My First Week in Port Vila

Sorry for the delay in updates. I’m enjoying the amazing hospitality so much here in Vanuatu that I haven’t had a chance to get online. Volunteering at the hospital here has been an incredible experience and I am learning new things every day. I thought I would give everyone a highlight of my most memorable experiences over my first week. I've also included a few photos. The first is a picture of Hideaway Island from the ferry. The second is me at Mele Cascades. To the left is a picture of the labor room here at the hospital.

The first that comes to mind is a really sweet twenty-year-old primip (first time mom) that labored for a little over seventeen hours before she was fully dilated. Back in the US we wouldn’t think much of this, but here it isn’t common for it to take that long. Due to the amount of time it was taking her to dilate, she was put on syntocin to augment labor. She had the classic back labor throughout indicating a baby that was occiput posterior. By vaginal exam it was also clear by palpating the baby’s fontanelles that we had a malpositioned baby. Throughout her labor she would ask me “how much longer?” and I kept answering by shrugging my shoulders and saying “if only I had all of the answers.” For a first time mom who was going through agonizing back labor on a syntocin drip without any pain relief, she was an amazing trooper. I was in awe of her determination. When it came time for me to go home for the day and she was at 8 centimeters, I decided I would wait to leave until she delivered. Four hours later she was “fully” and ready to push. While I was managing her labor, another mother who was in preterm labor at 32 weeks was delivering on the other side of the labor room. The doctor on call had been paged to her delivery so once she and her baby were stabilized she came over to see if she could help my mother. My momma had been pushing a little over one hour and had made progress, but it was decided that assisting her with vacuum extraction was indicated. This is the first time I had seen a vacuum extraction so was excited to gain the experience. Before the vacuum was used the baby was at 0 station and with only two pushes the baby was delivered. We had been using intermittent monitoring of the baby throughout labor with no indication of distress and were surprised with thick meconium on delivery. Smol baby girl “Allison” required deep suction and a few minutes of resuscitation before fully coming into her body. This became the first little baby named after me and I feel deeply honored. Allison’s mom was truly incredible in her strength and determination. Afterwards she thanked me for believing in her and apologized for complaining too much and I told her that she should be very proud of herself and that I felt she didn’t complain much at all. She looked at me and said “really?” It is hard for me to express my amazement and sorrow at how much pain these women endure and are expected to not show it.

During my first week at the maternity ward I assisted thirteen women in welcoming their little ones into the world. For many of these births I was accompanied by nursing students here in Vanuatu. Many will graduate as RNs in a few months and will then return to their respective Islands here in Vanuatu. As a part of their training, they are to perform twenty deliveries. Due to the shortage of medical personnel here in Vanuatu RNs perform many of the same functions as doctors and midwives in their local villages. During my stay here I have been given the honor and responsibility to help train these students in the art of normal delivery. They are incredibly excited to learn and are catching on quickly. It has also been a great opportunity for me as well, because as they say you only truly know it yourself when you can teach it to others. I have made it my mission to reduce the number of umbilical cords that are cut on the perineum to reduce the number of resuscitations required. So far I have somersaulted four babies out with nuchal cords that were too tight to reduce. I’ve worked hard to explain the process to the nursing students and they are very appreciative indicating that they have seen the difference and lack of need of resuscitation that is common with cutting the umbilical cord on the perineum. I’m hoping that they will be able to practice the skill while I am here so that they feel comfortable somersaulting a baby out with a nuchal cord. Many will be in very remote areas with very little medical equipment or assistance in the event a baby is experiencing respiratory distress during transition.

After my first six days at the hospital I decided to take two days off and explore Vanuatu. Due to the resort being full with a wedding party, I was given the opportunity to spend a week at the house of the resort owners out on Mele Beach. Their house is really close to Mele Cascades and Hideaway Island, two very popular tourist destinations. I took my first day to explore both and really enjoyed the beauty of Mele Cascades’ waterfalls and cascading pools and the colorful fish all along the coral reefs off of the shore at Hideaway Island. I wish I had a waterproof camera to share the beautiful sea life with all of you. My second day off was spent preparing for my second week by going grocery shopping and relaxing on the porch out and walking along the beach at Mele Beach. While I was at the open air market in downtown Vanuatu, I was stopped by one of the family members of a momma I assisted and presented with a papaya as a thank you. My heart was filled with such love and warmth. The NiVanuatu (native people of Vanuatu) are an incredibly giving people.

Greetings from Vanuatu

To my family and friends, I have arrived safely in Vanuatu after a little over thirty hours of travel and have spent two wonderful days in the Maternity Ward here. The people of Vanuatu are incredibly welcoming and have made me feel at home from the start. I plan to take some photos soon and post them to let you witness the beauty of Vanuatu -- both the people with their warm smiles and the lush vegetation and spectacular views. Here is a brief summary of my first day:

Day 1: Wednesday, Sept. 15th 2010

I arrived a few minutes before 7 for the morning rounds. This is the time when the charge nurse gives her report from overnight to the new nurse coming on duty. I learned that they had quite the busy night at seven births and that we currently had five women in labor. It turned out to be quite an exciting first day. A midwife from New Zealand was able to give me a quick tour of the ward and location of supplies. Then we were off... As we were finishing up our tour a mother in active labor presented at the front desk so we began the process of checking her in. I set her up on a twenty minute CTG strip, took her vitals, and checked her cervix. She was a primip (first time mom) and 8 centimeters dilated. Things appeared to be proceeding quickly so we brought her back to the birthing rooms. Within an hour and half she had a small anterior lip, but not quite complete or fully as they like to call it here. The mom desperately wanted to push, but we instructed her to pulum gud wind (take deep breaths) and not sit sit (push) with the next few contractions. She was soon complete and then pushed for a little over 35 minutes which they consider a long time here. Moms here are incredible pushers and generally push for less than 10 minutes. I think the mother expected to not push for so long and kept asking when the baby would come.

As I was managing this momma's delivery, the other three beds in the birthing suite became occupied as three momma's began pushing. I quickly finished up with my momma and went to see if I could be of assistance in the other births. The next baby to be born had a nuchal cord that was not able to be reduced. They aren't familiar with somersaulting the baby out, so instead the nurse clamped and cut the cord on the perineum. This little baby boy then required ten minutes of PPV (positive pressure ventilation) before he took his first breath. I can't help but wonder if he would have had a smoother transition if his cord had remained intact during the delivery. As I was assisting with this delivery, two more babies were received into loving hands.

My final catch of the day occurred right before I was getting ready to go back to the hotel for the day. It was a mom I had been following her progress all day and she was fully and wanem sit sit (wanting to push). She was a first time mom and proceeded to push her baby out in seven minutes with only a minor first degree laceration. Mothers here are amazing to watch. They push very effectively and are quite stoic in the process.

I had a great first day at Port Vila Hospital. I met many lovely midwives, nurses, and nursing students. I also had quite the crash course in getting familiarized with the Maternity Ward -- where supplies are located, proper hospital procedure, and very basic bislama. I look forward to the next few days and becoming more and more acquainted. Stay tuned for more updates on my experiences here.

Thanks for reading,

Allison

Special Thank You To Jim Key and Tim Dempsey from Orion Medical Supply

The Thursday before I left on my trip to Vanuatu I received a wonderful donation from Orion Medical Supply for the Maternity Ward at Port Vila Hospital. Jim Key, who is an incredible guy and very supportive of local Seattle midwives, was able to put together a sizable donation of chux pads, sterile and nonsterile gloves, sterile lubrication, and hand sanitizer. Having spent two days at the hospital I can tell you that these supplies are in great need and extremely appreciated. I can't thank Jim Key enough for all of his help. Special thank you as well to his Manager, Tim Dempsey, for his assistance in the donation. If you practice in the medical field in the Pacific Northwest, Orion Medical Supply is a great company with which to do business.

Tips for those planning trips

Elias here. There are a few folks planning their trips for next year, and I've been holding onto this tip post, but I figure now is the time to share it! Hopefully Hillary will add her own tips to people planning to go.

Flights:

ITA Software has some of the best searching capabilities, including their monthly or beta "Matrix 2" feature that lets you find the cheapest days to fly, if you're flexible, which we usually are. Some of the flight combinations are complicated and it's helpful to book using a travel agent, but travel agents can't book some of the airlines (like the discount Australian airlines or Air Vanuatu). I found my flights on ITA and brought them to a travel agent at STA in the University District (hi Dave!) and he managed to get me an even cheaper itinerary. It cost $50 to book the itinerary with him, which was definitely worth it, though I had to book some of my flights on my own. He also booked my tours in Australia, and I was pretty happy with that service (I emailed him from Vanuatu asking him to book me).

For internal Vanuatu flights, Air Vanuatu offers a baby doc discount, and you can search for flights on their web site. You can book those flights pretty close to when you want to leave and can walk into their office downtown. Tanna and Santo are popular internal destinations.

Where to stay:

Many baby docs stay at Coconut Palms. Booking through wotif.com or FlightCentre is cheaper than booking directly (though you don't always get breakfast included). They don't advertise it, but they have a baby doc lounge with a kitchen, fridge, and free internet access. This is important because only the most expensive Coconut Palms rooms have cooking facilities. Some even have shared bathroom facilities. You can get a discount for staying an extended period of time, and some have gotten discounts for being medical students. The manager is extremely sociable and often looks after the baby docs. There's a pool, a pool table, restaurant, bar, and laundry (250 vatu to wash).

If you're not coming alone, or you don't need the social aspect of Coconut Palms, Tradewinds is closer to the hospital (marginally), can be cheaper, and even the studio apartment has en suite bathroom and full kitchen. We're paying 4500 vatu per night over the course of our extended stay ($45/night for 2 of us). This is a much smaller facility than Coconut Palms, but it still has a small saltwater swimming pool, ping pong table, gas BBQ, and kayaks available to be hauled down to the lagoon. The housekeeping staff will do your laundry for you for 1000 vatu, or you can use the machine yourself for 500. We hand wash. There's a clothesline setup alongside each apartment (which are each stand-alone).

Hillary probably has something to add on this count -- she stayed at another resort (Mangoes) and got an even better deal, but she was there during the wet season. Mangoes, Tradewinds, Coconut Palms are closest, then Poppy's on the Lagoon (where some folks stayed a few years ago) and then other resorts further out. If you're going in a big group you can rent a house.

Banking:

Beware the following:

• Your bank will probably charge you to use someone else's ATM (or if they're evil enough, like ANZ, their own ATM)
  
• Your bank will probably charge you a foreign transaction fee for the currency conversion when pulling out cash
  
• Your credit card will probably charge you a foreign transaction fee for the currency conversion
  
• Local businesses are charged for their credit card transactions, so they charge you to use a credit card

Bank of America has a partnership with Westpac, which has ATMs easily available in town. I'm a BoA customer and have yet to pay an ATM fee (though I do pay a 3% foreign currency transaction fee, I think, although in retrospect I see no evidence of that).

Speaking of fees, almost everyone in town charges an extra fee to use your credit card. This can be as high as 5% on top of your bill, so most of us use cash most of the time. If you're going to use cash to pay your hotel bill though, you need to work around your bank's ATM daily withdrawal limit and also deal with the ATM fees (if you have them), so in our case, the hotel's 3.75% credit card surchage was close enough to the ATM foreign transaction fee, and I was sufficiently disinclined to pull out that much cash, so I just used the card. Capitol One is one of the only credit cards that doesn't charge a foreign transaction fee -- I got a Capitol One card just for this trip.

Bank of America also has a foreign currency order service. Before I left I ordered currency online, both Vatus and Australian dollars. They were delivered to the branch of my choice for a $7 delivery fee and took around 2 days. (They can deliver it to your house, too, but you have to be there to sign for it.) I got a pretty decent exchange rate, and I had the comfort of knowing I'd be set for money for a little while, and the pleasure of showing off the pretty money to folks before I left. The huge foreign currency service in the States didn't carry Vatus, so I'm pretty impressed with Bank of America.

Au Bon Marche (the big supermarket) doesn't charge extra to use a credit card. Everywhere else I use cash.

The hospital:

I had the intention of wearing scrubs. I bought good quality scrubs, knowing I'd be washing them a lot, and wanting the pockets all down the side. It's like wearing jeans in the tropics. Within a week and a half I'd switched to wearing my cargo shorts and a scrubs top. Nobody wears pants at the hospital. The midwives and nurses wear uniform dresses, the doctors wear shorts and t-shirts or island shirts. Actually, the nursing students wear white pants and tops, but they're the only ones. Nobody wears closed-toe shoes. Everyone wears sandals, closed cell polyethylene clogs (aka Crocs), or flip flops. I got closed-toe Nothinz-brand clogs (which are cushier than Crocs), but the closed-toe nature means I sweat hugely in them, so I wear them with socks, which I powder liberally in the morning. If you go into the operating theatre they have clean scrubs there to change into.

Bring a tote bag for your hospital stuff. I bring a supply of gloves (sterile and non), food, water bottle, headlamp, and reference material.

I sweat profusely, especially when I have to suture, so I've acquired a couple bandanas/headcoverings from the operating theatre. My sister also sent me a Croakies to keep my glasses on, since they just slide down my nose. Thanks, sister!

Travel insurance:

I got it through STA. It was only a few hundred bucks for my 3-month trip (it's priced based on length of trip), and covered medical and electronics, and since I got it within 2 weeks of booking my flights, covered terrorism and the airlines going out of business. You can get a rider for sports, too. Some diving outfits offer their own travel insurance.

Last Days

I am relaxing listening to the sound of rain and wind. Contemplating going for a surf in this weather. Its my last few days here. Savoring it. I worked with Lissie last night, I hate to pick favorites but she is my favorite. She has such a warm heart and makes me feel appreciated. She always gives a little clap and a smile when I walk in to her shift. She pulled me aside and gave me a little purse with that says Vanuatu. Made me cry, it was sooo sweet. I will miss her. Nothing of particular interest has happened on the maternity ward, I have just been developing my skills, gaining muscle memory and learning a few new things. I had one of the interns to teach me to put an IV catheter into an infant, I have done one short straight forward neonatal resuscitation and I have done enough suturing now that I feel like I can effectively use the instruments. I am a little worried about what it will be like to go back and do births in the US where women don’t just slide up onto a table when their fully dilated and push their babies out. I am used to looking at my watch and feeling like 30 minutes is a long time to push. Back in the states I think an hour is closer to average. My perception of certain things is skewed. I used to get squeamish at giving babies shots, I hate to hurt them when their brand new. But I have put so many needles into baby thighs here, I barely think twice. It will be interesting to go back and feel what it is like to do homebirths and practice as midwife in the US again. There are few things I wish I had the opportunity to experience… a breech birth, a shoulder dystocia, but all in all I have learned so much. Last weekend one of the chief pilot’s brother came into town. I was taken along for the ride of showing his brother a good time. Wined and dined, gambled, drank kava, stayed up late laughing and raiding the pool at their resort. Then I would wake up tired, and they would pick me up to go for a surf, I’d do several hours at the hospital and meet them for dinner to do it all over again. It felt like an episode of entourage or something. I ‘reckon’ I will never experience anything quite like this again. Loving my work, picking my schedule, learning, playing hard, enjoying the sun, honing my intuition as I am free from structure and schedule. There is a reason I haven’t been on the blog in a few weeks. I have been too busy living life to the fullest to spend time writing about it on the computer. I will miss the beautiful smiles on the mammas on the maternity ward, the sweet moments bathing the babies after the birth, the giggles of the midwives, the warm waves, the Australians that seem to speak a foreign language that makes me laugh with every conversation, the relaxed sense about life in island culture. To all who have followed my adventures: thanks for listening, this was an important part of my process here

3/3/09 Surf and Sky

The maternity ward has been slow. Lots of scrubbing the beds, making cotton balls and folding gauze. I have really grown fond of the midwives. They are such kind souls, we make faces at eachother, discuss their culture and laugh. We laugh a lot, now. Always something to giggle about, its so much fun to be in on the ward and feel like I am really helping and I am so glad I have a few more weeks here. Outside of the maternity ward, I have taken up surfing. I go out to the point every chance I get rent a board and head into the crystal blue water. It is reef break so I can only surf at high tide. I have stopped working regular shifts at the hospital and go into work based on the hours I can surf. The water is warm and the waves are small and perfect for learning. The kids all chatter, scream and call out and cheer me on. Its such a joyful place. I love being out there, its been a while since I have taken up a new sport its great to get my body to learn something new. I also have made friends with a gang of pilots. The one airline over here, Air Vanuatu has about 30 young guys from Australia and NZ that work for them and they are all tight group of friends. It a click that reminds me of capoeira a little bit and I have good time hanging out with them. Its nice to have a crew of people to do things with. This trip has been perfect, time with my mom for a couple of weeks, lots of alone time for a couple of weeks and now it looks like lots of going out with new friends for the last couple of weeks. I love Vanuatu!

2/23/10 For Autumn

Today I am missing my friend. She was killed in an accident 3 years ago today. Its nice to have time a space to contemplate her. Woke up did sun salutations, one for every year of life and one for each of the years of her life I have now missed out on. She was golden. I wasn’t sure if I wanted to go into the hospital or just sit with my memories but intuition drew me into the maternity ward. It was busy! Two women were being prepared for ceasar (c-sections), which never happens (two at once) and there were several antenatal women getting close to delivery. The midwives and nurses were all busy. I took one women back to the delivery room, she was saying that she wanted to sit sit (push). No one was around to help me so I prepped everything, hemorrhage meds, IV ready to insert if need be and layed out all the supplies. I did an exam and she still had a bit of cervix there, we tried to push it back but it didn’t work. I had her do some sidelying contractions, still there. I could tell that the baby was a little asynclitic or crooked coming down by the sutures on the babies skull. This mamma had been up all night, she was exhausted and kept begging me to help her. Much to her dislike I made her get up out of the bed and put one foot up on the stool and do some lunges while I helped support her through a contractions. She cried while we swayed and then switched feet for the next contraction. Suddenly she started to grown so I had her get back onto the bed and slipped on my gloves. With the next contraction the babies head was crowning, it worked!!!! After the head I felt and there was cord around the babies neck. I told the mom to stop pushing so that I could try and slip it over the baby’s head… it was too tight. Another strong contraction came and told the mamma to pullum wind (breathe) through the contraction so I could cut the cord but she couldn’t stop it and the baby was coming. We learn this technique to sommersault the baby out in school but I had never actually done it. I held my breath and pinned the head to the inside of the mom’s thigh and the baby flopped out of her in a forward roll. Future acrobat maybe. The baby was quite blue and for about 30 seconds didn’t take a breath. My heart raced as rubbed the baby, trying to get it to cry. It let out a cough and then strong scream, and its skin started to get pink. Phew!!!! I gave the mamma her shots, delivered the placenta, examined her perineum and she had a small tear. I set up a sterile field, gave her 5 stitches, one of the best I have done and then took the baby out be weighed and given its shots. No other person came into the delivery room the entire time. I knew they were just out in the hallway and only a shout away if I needed help but it felt like such a sense of accomplishment and competence to be able to do it all on my own. Through a cervical lip, a nuchal cord and a tear. I starting to really trust my skills and feel proficient in my craft. Thank you Autumn, you are always giving me beautiful gifts…. I miss you!