Day 8: Saturday, Operating Theater

We left early Saturday morning. Having established contacts with the hospital, we headed straight for the maternity ward. We spoke with the nurse in-charge and were graciously welcomed to observe in the antenatal ward, where mothers awaiting labor, experiencing complications and infections were kept under observation. The ward is a long room with beds lined on each side against the windows. Caretakers would sometimes poke their heads in the to the lucky few patients who had their beds next to a window.

Maternal ward

Dr. Peter Mbabazi and Dr. Haijarah went down the row of beds on each side of the room, checking in on each of the mothers. Routinely, they used a fetoscope, bending over the bedside to listen in on and calculate the heart rate of the fetus with the help of a stopwatch. The whole process takes around ~1 minute on average, although it is sometimes laborious for the doctors to find the right spot on the mother’s tummy where they could hear the fetal heartbeat. “We had dopplers back in medical school”, Dr. Haijarah said, noting how much easier it was to get the fetal heartrate with the device. That was not a luxury the doctors had access to at Jinja.

Postnatal ward

Leanne and Teja visited the postnatal ward, where they kept the mothers under observation after delivery.

C-section

Kim Hwang and Pav returned to the antenatal ward where they found out that Dr. Peter was preparing a patient for a C-section. Dr. Peter briefly headed out of the ward to search for blood that the anemic mother needed for the surgery and returned to change into green scrubs and guide us towards some operating theater aprons so that we could observe the C-section. He then proceeded to setup the operating theater (OT), prepared a trolley to transport the patient to the OT, and speak with the patient’s family to request that they purchase 6 bags of cotton gauze that he thought the OT was short of. It was all in a flurry, and it was a deeply humbling experience to see the doctor handle so much alone. He also setup the surgical tools and readied the sterile field on his own as the OT nurse in charge was not present. It was a really impactful experience to see the surgical team work so hard to do so much with whatever they have on hand. It was rather upsetting, though, to learn that there are times when doctors just don’t have the resources they require and literally describe themselves having to watch patients ‘bleed to death’, helpless.

The settings of the surgical theater was in many ways a different experience than in Johns Hopkins where everything is set up and ready for the surgeon to solely operate. All the setup leading to the surgery would have been completed by different healthcare team members leading up to the surgery. With the patient wheeled in, Dr. Peter and Dr. Haijarah assisted in transferring the patient to the surgical bed. They then put on aprons and boots which uncannily reminded me of the butchers in wet markets in asia, who would put on similar rubber aprons and boots to prevent their own clothes from being soiled with blood.

In the OT, it was just Dr. Peter, Dr. Haijarah, the anesthesiologist, and the two of us observers, and we made do with whatever we had. At points in time, we as observers took up the role of circulating nurses, grabbing from the supply cabinet and helping in whatever the surgeons or anesthesiologist needed; at others, we helped assist the mother in sitting up as the anesthesiologist prepared the spinal. For the most part, the surgery went uneventfully. The C-section was a success, and the baby came out healthy. She was sent to the NICU though, due to the fact that the mother went through a complicated birth process, being anemic. The closing up of the C-section, however, was longer than what we were used to – the doctors seemed extra careful to make sure that the wounds do not re-open, sometimes double-stitching the wound. They also immediately injected oxytocin and inserted misoprostol pills into the cervix to help with constriction of the uterus in general to help with controlling blood loss and prevent the onset of PPH. These steps were taken whenever supplies availed themselves to help ensure that the mothers have the best chances of recovery after a C-section.

A second C-section

As the mother was wheeled out, there was a second mother who was lying on the bed outside the operating theater already waiting. As it turns out, she was bleeding out every second we were waiting. Dr. Haijarah proceeded to help put an IV line on her hand to no success, after the nurses have also failed to put it in. Dr. Peter, however, was unwilling to proceed with the next operation immediately. He wanted to ensure that the first mother was stable, given that she was still waiting for a blood transfusion and that she had just come out of a complicated surgery. He went out to talk to the patient’s family, and to look for blood for the mother. After failing to insert the IV line, Dr. Haijarah and the anesthesiologist sneaked in some time for lunch in the break room feet away from where the patient was laying down. Dr. Peter was still away, and Dr. Haijarah was hesitant on what to do next. As we ate our lunch (Dr. Haijarah shared half her lunch box with me), Dr. Haijarah and I spoke about our past education and what led us here – she was a really smart student who thought school was ‘easy’ and went to medical school because her father encouraged her to. She only developed a true passion when she began interacting with patients in her third year of medical school. At one point Dr. Haijarah said that she would have me assist with the operation if Dr. Peter didn’t return after we were done with lunch. “I will be the one cutting, you would only be holding the gauze to stop the bleeding”, she said. I couldn’t tell if she was serious. Luckily though, we didn’t have to find out. Dr. Peter came back as we were finishing, and I walked the second mother into the OT shortly after.

“Dizzy,” the mother said almost as a warning when we were right at the foot of the operating table. Supporting her weight, I felt her become heavier within a split second and I had to use all my strength to slowly and carefully lay her down on the ground, unable to keep her standing. The mother lay on the ground, her eyes threatening to close as we did what we could to keep her awake and attentive. The anesthesiologist brough over the oxygen concentrator and held the mask to her face – it eventually worked and was conversing with us. I can’t help but be concerned about the level of sterility on the ground (the floor looked clean, but just about an hour ago it was covered with blood from the previous mother), and see that the mother was still bleeding. Dr. Haijarah and the anesthesiologist proceeded to make preparations for the operation while I attended to the mother. She thanked me as I rubbed her hands and wiped off sweat from her face, intent on keeping her responsive however I can.

It was a deeply profound experience that led me to think about the satisfaction that I would derive from having a direct impact at some of the patient’s most vulnerable moments. Even though I was there as an ethnographer, an observer whose goal is to make a broader impact to women’s health, I felt it within me to want to make an impact to the mother now, to know what is best for her an to execute upon it. However, I knew within me that that was a far-fetched hope – a blue sky ideation. Nonetheless, I was inspired. Inspired to make an impact on these patients whose outcomes may directly be improved if our team was able to figure out something that could have a possible impact somehow. “You have to believe in the process,” I told myself. I was doubtful.

With the assistance of 2 other nursing students, the four of us including Dr. Peter lifted the patient onto the surgical table. This again, was the same C-section, a different patient. Still unable to successfully insert an IV line after several attempts, Dr. Vicent was called in to attempt an IV line at the ankle. The baby came out blue and limp. “Baby, baby,” Dr. Haijarah called out to the motionless baby, still attached to the cord. She massaged the baby multiple times to no avail before proceeding to cut the cord, handing over the baby to the midwife. The room was tense and the air, quiet as the surgeons continued with the procedure, the mother’s tummy yet to be closed. I was, and I think the whole room was expecting a choke and a cry from the corner of the room. This time, it never came. At last, the midwife sighed, shook her head and asked me for the time. She wrapped up the motionless child and proceeded to walk out of the room to fill in the patient sheet. The motionless, folded sheet was left in the crib in the corner of the room for the rest of the procedure. Half the time I was hoping that I would see a miraculous stir and cry from that direction.

We lost one battle but there was another one still going for the mother who was still losing blood. I looked on to the doctors who just kept going and I stood there, no longer a good observer but one who has attached himself to the operating theater and did my best to assist in whatever way possible. The mother, still awake, cried out some phrases in Lusoga. The doctors responded consolingly. I wondered what they were saying, if the mother knew she lost her child. As we wheeled the mother out, I looked on. The Women’s Health team was on their way back to the hospital to get me. I had to leave, but I was at a loss for words to say to the mother I was just consoling on her way into the operating theater. I walked off, silently saying prayers to the mother as Dr. Peter prepared for a third ectopic case.