Firsts and Lasts

October 31, 2012
Kasoa
Today was a day of firsts and lasts.
The first delivered baby in Ghana.
The last visit to the maternity clinic.
The first group lesson on Azonto dance.
The last trotroride to Bajwasi.
You have to understand: I am trying not to be sad here.
___
This morning was all about perfect timing. M, L and I went together on a trotro toward Bajwasi to see the Margo Maternity Clinic. It is a small, private, for-profit clinic run by Margaret (I guess I should call her Auntie Margaret, as a sign of respect), a nurse midwife who still practices. It is a gated compound that houses six discrete buildings:  on the left side are the screening room, waiting area, injection room/recovery ward/wards a and b/pre-labor ward/labor ward/consulting rooms; on the right side are the dormitories for the midwives and I guess, Auntie Margaret’s home too; on the center is the dispensary or pharmacy, facing a shady mango tree under which we first found Auntie Margaret and greeted her and told her of our intentions for the day.
We wanted to see a baby being delivered. I have seen it multiple hundreds of times before, but seeing how a baby’s head starts to show, teasing excited spectators outside, always gives me tremendous joy. I don’t grow queasy about it until the baby really descends with magnificent pushes from its mom and its head crowns, the labias are pulled apart like a woman bellowing out in laughter and staying in that position. I grow queasy because I know it is painful for the mother. I feel it, and I know it is more than painful. It is at this moment that I always feel in awe of all the mothers who deliver vaginally. If every one of us would see the torture that women go through in child birthing, we would appreciate our moms more. Men would have greater respect for women. With every inhale the baby’s head retracts, and with every exhale and PUSH, PUSH, PUSH (!) it swells again. Whenever I see this, I think: this is why we are all inexplicably and undeniably linked to our moms, why even the elders, whose mothers have long gone, still call out to their moms in trying times. Because child and mother have shared the same harrowing pain, and have together breathed to live the same exhilarating miracle, the bond is never severed. It is a friendship that is borne of shared adversity, of parallel labor, and ultimately of communal triumph.
As soon as we walked into the labor room and saw a hint of the baby’s hairy head, we stayed. M and L looked uncomfortable and curious. L remained on the side for the most part, seeming hesitant. I goaded her to come nearer especially when the head was definitively crowning.
___
So this is what happens: baby’s entire head pops out of the vagina and hangs in the introitus for what seems like forever. I knew there was something wrong, the way the head just hung like that, with that ashen color.  Typically when the baby’s head comes out the rest of its body just follows rather easily. This baby was not typical. The cord was wrapped around its neck. The midwife immediately but calmly uncoils the cord. I quickly scan the room and search for gloves. I know it— I would need to attend to this baby. Just as I don a pair of gloves the baby is set loose, its shoulders slide out, then its torso then its pelvis then its tiny feet. IT is a HE. He is a boy. I love boys. I smile.
He doesn’t cry. He is pale. And limp.
I rush quickly to the bedside, grab the suction bulb and start sucking away all the muck from his mouth and nostrils. First he gasps, and then he gives out a faint hint of a cry. Encouraged I suck out more and with my left hand dry him vigorously and stimulate him.
He cries. It is definitely a cry. I almost cry—in delight; in relief. He is alive. The first baby I helped deliver has made it to this world, has opened his eyes.
___
After quickly scanning him for his APGAR scores, I brought him to the counter by the wall to further dry him and examine him. Counted his toes, 10. Counted his fingers, 10. Checked his anus, patent. Checked his palate, approximated. Checked his chest, belly and back, what needed to be robust was and what needed to be straight was. He was perfect. Re-checked his heart and lungs, beating and breathing. He was alive. That thought kept repeating itself in my head. Alive. Alive. Alive.
Only later on did I realize why it mattered me to that much for him to be alive. It was because he was the first baby I delivered in Ghana. Heck, the first baby I have delivered ever, on my own. On my own, without anyone looking over my back. Holy cow. The baby and I made it. It is an exhilarating experience.
We asked his mom, the superstar of the show, what his name is going to be. ‘I don’t know,’ she said. M said ‘well, how about MJ for Michael Joseph?’ Michael Joseph is the name of her yet unborn nephew. He is set to be born today in the States. So we turned to his mom, ‘we have given your baby a name. Michael Joseph,’ we said.
Me and MJ
Later at night when we went back to the clinic, one of the midwives said, ‘oh Michael Joseph and his mom have left for home this afternoon’. We asked if he was indeed named Michael Joseph. And the answer? Oh yes! Woohoo. Would it not be great if two Michael Josephs in different continents shared the same birthdate?!
___
Apparently, according to one midwife whom I spoke to this morning, they never have sick babies in the clinic. I find it hard to believe, but I hope it is true because babies here are just secondary priorities. I saw with my own eyes how they almost ignored a limp, pale, non-crying baby. Now, it might have been because I was there; but— the first reminder they gave me as I brought the baby to the counter was, ‘here take this cup, this is oil; use this to clean the baby.’ Second order was to put the baby on the scale, then measure the head, the chest and the length. Nobody asked me how the baby was doing; only if the baby was already clean.
You can always clean a baby anytime; but for me I would rather clean a living baby over a dead one. I had to remind myself to accept things as they were and to just adapt to the circumstance and make do with what I had and what I didn’t. 
Being a doctor for kids, I worry when there is not even a stethoscope in the room, nor a suction machine, nor an APGAR (a brief scoring system to see if a baby is doing well or not in the first 1,5 and 10 minutes of life) scorecard on the wall, nor a lamp for heating, nor a thermometer. I think this is appropriate worry, no?
____
This afternoon we went back to the clinic, this time with Una who was going to work with us for the first time in 6 days since being sick. We were hoping to get timing as perfect as the one we had this morning. On the way to the clinic, which is a good 30-40 minute ride from our home base, this was what I saw:
It’s nostalgically beautiful.
When we arrived at the clinic, the midwives were gathered in a circle near the wards talking amongst themselves. They called us and as inclusive as ever, they invited us to join their circle. When we finished our introductions and basic getting-to-know-yous, and after they clarified that condoms here are referred to as condoms and that romantic is just a brand, someone noticed U dancing in her seat. ‘You are dancing,’ she tells U. U says she was. I took this as an opportunity to ask for a dance lesson so I say, ‘actually we are all trying to learn Azonto dance.’
‘Ahhh!! Azonto!!’ They giggle and rise from their seats, immediately goading us to rise and dance. Music starts to boom from a cellphone and we have fun.
Me trying the Azonto

Group lesson

Girls having fun
___
After calming down from the dance, we heard a car pull into the driveway. ‘We have a case!’ C excitedly tells us. U, who just pulled out her packed dinner and was about to start digging in had two people telling her different things: ‘eat!’ ‘No, don’t eat yet!’ I said I didn’t think the baby would come out within the next 5 minutes. Seconds later, two men came in carrying a frail looking, middle-aged woman by her armpits. My eyes immediately go down to her belly and the first thing I say is, ‘but she’s not pregnant.’
Apparently they also accept non-pregnant patients. As this woman was. I let the nurse and the midwife attend to her first and only went to the woman’s side when the nurse said she couldn’t get a blood pressure. The moment I was at her side it struck me how sweaty she was.
I felt her pulse rate and I didn’t have to count through the full 60 seconds to know that she was tachycardic (has a fast heart rate). At 15 seconds she was already a 30-40. I still went ahead and attempted to get a blood pressure though. Three times I tried and I could not get anything.
Sunken eyeballs. Skin tenting. Cool, clammy arms. No blood pressure. Fast heart rate. S***, I thought, this patient is sick. Immediately I ordered for the woman to be laid down on a bed, given an IV fluid bolus. This patient is clamping down on us, I told the nurses, we need to assist her heart to pump blood. I went to the dispensary with the nurses and together we picked out IV fluids and medicines to give. They asked me if I could do the IV insertion. I said yes, but when I realized that this woman had only one or two chances for an IV insertion and that the family may not be able to afford a second IV kit (should I fail), I asked the nurse to do it instead. The unfortunate thing about training in a hospital that is well staffed is that residents like me don’t get enough opportunities to do simple procedures like this, and even when we do there are non-resident trainees and PAs and NPs who sometimes fight tooth and nail with us to get it. So a simple procedure like an IV insertion, once a natural skill I had, is now lost on me. Hopefully I will have a chance at redemption.
After 1.5L of IV fluid boluses and 2 hyoscamine injections, the woman regains an acceptable blood pressure of 90/60.  Whew! Now I can wipe the sweat off my armpits. She lived! Like my baby this morning, she was alive.
I cannot even begin to explain how rewarding it is for me to feel that the work I do, actually matters. That what I know, can save a life (and what I don’t know, can fail to). My heart swells just thinking about it. What utter privilege it is to be able to care for people, to be able to touch them in ways that probably go beyond the present moment. An utter privilege.
As doctors it is frustrating to be unable to practice ‘right Medicine’ each time because of the unavailability of services or financial limitations. Tonight after the woman regained her blood pressure, the nurse and I had a discussion about the IV fluids. The outgoing nurse told her during their sign out that it was ‘ok not to give the 4th IV fluid for 30 minutes because she has already received 3 bags.’ Don’t ask me where they got the 30 minutes. I reasoned that the woman still needs the fluids. The nurse, hesitant to carry out my orders, finally says ‘but the family will need to pay for the 4thbag.. does she really need it?’ I look at her in the eye. I say I truly understand but I ask, ‘how much is her life?’
I know how it is to lack, and I always explain to my patients and sometimes to nurses like the one tonight that I am not one to order labs and medicines unnecessarily. I always say that I apply the same principle to myself. I give thought to each order I give, fully aware that these orders don’t act in isolation.  A patient, a relative will have to pay for each centavo, sacrifice upon sacrifice, blood upon blood.
___
L and U meanwhile busied themselves practicing BP measurements on each other. U learned it in school, L learned it from me this morning. U did it several times on L that by the end, L’s arm had indentations.

‘My heart is beating!’

Writing orders

They came with me to the labor room when I did a cervical examination on a woman who has been laboring since this morning. It has been at least 7 years since I last did a cervical exam on a pregnant woman, so I had to ask the midwives for assistance to help me measure the cervical opening. 4-5cms of thick cervix was what we estimated. I regretfully told the girls that it was impossible for the woman to give birth within the next 30 minutes, and that we would have to leave the clinic without having a delivery tonight.
R, one of the midwives, insisted that L and U come back. She reassured them, saying, ‘don’t worry before you leave here you will come to something.’
I thought her choice of words was spot-on. You will come to something.
On my last few days here, this has left me thinking. Indeed, what have I come to, what have I arrived at?  
­­­On a day of firsts and lasts, I know that whatever virgin place within me I have arrived at and whatever sacred truth I have come to since coming here — I have been changed.

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