Our residents and fellows in the Global Health Pathway have many stories to share about their experiences providing clinical care and conducting research abroad. Here are two such stories.
By Jana Halfon, MD
Global Health Pathway Fellow - OBGYN
For anyone who has ever worked in a resource-limited country, you know that nothing ever goes the way you plan. Rules suddenly change or visa applications go astray, your planned budget increases exponentially when trying to hire research assistants, there are language barriers, the electricity surges and causes your very expensive equipment to explode, the lights go out in the OR as you suture the uterine artery on a hysterectomy, or you just get malaria. These things have all basically happened to me. And why would I want to keep doing this you ask? Because there’s nothing quite like it. Global health research follows its own set of rules and its oddly exciting to figure them out. Utterly frustrating at first, but interesting none the less.
You can also discover things of great significance to the location where you work, something that can make a tangible impact. It has its own sense of gratification - from the partnership with local investigators, to the capacity building contributed by your research dollars, to the potential for further investigation. I’ve laughed, I’ve cried, I’ve cried some more, I’ve had truly great days, and days where I just couldn’t watch any more patients die and left the country for the weekend. But it’s been an amazing year, and I have been very fortunate to not only collaborate with some brilliant Rwandan doctors and residents, but to have had some small successes with my research projects, to my absolute shock.
But the research successes, though wonderful (and possibly temporary), were built on stories, on experiences, on the terrible truth of global health in obstetrics and gynecology – sometimes you watch women suffer who would not in resource-rich areas, sometimes you watch women die just because they became pregnant.
Here is one such story.
“She’s gonna die.” Chris whispers this to me in a soft voice, confident and unphased. His eyes are looking past me, his expression one of simple acceptance. We are discussing one of our patients on Ward 5, the sepsis ward – a woman who went into labor, did not progress, and underwent a routine cesarean section at our hospital. She developed a surgical site infection, one that ate away her fascia and subcutaneous tissue, requiring an extensive resection of her abdominal wall and a need for a temporary closure device, In Rwanda, the only device available is a sterile plastic foley bag sutured to the skin.
“Oh no, that’s not happening,” I say nervously, in response to Chris. My words are a little sardonic, but sadly sincere. I reveal myself in that moment, uncover the truth of my emotions and erase the strong indifference I attempt to convey when rounding on this ward of perpetual death. Chris catches it. He’s been doing this for over 20 years, a plastic surgeon trained in military trauma - of course he sees through my facade. “Be careful Jana. Don’t get too attached. It will destroy you. I’ve seen it before.”
I know he has. I’ve heard the stories of those who came before me. The young ones, like me, not tempered by age, experience, and the inevitable. When I started on Ward 5, I thought I was different, detached, dispassionate. I was horribly wrong. The truth began to seep in after we lost 3 in one week. Chris texted me early Saturday morning. “Jana, what is the state of all the ICU patients? Did they all die?” Me: “All but one. The patient who herniated through her T incision made it. She’s doing well.” Chris: “I was sure they would all die.” And then later. “Be strong. Take time off. Find someone to talk to.” I scoffed at that statement - be strong. It didn’t affect me. I went out as usual. I slept through the night. But then something started to take hold of me, Chris’s words flashed across my memories one too many times. Such is life - you bottle the truth unknowingly, keep it hidden out of sight, until someone unearths it, breaks it open, and forces you to deal. And then it all comes pouring out.
“Evisceration is not compatible with life,” Chris says. Our patient, JU had developed a rare surgical emergency, evisceration, where her bowels were now outside her abdomen, unprotected from the outside world. Ward 5 is full of open abdomens, a result of necrotized skin, fascia and organs all due to post-cesarean section infection. One of the most dangerous things that a woman can do in the developing world is to become pregnant.
“Evisceration is not compatible with life." Chris said it yesterday on rounds, a teaching point to our residents and a slight nudge to get them to act fast and move her to the OR. They impressed me, calling in favors, advocating for their patient. But the same thing happened again today, and now we were faced with a broken autoclave and no sterile equipment. All surgeries were delayed, including the operation that would save this patient’s life. Our hands were tied. We had no equipment to proceed with surgery. Rounds were over. “Ok, remember what I said Jana, good luck, see you next week.” What could Chris do? He is there for guidance, and even then, he is leaving the country in three weeks. Our wound expert for our wound ward will leave and they will be left with inexperienced me.
We finally moved her to the recovery room, a place where there is slightly more nursing care - for example, in an open room with limited nursing availability rather than at the end of a hall with limited nursing availability. I saw her the next day, looking worse, on maximum oxygen through a non-rebreather mask, with paroxysmal breathing and a heart rate in the 120’s. Her bowels were poking through her dressing, clearly visible if you pulled back the sheets. There is a reason we have skin keeping everything inside. Evisceration is not compatible with life.
She was my first death from the ward, a statistic that I was proud not to have had before her. As if it were a true reflection of me. Her death sparked all the thoughts and questions and doubts of global health work – does my presence make a difference? Why am I here? Am I contributing? Am I doing something more than collecting data points? What is my agenda?
It is the ultimate question in global health, the question that should be asked of any person traveling to a resource-poor environment. We all have one, so what is mine? Do I think I’m going to solve the problem of pelvic peritonitis in 8 months with one research project?
No, but I’m going to try. If it is all for nothing, fine, it’s all for nothing. But I need to try. I am not a quitter. These women are dying, and not from lack of resources. From too much.
There is an epidemic occurring across the Rwandan countryside, an epidemic that is killing young, healthy pregnant women. It’s not lack of blood, or lack of hospitals. It is the c-section. It’s the horrible infections post-cesarean section. Infections that eat away the uterus. Infections that necrotize the fascia. Infections that induce septic shock and its 60% mortality rate. Multi-drug resistant infections unresponsive to available medications. Devastating infections. Cesarean sections are supposed to reduce mortality from childbirth by hastening delivery in cases of eclampsia, hemorrhage, or obstructed labor. And they have. But they are doing something else now, something that we don’t quite fully understand. And it is up to me to find out why. Not because I am uniquely skilled and brilliant or a better doctor than any of my Rwandan residents. But because I have the time. If I don't do it, who will?
I’ve spent a year in Rwanda researching this disease, analyzing my data, formulating new projects and research directions, discussing department protocols and possible institutional change, mentoring residents to continue my work when I’m gone. The research is promising, though only just a start. But it is the stories that I will never forget – the patients we lost and the patients we saved. At our core, us doctors are all just storytellers. And this was mine.
by Andrew McCrary, MD
Global Health Pathway Fellow - Pediatric Cardiology
There is a pediatric cardiology clinic in Eldoret, Kenya that reliably sees over forty children every Friday. Taking my share of the patients, I was immediately overwhelmed with the burden and severity of disease. Rheumatic heart disease with multiple affected valves and significant congenital heart disease patients fill the clinic. The lesions are so severe that I usually know the diagnosis before the stethoscope comes out of my pocket. By placing my hand on the child’s chest or wrist, I can feel the diastolic thrill of mitral stenosis or Corrigan’s pulse of aortic insufficiency, for example. During many cases, I ask the clinical officer joining me in clinic for language, cultural, and system translation to begin discussing the need for surgery with the family as I bring my stethoscope to my ears.
Towards the end of a particularly busy clinic, a young mother brought her swaddled baby into the consultation room. I review the documents in the baby’s brief chart. It seems that the four month old was admitted recently due to concern for neonatal fever and treated with an appropriate course of antibiotics. During the evaluation, an echocardiogram was performed and revealed a structurally normal heart with a patent foramen ovale (a necessary opening between the two collecting chambers of the heart during fetal life that does not completely seal after birth in up to twenty-five percent of the general population). Due to the finding, the pediatric team referred the child to the clinic for follow up after discharge. I asked the relevant questions and found out that the baby had been feeding and growing well. I told this young mother that I was very happy to let her know that the child does not have heart disease and does not need any different treatment that usual infant care. Mom gave a blank look as she studied me. I could tell she was prepared to hear the worst and not hearing that struggled to assess the degree to which she would believe a foreigner she has never seen before. I discussed the finding on the test and ultimately found some traction when I told her that we would be happy to see the child again if she had any further questions or concerns. That seemed to relieve her, and she left smiling.
Similar to parents in the west, the question of heart problems in their children is gravely serious. Unfortunately this child was the only healthy child I saw that day. As I conclude this short visit, I reflect on the limitations of this health system to treat children with heart disease, and equally the strength and pain displayed by families caring for their children. My prayer is that I have the strength to enter into this struggle.