A small opportunity to make a big difference

A couple of days ago I was on call and was called in the middle of the night to see a girl on labour ward. She was a 19 year old primip (first time mum) who was having a prolonged labour. Following advise from my registrar James I prescribed her some oxytocin to make her contractions stronger. This is something we use regularly at home, and dramatically reduces the rate of needing to do c-sections for dangerously long labours. In many ways it's a fantastic drug, but you have to be careful not to give too much or you can make the contractions too strong/long which reduces the baby's blood flow from the placenta. This is relatively easy to monitor, by listening to the baby's heart rate frequently to check it doesn't drop - a sign of distress. If it does then the oxytocin infusion can be slowed down or stopped.

At home all women on oxytocin will have continuous monitoring of both their contractions and the baby's heart rate with a CTG - a fancy machine that draws lines showing how they fluctuate up and down. Here we have a pinard - a plastic or metal tube that you place on the lady's tummy and listen! 

We haven't used them in the UK for many years (outside of exams!). They're notoriously difficult to use, firstly just to find the baby's heart beat and then to count the beats - a happy baby should be going at 120-160 beats per minute, so that's pretty difficult to count accurately!

After starting oxytocin, the policy here is that the midwives listen in every 15 minutes and we review patients again at 2 hours to check they're progressing well. I went to see my lady at 2 hours and she was fully dilated, and had been pushing for 30minutes. The midwives were concerned that the baby had a big head and she was OP (back to back) which makes it much harder to deliver. They had recorded a good fetal heart beat throughout though, so I wasn't too concerned. I was just about to call James in to see if maybe we should try a suction delivery, but thought I'd see how well she was pushing first. The head came down really well so we kept going and within a few minutes the baby was out. 

When it came out it was blue and completely lifeless except a slow heart beat, making no effort to breath, let alone cry. I quickly rushed it over to the resuscitaire where me and one of the midwives bagged it for 20mins - doing the neonatal life support course before coming here was literally the best thing ever! Initially its heart rate picked up but it still wasn't making any effort to breath. Eventually after about 15 tense minutes it started gasping and then properly breathing for itself. When it was breathing regularly we transferred it to the Special Care Baby Unit for oxygen therapy (basically a very hot room with one oxygen concentrator which has split tubing for up to 4 babies). It looked seriously unwell, hardly moving, so I was really worried that it would have a hypoxic brain injury. In the morning it looked a LOT better, was moving all four limbs and crying, but it's really hard to know what the long term effect of that hypoxia will be. 

The next day I discussed the case with James - had I done something wrong by giving her the oxytocin? He reassured me that no, oxytocin was the exact right thing to do, if she hadn't had it she would have needed a c-section, which out here in a primip is an last resort because they normally go on to have 6-8 kids. No one wants to do a c-section in someone who's had more than 2 previously, let alone 7!

The trouble is, he said, we'll never really know exactly what happened because of the lack of accurate monitoring. The most likely thing is that the baby was having bradycardias (slow heart beat) but that the midwives weren't picking them up. Had they been picked up we could have slowed the rate of the oxytocin infusion or held it and given the baby a rest +/- taken her for a c-section. 

There's a fairly simple solution to this, and you may have guessed my ulterior motive for telling you this story! 

CTG's are incredibly expensive and delicate machines that wouldn't last long out here - in fact there actually is one in a store room, but it's unusable because it's run out of paper! (Like the ECG machine! Or maybe that one's run out of ink...) Instead I am hoping to obtain some handheld dopplers. These are simple devices that are basically a mini ultrasound that project the sound of the baby's heart beat and count the rate for you. Midwives in the UK use them for home deliveries. I've spoken to James about this suggestion and he agrees that having such a simple small device would a) encourage the midwives to listen in more regularly, for longer and b) give a much more accurate reading of the baby's heart rate, allowing us to pick up fetal distress and act on it much sooner. They're really not very expensive (about £30-40) and only need AA batteries and ultrasound gel - the first can be rechargeable and the second is something we have here anyway because we have an ultrasound machine.

A lot of people I have spoken to at home have said they wish they could do work like this, but don't have a career/personal life that would allow them to move halfway across the world. Would any of you like to help me and the team deliver babies more safely by investing in one of these devices? It would be an amazing gift to the hospital and I feel sure that it will significantly reduce the number of bad outcomes. There's also no worry about things getting lost-in-transit as I'm coming home next week for a job interview, so plan to take them back out with me when I return.

I imagine there are a few people who might be interested in helping us out so here are a few suggestions of things people might want to buy, with a variety of prices. If any of you are able to buy one of the following it would incredible! (Where I've put 4x gel etc I mean 4 people could buy one gel each)

2 x handheld Dopplers - £30-40 each (I'm waiting to hear back from my UK labour ward lead consultant on which one is best)
4 x ultrasound gel - £4.95 each (this one @ £2.50/any of them are also fine, but they seem to be add on items, so don't think you can buy them alone)
1 x battery charger (includes 4 AA batteries) - £17.99
4 x spare batteries - £7.79 each

If you do want to buy one of these things, firstly thank you SO much, and secondly please don't buy it without speaking to me first - partly because I'd like them to be sent to my mum's house and partly so I can make sure there are sensible numbers of each item, since I'll be carrying them! Also unless you've agreed with me first please only buy those specific ones as I've spent quite a long time looking through the different options and they seem to be the best combination of quality and value for money.

Thank you guys so much! Sorry this is an entirely shameless post asking for money! In a way I feel bad asking, but actually it's a fantastic way in which you can make a real difference to a significant number of people's lives without even getting off the sofa, and you know exactly where your money is going. We all spend a lot of money on ourselves, which of course isn't wrong, but it's so great to have an opportunity to be generous and to see the impact it makes. Lots of people wrote to me last week saying how good it was to be reminded of how much we have in the West, so this is a chance to use what you've got for good!

Being honest, I can't guarantee they won't be stolen, but the hospital is actually very good about keeping tabs on its equipment. The other week a glucose monitor went missing and there was a big commotion until it was found. Turns out it had just been borrowed by another ward. So I'm reasonably confident that they will stay put!

A few thoughts on the New Year, with love from rural Zambia

I'm not sure if I'll post this, but I want to write down a few thoughts I've been having lately...

It's a little strange living here in Zambia, watching the rest of the world through BBC news and social media. I'm sure it's a fairly distorted view of what's going on back home, but a few things keep cropping up at the turn of the year, so they must hold some truth about how the nation is feeling. The main theme on social media at the moment seems to be "Thank **** 2016 is over" and "what can I take for myself in 2017" or "how can I make 2017 better for me than 2016?"

I know 2016 has brought us some serious curveballs, and I was among the sorely disappointed at the results of Brexit and the US election, but I suppose I want to challenge all of us, myself included, to take a step back and appreciate what privileged, stable lives we live. We may not be pleased with the outcome of these votes, but we mustn't forget how incredibly lucky we are that we have a democratic political system that is not based on corruption, where as a nation we are able to change the course our country takes.

It's also interesting watching the responses to the many celebrities who have died this year. I don't mean to undermine the grief that their families are going through, but living here does bring a different perspective to death. Working in obs and gynae, back home you ask patients how many pregnancies they've had, including have they had any miscarriages? Here I ask my patients how many pregnancies they've had and how many of their children are alive. A typical history will look like this:
2001 - stillborn at 9 months
2002 - spontaneous vaginal delivery, alive
2004 - spontaneous vaginal delivery, died at 3 months
2005 - spontaneous vaginal delivery, alive
2006 - spontaneous vaginal delivery, died at 5 years
2008 - c-section, neonatal death
2009 - c-section, alive
2010 - miscarriage at 3 months
2011 - c-section, alive
and so it goes on... Back home we use an abbreviation system to denote how many pregnancies a women has had (gravidity) and how many she has carried to 24 weeks (parity), so someone might be G3P2 if they've had 3 pregnancies and carried 2 to 24 weeks. Here we have a third abbreviation - alive. The above woman would be G9P8A4. 

The idea that we can live in a nation where people are genuinely upset that actors/pop-stars - people we don't know personally - die in their 50s and 60s, over here seems a little ludicrous. I don't say this in any way to criticise people who are grieving loved ones. I just want to remind us what a privilege it is to live in a country where we have a very high standard of healthcare, free at the point of access, so we don't frequently have to experience the natural course that life often takes. It's so easy to complain about waiting 30 minutes to see the GP, and to forget how lucky we are to have a GP to see in the first place. At home we don't have to decide whether we can afford to sell the last cow to pay for our 10 year olds chemotherapy or whether actually the rest of the family won't be able to survive if we do that. We don't find ourselves in the position of being transferred from one hospital with a live, but threatened pregnancy, because they don't have enough equipment left to do any more c-sections, only to find that by the time you arrive at a hospital that can, that the baby has died. These may not be easy things to think about, but this is a daily reality for many of my patients, who have done nothing "wrong" to be born into such different circumstances.


The second half of this little ramble is to challenge how easy it is to get caught up in self-serving and to think that perhaps there are some better things we can focus our efforts on in 2017 than just "getting really fit so people will find me more attractive" or "earning more money this year". I feel challenged as we enter the new year, not to be seeking what can I take for myself, but to look at how I can live more generously. I haven't quite figured out how I plan on doing that but here are a few thoughts. 

There are a few of people who wander round the hospital compound begging or looking for work. There's a man named Andrew Phiri who comes to my house asking for bottles of water, blankets, anything he can sell/knows the English word for. He's a sweet guy, but is an alcoholic and doesn't inspire a huge amount of confidence that anything you give him will benefit him beyond buying himself more booze. Because of this and because I didn't want to encourage him to keep hassling me I've not given him anything more than the odd bottle of water. I justified this by the (not unreasonable) argument that giving people hand outs isn't a sustainable form of charity and is of little long term value.

And yet there's a lot of irony in this situation... I think I've mentioned before we have a number of animals living on the hospital compound who have a fairly communal ownership. There are 2 dogs in particular who have wormed their way into our group - Tiger and Danger. They're a bit of a nuisance, but are sweet enough and everyone has a bit of a soft spot for Tiger. Every evening they let themselves into the mess where we have dinner and if there's any food left on our plates often we feed it to them. They're pretty skinny and despite the complaints we make about them smelling bad, we're all mildly concerned about them going hungry. One of my colleagues even went as far as buying dog food for Tiger in Chipata.

Tiger looking very pleased with himself having just dug up half of my sunflower seedlings!

I've been challenged lately - why am I concerned about the dogs going hungry and yet I allow myself not to be concerned about the humans? This hit home the other day. For Christmas, among other things, I made a trifle using some stale cake that Kars and Marloes gave me. There was more cake than could fit in the pudding and since it was already stale and we had so much better food on offer, I didn't particularly want to eat it. It sat on my table for a day getting more stale, then I put it in my kitchen bin where it sat for a few more days, until I took the bin out. As I was emptying the bin I remember thinking how gross it had become - there were rotten mangoes that had started to go mouldy! (Don't judge, it's hot and I'm busy :P)

Later that day I saw Andrew Phiri and we had our usual nonsensical chitchat (his English is poor and his brain pickled), when suddenly I noticed him holding the piece of discarded cake. I know what was in that bin - he must have been seriously hungry to think that this cake was a good meal! I was talking to Alex about how this bothered me and he pointed out the unsustainability of feeding Andrew Phiri. In many ways I entirely agree. But then why do we feed the dogs?! Surely the same argument applies. 

I'm not really sure what the solution to this is, but I just feel a bit sick that I allowed myself to be more concerned about the dogs welfare than the humans. I'm still working on the practicalities of how that will change my actions. So I suppose the point of this ramble is to encourage us to be a little more grateful and a little less self-absorbed as we enter 2017!