MAKING A DIFFERENCE

Today I want to share two of my many stories with you.
The first time I met Flora she was lying on a bed in labour ward her mum was standing alongside her. I was suprised at how young she looked and immediately noticed the worry and concern reflected on her mum's face. Maybe that was how I identified with her in that moment, somehow not as a patient and guardian, of which I see many, but as a Mum with her precious daughter. It is unusual to find mothers on labour ward except with very sick patients so I immediately presumed that her condition must be critical. I inspected her file to familiarize myself with her case and found that indeed she was a very ill girl/woman. Flora had been referred from the health centre in Salima, more than an hours drive from Lilongwe and situated on the side of Lake Malawi. She was around 30 weeks into her first pregnancy but was carrying a dead baby. She had last felt her baby's movements over one week ago. But that was not her only problem. She was suffering from severe and chronic anaemia. Her Hb. (normally 12 to 14) was 3.1 .The clinician who had admitted her described her appearance as "paper white" This may seem a strange way to describe a person with black skin but certainly makes you realize the seriousness of her condition. Flora is 20 years old, but looks 15! Apart from the pregnancy she had also been vomiting blood for several days. The reason for this was not known at that time but was an important contributing factor to her anaemic state. The hospital at Salima had transfused 3 bags of blood but could do no more. It was now extremely important to deliver the dead child but her critical condition made this very dangerous so she was referred to us at Bwaila.
By the time I arrived she had been transfused one more bag of blood and induction of labour had been iniciated. I decided to take over her care. I quickly made friends with her Mum, even though she spoke very little English and was grateful for her presence throughout the day. I soon realized that they had arrived in an ambulance from Salima with no posessions, money or food. I gave her Mum 500mk(less than 3 euros) with which to buy some basic food and essentials. It quickly became obvious that Flora had been sexually abused and therefore it was very difficult to perform the necessary examinations and procedures. However, I refused to do this by force ( she had been forced too many times) and though it took a great deal of time and effort, talking and explaining, and being as gentle as possible, I slowly began to gain her trust and confidence. She laboured quickly during the day and by early afternoon she was ready to deliver. I had been able to transfuse 2 bags of blood and also blood extracts during the morning and hoped that would be enough. It was all that was available. We had been promised more later. I was concerned as to how she would cope during and after the birth and did all I could to ensure minimum blood loss at that time. The fetus and placenta was expelled easily without haemorrage but she continued to ooze afterwards. When I left her on Friday afternoon she was on the way to operating theatre for an exploratory procedure to establish the cause of bleeding. It was just too difficult to examine her properlywithout sedation or anesthetic. My last words to the clinical officer was " Please look after Flora I want to see her on Monday"
" I'll do my best " he replied. I could ask no more.
I spent most of the weekend thinking of her.
My first call on Monday morning was to post natal ward. I was delighted to find Flora alive. Not healthy, not strong, but alive.
The same day she was transferred to the gynae.ward at the central hospital for further investigations. She was still vomiting blood.
Today I went to see her and took her some boxes of milk, nutricious cereals, a bar of soap and some washing powder. I found her sitting up in bed, still ' paper white' but still alive.
When I enquired of the clinicians as to her condition I found that the investigations were still not done and they were not aware of her most recent blood results. Her Hb. post delivery is now 2.9.
I do assure you that in the developed countries 2.9 is considered nearly dead!
I requested that they ensure she receives more blood and that the investigations be carried out as soon as possible. I will return in 2 days to make sure.
Now I must quickly tell you about Larson.
My friend and fellow midwife Joanne, now living in Ghana, but who spent 3 years working at Bwaila, is here on holiday. It has been great to spend time with her, she's a remarkable lady.
On Saturday she sent me a message telling me of a Malawian family that she knows. Larson was desperate to find work. Did I know of any opportunities? At the time I didn't. Later that day I was talking to my neighbour who informed me she would be moving to a new house. It would be a good thing as there would be a big garden for her boys to play in but unfortunately being the other side of town she would need a driver to shuttle her sons back and forth to school and their various activities. I immediately thought of Joanne and her friend.
The interview was arranged for Sunday morning. Joanne arrived with Larson and I introduced them to Rose. We sat on the verandah and Larson began to talk. A married man with 3 children his wife was expecting the 4th. He had been out of work for 2 years and during that time had trained and gained a licience to drive taxis. He started his own business as a taxi driver but a year ago he was attacked at gun point and his taxi was stolen.He is lucky to be alive. Understandably, he will not drive a taxi again.
We asked how he and the family had survived during the past year? He explained that by doing small jobs he could earn some money so the family could eat and if not they just had water. It was shocking to hear this type of story first hand. We all know how many families here in Malawi live this way but it was disturbing for us to listen to his words and hear the emotion in his voice. The voice of a good man who so often could not provide for his family.
" I promise I will work hard, madam. " he said. " You can trust me. I will look after your boys as if they were my own. "
Rose decided to offer him the job. She was concerned that it would not start untill January.
" That's OK, madam, I have been waiting so many months I can wait one more"
The tears in his eyes and the smile on his face as he left to walk the 6km home to tell his wife the good news were a joy to behold!
What an incredibly humbling experience it had been for us all.
" You have just employed a driver " I said to Rose " But you have turned his whole life round"
Larston would go home to tell his pregnant wife that the future was brighter. 2009 would bring food on the table, clothes for his children and who knows maybe schools and medicines too.
" There was always much love in that family." said Joanne.
" Now there is hope"
How little we really had to do to make a difference. How little YOU really have to do to make a difference.

BLOODY MATTERS

A new blood bank is being built in Lilongwe. Until this is finished the blood comes from a central supply in Blantyre., more than 3 hours drive from here. It is ordered and received daily but invariably there is never enough. Most of the donors are young students which means in holiday times there is a marked shortage. Iam sure that the particular lack of supply two weeks ago was the cause of many tragic incidents all over the country but I can only tell you of those in which I was involved. The lady that I talked of last time was eventualy delivered of a still born infant later in the day. A normal delivery saved her from a c/section. Her life was not put at risk by operating with out the necessary blood supplies but for her baby it was too late. The following day I was attending a very young girl, just 17 years old, having her first baby. She had been suffering from severe malnutrition and chronic anaemia for some time. (Hb 4.2) As her labour progressed I prepared myself and her for possible complications. An IV line was inserted and the appropiate medications were prepared and ready for use as soon as the baby was born. Her blood loss should be minimal if she was to maintain her condition. I aided the last part of her labour by assisting with a vacuum extraction. Such severe anaemia brings with it an overload on the heart and inability to cope with extreme effort such as pushing out a baby. The placenta was delivered quickly with minimum blood loss. It was then she started to haemorrage. I knew that I would be lucky to find blood for her but had send off a petition earlier. It was still not available. After following all the procedures in event of severe haemorrage she still continued to bleed. We were begining to get worried. As with any wound or area of blood loss, compression of the site willreduce bleeding. It was the only thing left to do and for the time necessary to stem the haemorrage or untill the arrival of the blood so that she could be taken to theatre for a hysterectomy.The poorly contracted uterus was the cause of the haemorrage with the underlying chronic anaemia. This meant that removing the uterus would be the only option. So it was that I found myself performing bi-manual uterine compression for more than 30 minutes. This means that I had to compress the uterus between my two hands, one externally and the other internally, in the vagina. It is a procedure that we are taught in our training and that I continue to teach for emergency situations but is rarely needed as by this stage the woman should be in the operating theatre. The senior obstetrician was called to review the situation. She decided to go ahead and operate. The anaesthetist was not happy. "She can die here from her bleeding and we do nothing or we can try and operate and she dies in theatre.... we must give her a chance. Some things we just have to leave to God" the obstetrician remarked encouragingly. I found myself in operating theatre with this young girl. At worst she would not survive and at best she would be 17 years old with no uterus! I waited by her side for the surgeons to get ready and the theatre to be prepared. I was continuously checking for the contraction of the uterus and signs that the bleeding had ceased. All was ready. "Please can you check the vaginal packs once more " I asked, " I think she has stopped bleeding ,her uterus is contracted " And it was! There was no need to operate, I couldn't believe it! She was taken to post natal ward where later that night she received 5 packs of blood. When I went to see her the next day she was sitting up feeding her baby!
Maybe I should end with that story so that you can all feel better and happy? But no .... I cannot, you need to know the whole truth, all the stories. The following day the situation was still the same. Little or no blood to be found. The lady who was brought to us from the health centre was already in a poor state as she had started to haemorrage in her home, in the village. The placenta was lying low down, in front of the baby's head (placenta previa)as the cervix began to stretch it was pulled away from the uterine wall and began to bleed. She had already lost a huge amount of blood when she arrived in the early hours of the morning. The treatment for this condition is emergency c/section. She was unstable and there was no blood available. The anaesthetist decided her condition was too precarious to operate.The young clinician could not contact his superior and the woman bled to death one hour and a half after arriving at the hospital. Her baby was still inside her. Should she have been taken to theatre in any case? without any posibility of transfusion! Maybe yes? Maybe no? Would any doctor like to be faced with that decision? would you like to be faced with that decision?
Don't worry you won't have to ! You'll always have blood available for transfusion. Your blood banks work, your donor schemes work. You are rich, you can protest and complain! The women...especially the women...the poor women of Malawi have no voice, will not be heard, so they die because there is no blood to give them.
The new Bwaila hospital is well underway and nearing completion.It should be ready March of April next year and I'm getting involved!
The Rose Project from Ireland (www.roseproject.org). are funding the building and equipping. It will then be turned over to the Malawian district health authority to staff and run. So thats where I fit in. I will be co ordinating and advising to help to achieve the vision and aims of the donors and sponsors. To create a maternity hospital of excellence here in Lilongwe.
More about that next time.Suffice to say its all very exciting for me and a whole new challenge. Keep supporting me, please, I'll need it!