Tanzania OB and HIV

It is the end of week three here in Tanzania, and I’m going to try and describe a few of the highlights from my time at Gonja Lutheran Hospital.

One of my favorite parts of medicine is delivering babies. Probably this is because it is generally a happy and exciting thing and also because you get to see the results of your work right away. I already described the first delivery we saw, and I’ll briefly mention the other obstetric events I got to participate with.

The day after the high intensity resuscitation efforts, Kendra and I were present for a vacuum assisted delivery. The young woman delivered a healthy baby girl who cried almost immediately after being born (both are in picture to the right). The interesting part of that delivery was to see the vacuum/suction device they use here. It is not a hand held self pump, but rather a rubber apparatus that has a head like a plunger.  Instead of a wooden handle there is a rubber tube to connect the cup to a mechanical suction machine. Dr. Amini cut a mediolateral episiotomy (cringe!) to help place the cup on the baby’s head. Once placed, he asked the nurse to turn on the suction, and then waited a couple minutes for it to form a strong seal. After a few attempts – the seal kept breaking and he would have to replace the cup, waiting each time for a new seal– the baby was born. I delivered the placenta, and let the OB nurse stitch the episiotomy.

One week ago, I saw and scrubbed for my first C-section. There have been plenty of c-setions, but for whatever reason I never hear about them until they are already underway. In this case, Dr. Lusingu is my neighbor and this is his week of call. I asked him to get me on his way to the hospital for c-sections, and so around 2 in the morning I heard him calling for “Doctor Kendra” (Kendra is currently away, but it is not uncommon for our names to get switched here. I guess it is the similar –ndr– in the middle of them that get people confused?). I yawned all the way down to the hospital, and all the while that they were setting up. I was awake enough once the surgery started and I first assisted Dr. Lusingu. Dr. Yona did anesthesia. The surgery went smoothly and the baby was healthy. They cut a vertical incision into the skin, fascia, and peritoneum. Then a horizontal incision into the lower uterine segment.

The night after the c-section, there were 2 deliveries back to back; the second one I was in charge of guiding the baby out. It was pretty exciting to have my first hands on delivery in Tanzania. The woman did have a 2nd degree laceration, and when I was recording in the chart afterwards the nurse told me I should write episiotomy. I still don’tknow if that is because they only understand episiotomy, or if there is another reason that they want to report iatrogenic injury to the perineum instead of trauma from delivery. Whatever the reason, I refused and wrote “2nd degree laceration” because that is what happened!

On Sunday, February 17, two new DMU students arrived. They will be here for 4 weeks and are living in the same house as me and Kendra.Their names are Natalie and Eva and I have enjoyed their company. We have fun talking about things we have in common, as well as sharing about our different experiences and knowledge. For example, Natalie grew up in Key West, and recognizes many more of the plants here. She has been sharing some of their names with us. Eva grew up on a farm in Oregon and did goat and pigs for 4-H. She has educated us some about goats, since we see them frequently grazing by the road/path.

Last Thursday night, there was another vaginal delivery. We were called at 2 am and all 4 trooped down to participate as we could. I felt that I shouldn’t hog all of the deliveries, so Natalie delivered the baby. It was her second time delivering a baby, and the first time repairing a perineum. She did a good job, and asked at times for advice/suggestions. It was strange to be helping her, because I feel like my training or experience isn’t that much more than hers. I guess I have sought out more OB experiences than she has, because her particular interest is in HIV care and treatment.

Because Natalie is hoping to care for HIV patients in the future, she is especially excited for Thursdays here at Gonja, when there is an HIV clinic in the Care and Treatment Center (CTC). This week was actually my first time in the CTC and it was interesting to see the routine in clinic. With every patient, they go through a questionnaire to screen for tuberculosis, as well as asking about other signs of opportunistic infections or medication side effects. They have a flow sheet that makes it easy to compare symptoms from previous visits as well as weight gain or – more likely – loss. Most patients seemed healthy by just looking at them, but one woman had lesions that were very clearly Kaposi’s sarcoma. She also had a lot of swelling in her right leg only, to the point that we got worried about elephantiasis and felt the need to think about tropical medicine and clarify the filarial diseases in our heads.

I think that for awhile, the people at Gonja considered HIV to be a disease of the cities and if a patient was positive it was because they had traveled to Dar Es Salaam, or Moshi, or some other big city.That it no longer the case. We have seen many patients with HIV; some patients are new diagnosis and others are known cases that come in because they are very sick. One HIV positive man in his 30’s or 40’s came in with severe shortness of breath. He had a serious case ofheart failure – not only was his JVD the most prominent I had ever seen, his anterior jugular was also distended, and the small thyroid veins were clearly visible. He did not live 24 hours after being admitted, and the doctors attributed his heart failure to the virus (I think dilated cardiomyopathy is a known complication of HIV, maybe that caused his decline). Another patient was brought in with altered mental status and cranial nerve findings (left sided facial droop and disconjugate gaze). His “blue card” that the government gives to all HIV patients indicated that he hadn’t been taking ARV therapy since 2010. That meant that he could have a number of infections affecting his brain, and Gonja doesn’t have the diagnostics to determine which organism is most likely. Instead of diagnosing, apply the shotgun approach – the patient got antifungals, antibiotics, and of course was restarted on antiretrovirals!

The topic that merges HIV and OB is Preventing Mother To Child Transmission (PMTCT). They are very careful about checking a new OB’s HIV status, even requiring both husband and wife to come to the first OB visit together so that both partners can be screened. The charts have a number designation written on them to communicate the HIV status. If the result is not known, the woman is PMTCT 0. If the result is positive, she is PMTCT 1, meaning she has HIV and needs to receive ARV therapy. If the result is negative, the woman is PMTCT 2. There have been a few PMTCT 1 deliveries, but Kendra and I always missed them because they happened in the night or they didn’t tell us they were going to C-section. However, we did see that they are careful to document delivery of the correct medication to both mother and baby to prevent transmission.