The One Where I Retreat Back into My Statistics

One of the things I find interesting about working overseas is that when things go wrong, I can just blame the country. I know that I am certainly not the only expat who has ever done this--I think it's a pretty common response. Since, for the most part, you're going to leave the country after some period of time and return to your "own" country, its a way of absolving responsibility when you face a problem you don't really understand, or can't figure out how to solve. It functions as a kind of coping mechanism: This is a big problem, but it is a problem with this country, and after two weeks, or three months, or 2 years, it won't be my problem anymore. This distance can be pretty critical to mental well-being in some circumstances where acknowledging that no matter what you do, the problem will keep popping up in some form.

This morning, I went downstairs and immediately went into a c-section. I've been trying to be at most of the c-sections because those are the babies most often in need of resuscitation, and I've still been working with the midwives on perfecting their resus skills. We had to wait awhile for the c-section to start after everything was ready on the baby cart:


So the midwives entertained themselves by watching Bob Dylan music videos on my iTouch, which I keep with me to look up dosage information for meds I give. I tried to explain to them that Bob Dylan was very famous in the US, but they were pretty skeptical. I entertained myself by imagining the origins of Mersilk-type sutures: silvery strands of mermaid hair?


Here's what surgical scrubs look like, Somaliland-style:


Fortunately, we weren't needed: the baby came out pink and kicking and screaming. We dried her off, wrapped her up and set her on her way to her family waiting outside. Meet one of the newer members of the world:


After I had given the baby to the family, the matron, Katherine, asked me if I would look in on a baby in the "ocubator", which is what everybody here calls the incubator, which always makes me think of some 8-legged octopus-like machine. Anyway, the baby was about 30 weeks gestation, born via c-section about 7 am this morning after a placental abruption, an obstetric catastrophe where the placenta pulls away from the wall of the uterus, depriving the baby of everything it has been getting from the mother, which is to say, everything.

When there's a critical baby in the incubator, there's usually one community midwife assigned only to watching it. The baby was small, but looked pretty good, actually.


But when I took his heart rate and oxygen saturation, I was a little concerned. The O2 sat hadn't been great since he was born, but had dropped down to 70%, and the heart rate had dropped off quite a bit too. Not action time yet, but I decided to stick around and take vital signs more often than the every 30 minutes they had been being taken. 5 minutes later, the HR had dropped more, below the critical 100 bpm mark and his respirations were labored and irregular. I sent the community midwife to find matron and began giving the baby breaths with an ambu-bag (not my photo):

After each 30-second set of breaths, the heart rate would go up for a bit, but then drop more. At this point, had we been in the US, the baby would probably have been intubated and put on a ventilator, but they don't have any ability to do that here. Instead, I kept giving breaths by hand. By the time matron got there, doctor in tow, the baby's heart rate was weak and irregular and had just dropped below the even more critical 60 bpm mark. The doctor ordered hydrocortisone (which increases the blood pressure and susceptibility to adrenaline) and adrenaline (which increases the heart rate).

This was where things started to really get frustrating. The midwife puttered off to find the materials to give these things, but only after I interrupted her social conversation and said, "NOW!" She came back and slowly began preparing them, me in the background suggesting in an increasingly irritated way that this was an EMERGENCY and she needed to BE QUICK. Meanwhile, matron and I are doing CPR.

Finally the baby got the meds, and his heart rate increased up past the 100 bpm mark. Naturally this means that the baby must be fine, and its okay for everybody to leave, right? Because the baby might have almost died less than 2 minutes ago, but I'm sure it's fine now, right? So it's back to just me and the midwife again. Are you picking up the theme of me being left alone with critically ill babies?

This midwife in particular is a sweet girl and pretty receptive to teaching, but not terribly quick on uptake, and critical situations aren't great for this. The baby's heart rate started to drop again almost immediately, and I went back to giving breaths. The midwife then noticed that, oh no, she had missed the 12:30 time on the monitoring sheet! She needed the baby's vitals! Its O2 sat! I tried to suggest, with all the gentleness that I could muster, that the monitoring sheet was NOT A PRIORITY RIGHT NOW, and that if you look at the blue baby lying in front of us, you pretty much know what you need to know about the 02 sat, more than a portable adult oximeter inappropriately jammed on the baby's foot is going to tell us.

And then the power went out. When the power goes out, the oxygen stops, and the incubator cools off. Moments later, the baby's heart rate dropped below 60 bpm again. Now, there's just no way 2 people can handle this situation. You need two people to give CPR, one to give adrenaline and one to go tell the front to turn the generator on. Instead, there's two of us. I told the midwife to run don't walk to the front desk and tell them to put the generator on now now now and then call the doctor while I gave the adrenaline and began CPR, which is really a challenge with just one person. And then the midwife didn't come back, and didn't come back, and I'm just in there alone giving round after round of CPR, in between them listening to the heart rate keep dropping, getting weaker and more irregular, watching the baby getting bluer and bluer. Finally the midwife came back, still no power, oh, and the doctor, he's in the toilet. He'll come when he's done.

And then there was no heartbeat. No doctor, no heartbeat, no spontaneous respiration, no power, no oxygen. 10 minutes is the generally accepted length of time for attempting CPR in neonates, and I was at 15 minutes of straight CPR, an hour and half out from initially noticing his declining condition. So I quit, because there wasn't anything else to do or anyone else to call it. And I took the IV out, and the oxygen out of his nose and wrapped up his tiny blue body and found somebody to tell the family and touched their shoulders and listened to them wail because there wasn't anything else to do or anyone else to do it. And then I walked away, because there still wasn't anything else to do.

At slightly loose ends, I went to tell matron, and found her with a semiconscious eclamptic woman about to give birth. Good, I thought--a distraction, something to focus on. There's no tradition of labor support at this hospital, but I've found when offered something to hang onto while they're laboring, every woman will take it. She delivered the baby, literally hanging around my neck. A healthy but pretty tiny baby girl.

But, surprise! It's twins! There's another baby, previously unknown to exist, in there! First, let's switch shifts, so that everyone who knows anything about this woman is gone. And let's replace the competent staff midwife with the widely-recognized as worst staff midwife. This is a community midwife who Edna hired at the beginning when there were no other midwives in the country and who has a staff position but is also enrolled in the post-basic midwifery program, which she is in serious danger of failing, yet continues to have staff authority--for now.

Oh, hey, let's have the staff midwife press real hard on this woman's abdomen to try to make the baby come out because even though its heart rate is good, it's not coming fast enough! No, no, don't worry about uterine rupture or anything, just keep pressing, I'm sure that will make the baby come out. Hey! Let's pull that cord and see if that makes the baby come out faster! Whoa! That's a lot of blood that just came out! No, no, I'm sure she's fine, don't worry about taking her blood pressure.

Ultimately, and luckily, mom and both (identical twin girl) babies are fine, but the mother lost a tremendous amount of blood and watching the delivery of the second baby was one of the more distressing things I've seen here in terms of skill level and total disregard for evidence-based medicine. Right up there with what they used to do (and which several staff members still try to do) with newborns who weren't breathing well: hang them upside down and smack them hard on the back. Right.

At this point, it was 3 pm. I blamed Somaliland for not caring at all about babies or women and skulked off upstairs to eat lunch and spend some time with my lovely, lovely inanimate, infinitely cooperative statistics I'm working on for Edna.

The reality of it, of course, is that no matter where in the world you are, you're going to have bad days and bad colleagues and see bad decisions. Sure, I'll leave Somaliland in a couple of weeks and be back in the US where there are more options for both of these situations, and a higher level of training for the professionals involved. But I will see (and already have seen) these professionals at home regularly disregard best practices and piles of evidence and do stupid things. It's not Somaliland, it's humans.

Bummer. Maybe I should have just stuck with statistics.*

*I don't actually feel this way at all, because then you're just looking at and calculating neonatal mortality statistics instead of also directly working on doing something about neonatal mortality. What it really makes me want to do is stay very on top of new research and keep teaching midwives best practice care for wherever they are, the US or Somaliland or the Congo and writing about and keeping really good stats what works and what doesn't so that other people can do the same thing. This is exactly what I'm working on doing now, so for being a pretty bad day, I'm feeling pretty positive about my recent career choices.