I've been meaning to sit down and write
this for a while, but the holiday season has been a busy one, filled
with dear friends, lots of baking, and a litter of kittens.
A couple weeks ago I got my first real
glimpse of the medical system here. Don't get me wrong, it's not like
I didn't know what kind of crazy stuff happens here, but this time I
was right there in the middle of it. When I first got to Jinja in
September, my roommate Kate introduced me to a pregnant 16 year old
girl (Sandra) she was working with because she was concerned for her
health and safety once labor started. I first came to see her in the
small shack she lives in in one of the villages down the road. She
told me that she thought her baby was due sometime in October but
wasn't sure of the exact date. One look at her belly and it was
obvious that her baby was not coming anytime soon. After a bit of
digging in her medical records (with was nothing more than a notebook
with a few bits of chicken scratch in it) and asking her a bunch of
questions, I gave her the due date of December 4.
On December 10 the call came that she
was in labor at Jinja Main (the main hospital in town) and they were
wanting to do a c-section because she wasn't dilating. Luckily, Kate
was smart enough to recognize the giant red flag and asked me to come
and see her. Upon my arrival I found a very comfortable Sandra
walking around the grounds with Kate hoping that labor would pick up.
A few little details for my OB
friends....
- She was 2 cm since the previous night when she arrived at the hospital
- She was not contracting other than the occasional mild one
- She had a possible ROM but no tests had been done to confirm and no further fluid was coming
- Positive fetal movement and good heart tones by fetoscope
- No ultrasound had been done (despite the fact that they had an u/s machine there)
After I got there we waited for a few
hours for the doctor who was supposed to come and assess her and
decide whether or not to do a c-section. We waited and waited and I
did everything I could to try and bring some contractions. Finally,
after seeing that the doctor was not going to come and see her and
that we would be sitting in the hospital all night waiting for
something to happen and would then most likely go to c/s in the
morning, we decided to check out of the hospital. I spoke with the
nurse and told her we would like to leave and would bring Sandra back
when her labor picked up. Of course, the nurse was not particularly
happy with this plan and said that we needed to wait for the doctor
to see us... in the morning. So we left.
Labor ward in Jinja Main Hospital
After bringing Sandra home for further
assessment I determined that she was indeed 2 cm and that her water
had most likely not broken. So I sent her home for the evening with
instructions to call if anything changed. That night, unbeknownst to
us, her roommate brought her back to the hospital for fear that she
would not be treated later since she left the hospital against the
doctor's advice.
The following morning we received a
call that Sandra was there and the doctor's wanted to do a c-section
because the baby was too big for her pelvis. She was 16, after all,
and everybody knows that teenagers can't push out babies (note the
sarcasm in my voice). After debating whether I should even get
involved again since things were all ready in motion for surgery and
I didn't want to risk making the staff angrier than they already were
(the supplies were being purchased already... because in this country
you have to go and buy everything that's needed for surgery at the
pharmacy before it will happen. So basically, there's no such thing
as emergency surgery and if you don't have the money you're not going
to be treated) I finally, with Kate's encouragement, headed back to
the hospital.
“Be nice. Be nice. Be nice.” That's
what I kept saying over and over again in my head. Anyone who's ever
worked with me knows that when it comes to my patients and
disagreements about their care I tend to come at it with fists flying
and that's not the way to get things done in a country like this. One
wrong move and they would torture and abuse Sandra to get back at me.
So as I entered the OB ward I just kept saying to myself, “Be
nice!”
And, I'm proud to say, I was. I didn't
insult anyone's intelligence or tell them they were a bunch of idiots
who had no idea what they were doing. I calmly stated that I would
like to take her to get an ultrasound to get an estimated weight on
the baby and check his condition before we made any decisions. At
first, the doctor agreed, though not particularly happily. I'd
discussed the plan with Sandra and her mom, who both agreed. But
somehow from the time I walked over to talk to the doctor to the time
I returned, Sandra had changed her mind and decided she wanted to
proceed with the c-section. She was terrified. Terrified that the
doctors and nurses were going to abuse her out of anger.
And so back to the doctor I had to go
to tell him her decision. At this point, he's pissed. I mean really
mad. And so I got to stand there while he yelled at me, while the
head of the OB department yelled at me, and while a big angry nurse
both yelled at me and physically was trying to drag me through the
ward. “Be nice. Be nice. Be nice.” And so I stood there and I
took it. Madder than I've ever been because I knew everything about
the situation was wrong.
And so a c-section it was, later that
night.
I wasn't going to go back to the
hospital because of what I knew would happen if any of those doctors
or nurses saw me. But I got a call that morning saying the baby was
on oxygen in the nursery. I still debated going, but my plans for the
day had been cancelled due to rain so I decided to just go check on
mom and baby to make sure everything was OK. They told me the baby
was doing well, just weak. So when I walked in and saw a dusky,
blue-tinged, barrel-chested baby laying there struggling for breath,
I was shocked.
Meconium aspiration.
My theory: At birth his apgars were 5
and 7. Which meant they had to resuscitate. But, as I discovered
later, the entire town of Jinja is without a neonatal sized
laryngoscope. So how could they have properly resuscitated him (OB
friends.... that question's for you)? Most likely, they just put an
O2 mask on him and pumped the meconium right into his lungs.
So, to spare you the minute-by-minute
account of what happened that day, I'll summarize. After many phone
calls and running about town to try and find a western-trained doctor
to help, Sandra's baby was finally transferred to Kampala where he
could be properly treated. We managed to get one of the only
ambulances in Uganda that had oxygen on it, found the only place that
could intubate a baby, and sweet-talked our way into getting
transferred to another hospital.
All I can say is that when that
ambulance pulled up 7 hours after I'd arrive at the hospital that
morning with a well-trained doctor on board who immediately started
properly treating the baby, I felt like I could finally take a breath
again.
I am happy to say that baby Hansel returned home from the hospital on my birthday (the 27th) and is doing very well!
Those few days were a fight, a
struggle, both for decent medical care and for life. I saw the
corruption. The bribes. The lack of equipment. The horror that is
Jinja Main and having a baby in this country.
So for my medical friends who have been
wanting to know what it's like here, here are a few notes for you...
- Even though some of the technology is here, doctors don't want to use it
- If you don't have the money to pay a bribe, you aren't going to be treated well
- The OR smelled like urine
- There isn't a neonatal sized laryngoscope in the entire town of Jinja
- You can't ask questions about your care
- C-sections are possibly more common here than in the US
- You have to bring your own medical supplies to the hospital if you want treatment
- They can refuse to treat you if they want, even though they aren't supposed to be able to
*Side note: Another friend here just went into labor last week and they tried to do the same thing to here. The doctor's told her the baby was too big and she needed a c-section. She was smart enough to run and went to a village clinic where she delivered a healthy baby boy.
