Brave Woman

Adventures of a future nurse-midwife

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RCH

Posted by Lucille on June 1, 2011 at 9:20 PM Comments comments (0)

My first shift at the hospital was RCH, or reproductive and child health. Today's project was immunization outreach.

I was put in the front of a van with one leg on either side of the gearshift. There were no seat belts and we were on dirt roads so every bump sent me flying into the people next to me. A woman handed me a pile of plastic bags and a jar of red pills. "Put 21 in each bag," she said, "And make sure it's exact." For some reason the whole thing seemed hilarious to me and I laughed every time the pills went flying, but as far as I know each bag had 21 by the end.

The clinic we went to was packed with more than 500 women when we arrived. We set up a table and the nurse showed me how to mix the vaccines. The room was full of rows of benches, which served as a line as the women moved slowly up each row over the next six hours. They handed us their child's chart, which is two pieces of paper that are the parent's responsibility, and we gave them the drugs they needed. The nurse kept asking me to try giving an injection, but I had been told not to do anything I'm not licensed to do in the States (of course, I'm not licensed to deliver babies, but oh well). I observed for a while and eventually agreed to do the oral vaccines because they were a set dose and didn't make the babies cry. I was able to go a whole day of watching baby after smiling baby burst into tears, but I could tell that being the one making them cry would have worn on me fast. Instead I focused on the women and the older children, who loved listening to my botched attempts at speaking their language.


Hospital Tour

Posted by Lucille on June 1, 2011 at 9:15 PM Comments comments (0)

To prepare for our first official day at the Brikama Health Center, the head of the hospital offered us a tour. We saw the maternity ward again, plus a wide covered area and several rooms used for reproductive and child health, the eye unit, inpatient (which is a large building with three different wards based on age and gender), outpatient (which has two separate teams working in different rooms, though I’m not sure how triaging between the two teams works yet), the laboratory, and a separate building, far away from the rest, which our guide said was the TB unit. I headed over curiously. None of the units here look like hospital units in the U.S., obviously, but they have all had beds, or at least chairs and tables. This one had cells, locking cells, like a jailhouse from an old western movie. It reeked of death. Before I could see more, my team leader dragged me out by the back of my scrubs, with her own scrubs pulled over her face and mouth. I don’t know much about TB, but apparently it’s really dangerous and there was a reason the head of the hospital waved to it instead of taking us in. I’m glad I have less ignorant team members looking out for me. Here’s to not dying?

Naming Ceremony

Posted by Lucille on June 1, 2011 at 9:15 PM Comments comments (0)

We were invited to attend a baby-naming ceremony by someone who worked at the hospital. A van would take us to his compound and back to the hospital at noon so we could finish our shift. His family lives in a big house and are clearly well off. They slaughtered a bull for the occasion.

A man came up to the women in our group, told us that it was time to start cooking and directed us toward a basin of cassava. The two men in our group were directed to the men's area, a circle of lawn chairs in the shade.

Splitting cassava is a lot harder than it looks. We tried it for a while but eventually the women decided we were terrible at it and took it back from us. The men from our group were invited to help slaughter the official sacrificial animal, a goat. "This is how we do it here," a man told us, "The men rest because they do the work no one likes, while the women work all the time because they have nice work, easy work." I told him he should try splitting cassava.

The baby was presented with her mother and aunt. Her head was shaved while the women sang. I learned that the father gets to name the first two children. Women have no say until the third. A man announced the baby’s name and the guests cheered and sang.

We began packing our bags to leave while the women prepared food for that night's party. Noon passed and the people who had brought us showed no sign of leaving. We were reluctant to interrupt them but finally asked when we would be going back. "We are not going back," they said, "This is your entertainment program for today."

We explained that we needed to finish our shift, that someone from the lodge was taking a group of us to the bank, and that I had agreed to help our guide’s mom with dinner. It did not seem to have occurred to them that they should tell us about changes in the plan for the day or that we might have made plans of our own, but they graciously agreed to walk us back and brought us food since we had missed lunch at the hospital. Communication issues are still plentiful, but we are working on it.


Boundaries

Posted by Lucille on June 1, 2011 at 9:15 PM Comments comments (0)

I came back from my shower to find someone sitting in the common area, so I greeted him and showed him some of the pictures I'd taken the day before. After a few minutes I pulled a group member aside. We've been introduced to so many people in the last few days that we’re having trouble remembering who everyone is.

"Okay, I know I recognize him. What's his name again?"

"That’s one of the nurses from the hospital, the one who was doing fundal pressure and controlling the suction on the vacuum yesterday” she said, my instinctive reaction to which was to jump five feet back from him and map out potential exits. "He wants us to come to his house to meet his family today.” I was still staring at him. He was at the lodge, the place that would be my home for the next six weeks, outside the room where I sleep at night. This felt like a huge invasion of space. I am well aware that Saturday will not be the only difficult day I spend at the hospital, and one of the ways I had imagined dealing with it was creating a boundary within my life, where what happens at the hospital stays at the hospital. Apparently not.

I can tell myself that he treated the women the way he did because he doesn't know any different, that his way of viewing births as a simple matter of moving mass from point A to point B (never mind that the tissues in between are part of a human woman) is a product of having to attend to too many women in too little time with too few resources. I can also be honest with myself that he scares the crap out of me and I don't want to be around him. I don't know yet how this is going to play out.

I was relieved when others seemed to share a similar sentiment and we declined the invitation. One of the men from the lodge invited a group member to come to market with him and she invited me along.

We started walking to market and after a few minutes one of our guide’s friends joined us, I think because the man from the lodge wanted to talk to the other group member alone. So I found myself unintentionally on an unofficial double date. I made conversation for the sake of being polite. After a few minutes, I was approached by a filthy and intoxicated man who tried to put his arm around my waist. Before I could get rid of him, the friend shoved him back and told him to back off, which he did. I kept walking with the friend, feeling much more inclined to talk to him now. "Those are just the mad men," he said, "But don't worry. You are one of us now, they will not bother you."

Fatou and Lamin

Posted by Lucille on June 1, 2011 at 9:15 PM Comments comments (0)

EVERYBODY here is named Fatou! It is traditional for the first son and the first daughter to be named Lamin and Fatou (at least in the Mandinka tribe, which is most common- other tribes have other names that work by the same system) so there is a Fatou and Lamin in pretty much every generation of every family. We could use last names, but families are so enormous that it doesn't help much. We’re working on finding ways to distinguish when we need to talk about someone so we don’t all get horribly confused.

Goat

Posted by Lucille on June 1, 2011 at 9:10 PM Comments comments (0)

My roommate and I were the first to get up this morning, and a man from the lodge told me that they were going to slaughter a goat for charity and invited us to come. Another man said nothing, but I later learned that this is not something women are normally allowed to watch and he was uncomfortable with us being there.

“Do you want to come?" I asked my roommate as she walked by, "They're going to kill a goat."

"Not kill," the first man said, "Kill is angry. Slaughter is respectful, for food."


Rest

Posted by Lucille on June 1, 2011 at 9:05 PM Comments comments (0)

When we got back to the lodge everyone was quiet, trying to process everything we had experienced. Our group leader declared Sunday a rest day so we could sleep in. I have never loved her more. I think two births and a marriage proposal is enough excitement for one weekend.

Mad Men

Posted by Lucille on June 1, 2011 at 9:00 PM Comments comments (0)

Our group leader and I walked to the hospital to meet the man who was going to help us buy groceries, and on the way we talked about what had happened that afternoon. I was relieved to hear that I was not the only one who had been horrified by how they treated the women there. "It's different in the US, right?" I asked, "They know to be gentler. This would count as malpractice."

"In the US, this would count as assault."

Toward the end of our discussion I assured her that despite the difficult aspects of the day, it had still been an amazing experience, ushering two people into the world and being there for the women in such an important moment. I told her that I was still considering doing a nurse-midwifery program, something we had talked about before. She smiled a little and said that if I was able to find anything enjoyable about that day, midwifery in the US would put me over the moon.

Throughout this time we greeted the people we passed and some would walk with us for a while and put their arms around us as a sign of welcome. One man introduced himself as Kunta Kinte. (Anyone seen Roots? I just learned it was filmed in Gambia!) He put his arm around me, which slowed me down a bit as we went through the usual greetings. The Mandinka language has at least five different ways to say, "How are you," all of which must be asked. When we got to the last one it occurred to me that he should have removed his arm, and I began to notice his stagger, the force with which he held me, and the growing distance between us and the rest of the group. At that moment he slid his hand down my arm so that he was holding my breast.

I promptly broke free of him and ran to catch up with the others. He followed me, and continued following me for over an hour. We thought we'd lost him when we got to the wholesale store, which was packed so tightly with goods from floor to ceiling that only a few of us could go in. I waited outside, and a few minutes later the man came up and asked me to leave with him. I refused. My group leader came out and demanded that he leave, and he walked away and out of sight, but as soon as she went back in the store he came back. He wanted to give me his email. Whatever. Please would I give him mine? Hell no. But would I promise to keep his? Fine. Appeasement was NOT working. He kept going and I decided to ignore him. I kept watching the people around us to see what they would do. One person came towards us and I thought he was going to help, but then he told me I looked like an Arab and asked if there were many Arabs in Algeria. The crazy guy started introducing me to random bystanders as his woman. I stuck to ignoring him. But then he came toward me like he was going to kiss me so I raised both my arms between us, and he grabbed my hand, kissed it, and then knelt down and started to propose.

My group leader came out of the store with a look of disbelief on her face, cut between us, and pulled me toward the nearest taxi. Our guide got in the front, while my group leader pushed me in the back and climbed in beside me. The man tried to get in after her but she slammed the door. The driver started the engine.

I sat back feeling very relieved to be in an enclosed space away from him. My group leader reached over and locked my door. Before I could thank her for the precaution, the man's arm shot through the driver's open window, groping toward me, and my group leader slammed her hand against the handle of my door to keep him from opening it and yelled at the driver to drive. The man pulled his arm back just in time and eventually fell behind.

While we drove, our guide told us that the man had been one of the mad men, the ones who had gotten drunk too many times and came to the market to try to woo tourists. He told us there are some in all cities and as we meet people and integrate with the community here, people will be quicker to defend us. I thanked our group leader profusely.

And Then There Were Two

Posted by Lucille on June 1, 2011 at 8:55 PM Comments comments (0)

As we were finishing and pushing the last water into the drain, a pregnant woman came in, tore off her clothes, and started climbing onto a table. I started to protest, but one of the nurses said, "No, its ok. We’re done," at which point I realized that they do not have or use disinfectants of any kind. For the once-a-month cleaning, water is the best they have, which made me wonder what they do, if anything, the rest of the time.

We milled around for a while as the other beds filled, waiting for the head of the hospital to arrive or for us to be directed to another station. Then as one of my group members was passing by a bed, the woman grabbed her hand and pulled her to her side, grimacing from a contraction. Our group leader used to be a doula, and we modeled our behavior after hers to support the woman through each wave of intensity.

Thunder clapped outside and a wall of water pelted down. When it rains, it pours. The sound of the rain hitting the sheet metal roofs was deafening. Another woman came in, singing loudly, and I later learned that she had had two previous cesareans and had walked to the hospital in the pouring rain to be transferred to the bigger hospital in Banjul, but the ambulance had also broken down. She was singing to distract herself and try not to push. When a new ambulance arrived, two of our group members were invited to go with her to experience the transport system.

I soon learned that standards of patient care are very different here. In many cultures with high infant mortality rates, the baby is not named until a while after the birth, in this case a week. The birth is considered part of the pregnancy, and therefore not considered an emotional, much less sacred, experience. I knew this, but I was still shocked and horrified by some of the things I witnessed. No attempt was made to ask or even tell the women before anything was done. Vaginal exams were frequent and unnecessarily rough, to the point of being brutal. I started to feel like I was going to be sick or pass out, so I took a walk and thought about turtles for a while, and got back just as the baby was born and placed in a separate bin.

Midwives here seem to have a general idea of sterility. They wear gloves, but attend to multiple patients without changing gloves, and I’m not sure if this is just the way they are trained or if it is because gloves are in short supply. It might be some of both. The midwife who was tending the woman who had just had the baby unwrapped a catheter. Emptying the bladder is sometimes necessary to help with the delivery of the placenta, but I gathered that it is routine here, as the woman was given barely a minute after the birth. The midwife touched the end of the catheter as she unwrapped it and shoved it in, causing a woman who had just delivered a baby in complete silence to scream.

I severed myself mentally from the situation at this point and focused my attention on the baby. She was so incredibly tiny and adorable that I allowed marveling at her to occupy my attention for some time. After a while had passed they took her to breastfeed. I have the mother's expression captured in my mind and will not sully it by trying to describe it, but it was the one thing that made me understand how what she went through could be worth it.

Another woman had come in during this time, who was clearly mad with fear. When I walked by with two other group members, she clutched at us, begging us to help her. I stayed with her for a while, telling her that she was strong and doing a great job, and when I needed to take a break we took shifts so she would not be alone.

Attempts were made to forcefully progress her labor, which included a man kneeling with one foot by her head and one on the windowsill and shoving on her uterus. It occurred to me at this point that most of the more violent procedures were being performed by the same person, a male nurse I’ll refer to as the rough nurse to avoid confusion. The head of the maternity ward and most of the other nurses and midwives were usually more gentle.

When the woman had been in labor for an hour, her labor was determined obstructed (I wondered if her terror alone could cause this) and the midwives decided to send for a vacuum. The rough nurse wanted to use it but the head of the maternity ward told him no and sent for the head of the hospital. As soon as the head of the hospital arrived, everyone relaxed, because he carried an aura of calm with him and very gently began his work. The rough nurse was given the task of controlling the suction on the baby's head. After a few moments, the head of the hospital told him that was enough and started slowly guiding the baby's head out. As soon as he had turned around, the rough nurse started adding more suction, bracing his foot against the wall so he could pull harder. I turned away.

The baby was born, the placenta removed by tugging on the cord, and the head of the hospital left. The rough nurse took a dry cloth (I guess a wet cloth isn’t an option when there is no source of clean water nearby) and began scrubbing the dry blood off the woman's legs. I reminded myself that the skin on your thighs is tough and can probably tolerate that, but he moved down with the same force, scrubbing over extremely sensitive tissues with dry fabric while the woman gripped the table with one hand and bit the other to stifle her cries.

I turned to the baby to keep myself from passing out, and noticed that it wasn't breathing. No one had given the baby a second thought after it was put in the bin. I put my hand on his chest and could feel that he was choking, so I supported his head as well as I could, flipped him over my arm and tapped his back until he spat a good tablespoon of fluid into my gloved hand. I was already holding him by that point, so I decided to keep holding him and walked around for a bit marveling at him. His head had been badly deformed by the force of the suction, but he opened his eyes, smiled, and kicked his legs a bit.

By that point everyone else had left except me and the two group members who had stayed with the woman through the whole thing. She was still holding their hands and looked more relieved and happy than I can possibly describe, blissful. "Thank you, thank you, thank you. You are my friends. Thank you for helping me. Thank you. I will remember you." We told her how amazing she was and I brought over the baby to show her. When he kicked his legs we laughed and said he was strong like his mom. She was exhausted and fell asleep a few minutes later.

I turned to the woman next to her, who was having strong but far apart contractions. I remembered reading about the use of counter pressure to ease contractions for a school project, so using sign language and limited Mandinka, I asked if she would like me to push on her back. She gave an enthusiastic yes and braced herself against the wall so she could push against me. When she rested between contractions, I asked her her name. "Fatou," she said. I learned an African song in dance troupe called Fatou Yo, the rough translation of which is, "My name is Fatou and I live in Africa, where there are giraffes and elephants. I am alive, I dance and sing, my name is Fatou and I am happy." I asked her if she knew it and sang it for her, and she laughed and clapped her hands, and called to the women around her to look, look at the crazy American who knew the song of her name.

By the end of our shift we were so exhausted that we fell asleep on some benches in the courtyard while we waited for our ride.

The ambulance arrived to take us back and we all sat in silence, trying to process the fact that we had just helped deliver two babies and everything we had seen.

"We're all so tired," someone said.

"It was a big day," someone else agreed.

A third person looked up with wild eyes and said, "They said cleaning!"


Cleaning

Posted by Lucille on June 1, 2011 at 8:50 PM Comments comments (0)

The head of the hospital decided that Saturday would be a cleaning day, and although we do not officially start work until Monday we were invited to come help. An ambulance was sent to pick us up. When we arrived we were directed to the head’s office, which is an incredibly hot and stuffy room (though apparently only to us, as the Gambians did not seem bothered). We waited there an hour before news arrived that the car had broken down. The head of the maternity ward, a woman, wanted to get started and invited us to help in her station.

The labor room consisted of six beds, with no screens or curtains or anything. The women labor in front of each other. The "beds" are actually tables with no padding or pillows. In some places there was dried blood a half inch thick along the rim. There were layers of blood spatters on the walls. They brought in a hose and we set about washing the windows (thick with spiders) and scrubbing down the walls. The dirty water, trash, and cobwebs were swept into a drain in the floor.

Despite the conditions, we had a hell of a time. The women danced and sang while they worked with us. We threw sponges to each other over the others’ heads. Water ricocheted off the tables and sprayed everyone, and I remember thinking, "I’m hot, exhausted, and covered from head to toe in other women’s blood...and I’m having the time of my life."



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HIPAA Disclaimer

Sometimes I have the privilege of being a part of intimate, powerful moments in other people’s lives. I cannot and would not share these stories, because they are not mine to tell. However, they touch my life and become part of my own story. When I share these moments here, you can trust that I have not broken anyone’s confidentiality. The characters are invented. They are not real, but could be. I take creative license to communicate the essence of my experience while respecting the privacy of others.