Working Girl

**Warning: This post includes medical terminology and goes into some detail regarding the nature of my work so therefore people who are a) squeamish about medical things; b) prudish regarding talk of the female reproductive system; c) annoyed by women who talk about gender health issues or d) annoyed with people who use medical terminology to people who aren't medical maybe you should skip this post. Peace and Love, Amanda (P.S. Feel bad for Keith cause I can tend to bring this information up at inopportune times like dinner parties for example)**

So I am actually working while I'm here although I haven't really mentioned it in previous posts. I wrote a pretty scathing post about feminist issues while at the conference but decided it was maybe a bit too divisive and thought I would keep it to myself for now. As for work here in Nairobi things are going very well and I've already learned an incredible amount and seen pathology that I would never see back home.
Last Tuesday was the first VVF (Vesicovaginal Fistula) clinic (try this website for further information about fistulas http://www.fistulafoundation.org/) and although I feel I've seen a lot already in my short career thus far I was amazed at the things I saw just that afternoon. A young girl (she said she was 17 but I'm sure she was younger) came for her post-op visit with a catheter bag under her dress. She had laboured for days with her first baby that died after an urgent C-section when she did finally get to hospital leaving her with a hole between her bladder and vagina constantly leaking urine. This was so close to the closing mechanism of the urethra that there was some concern that her function even post-surgery would be compromised. We tested her repair using a substance called methylene blue (we use it in Canada as well) and she no longer had a fistula in her vagina which made her smile (she didn't speak English or Swahili) but when we removed the catheter urine poured out of her like a river. She'll go to physiotherapy (yes they do have physio for this) and hopefully regain some continence otherwise she will be doomed to a life of constantly leaking urine wherever she goes. She will smell, get skin infections, most likely be divorced by her husband and will become a social outcast....and she's not even 18.
That day I also saw a woman from a Somalian refugee camp that had been sent for fistula repair. She had given birth to six previous babies but this one was 4.5kg and more than her tiny, emaciated body could handle. Again with days of labour she gave birth to a stillbirth after a large episiotomy to try to expediate things once she got to medical attention. When she arrived to the clinic in Kenya it had been a few weeks from delivery and her episiotomy wound was completely open and when I examined her there was an abyss on the anterior (upper) aspect of her vagina and I could feel her pubic bone (something you should not be able to feel from the outside). She was so emaciated and weak she couldn't walk and had foot drop which is another complication of obstructed labour (and a bad sign) because the fetal head not only presses on the bladder causing that tissue to die and connect to surrounding structures but it also causes nerve damage and makes it difficult to walk. Also these women can end up with contractures and be severely dehydrated and malnourished because they think if they don't eat or drink the urine won't leak and if they don't move no one will be able to tell. It is heartbreaking.
Another patient we saw that day had skin infections from the concentrated urine ever-present on her inner thighs and we ended up being able to do her surgery the following day. It was an incredibly easy surgery (at least this particular case) and now this woman's life is completely transformed. It was amazing to watch.
I have had incredible experiences in the OR here already wearing scrubs and galoshes (they actually wear white galoshes on their feet). I was assisting on a myomectomy for large fibroids when the power went out in the hospital (thank God for generators). It was in an OR where there was 1 door between the OR and the outside world and the 2 theatres there had no door between them (sterile? really?). To operate here I had to change in a coat closet. We also did two laparoscopic ovarian drillings that day. It boggles my mind that they are doing laparoscopic surgery in a place where the electricity isn't always reliable (and this was a private hospital :))
Today I rounded with the acute gyne team. They seperate their gyne wards into acute cases and chronic conditions. On the acute side there were 5 large rooms with 12-14 people in a room and 10 beds (yup - do the math that means they are sharing beds - head to toe). There were a few sparse curtains in the room which were never used. We saw 60 patients this morning all with acute gyne problems - an entire room full to the brim with ectopic pregnancy patients - all of them had waited until they were on death's door to come in so all of them had had emergency life-saving surgery. There was a girl who hadn't graduated high school yet who bled to a hemoglobin of 15 (normal is 120-140), in that same room was a woman with choriocarcinoma with brain metastases, coma and hemiparesis (placenta cancer that left her with paralysis of one side of her body). There was another woman in the next room who was induced for a stillbirth and had been sick the whole pregnancy - turned out she had a tuberculoma in her brain. There are so many women here dying of cervical cancer that the senior resident told the admitting residents to not admit women who would survive in the community or who would die within the next day - only to admit women that they could maybe turn around in a couple of days because that's all the room there is. There is ONE place to do radiation oncology in Nairobi and it is constantly booked. These are women in their prime, emaciated and dying in inhumane ways. So someone tell me again why it's so horrible that the medical community has encouraged cervical cancer vaccinations? (http://www.macleans.ca/science/health/article.jsp?content=20070827_108312_108312) And don't fool yourself into thinking this is only something that happens in Kenya because even in my residency I have seen women dying of cervical cancer in our own country - the numbers are just more impressive here - they are begging for the vaccine here and it's just as expensive in this country which means it's out of reach for most African people. For those of you who know me you know I'm being circumspect on my opinions on this issue. I recently made a room full of women nauseous on this topic when asked about it over drinks at the Jahns residence (sorry Jo). I just think that, especially as women, we have to be informed (and outraged) about what other women in our world are going through and we need to stop being so fucking blind and stupid (and this, again, is me being restrained).