meet their male midwife. There's another guy working on Tanna (the island with the volcano), but this is the guy the other students have been telling me about. He seems nice, soft-spoken. We didn't have much time to chat before we went to catch the hospital truck for a ride home. I'm going to try and figure out how to get a placement on another island's health center to see what it's like. Tanna has a hospital too, which would be great, to combine working with a trip to the volcano.

Today was the kind of the day where every time you come out of the delivery theater with a baby you see yet another laboring woman walking in: a good day.

The above photos are part of my Vanuatu photo set on Flickr.

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