Contraception misconceptions

Last week I gave a talk to a group of mothers who have children in the hospital.  They gather twice a week for a talk given by a visiting med student, resident or attending.  I chose to talk about contraception.  I kept the talk pretty basic, covering the health benefits of contraception, the varieties of contraception, and how they work.  I knew there would be plenty of questions to take up the rest of the time.  What I didn't know was how much I would learn from the experience.

When I was preparing for the talk, I came across a number of interesting statistics, as well as a lot of mis-information.  I learned that the average number of children for women in Subsaharan Africa is 5.  (This reminded me of a woman who was being cared for by my team in the hospital - she broke into tears as she told us that her husband had recently passed away and she is now a single mother with 9 children.  She had just had a stroke and might not return to her full strength.)  I also learned that appropriate birth-spacing (18 months between pregnancies) decreases maternal complications during child birth.  The misinformation that I found was about the supposed malicious intent that the Western world has when it provides contraception to Kenya, written by an local Ob-gyn doctor.  There were also web pages citing numerous side effects from contraception, most of which were hyperbole or simply false.

After reading through some of these sources, I knew I would get some interesting questions during my talk. I was not disappointed.  Some of the questions seemed to be derived from male-centric social culture, with an emphasis on women's role as child bearer:

 "Is it true that if a women takes birth control pills before she has children, she will never be able to have children?"

"I heard that when a woman uses birth control she uses up all her eggs and can't have children.  Is it true?"

Other questions related to potential side effects of contraception.  Some were at least partially based on reality, while others were not.

 "My friend was told she can't take OCPs because she has varicose veins.  Why is that?"

 "I heard that the copper IUD will give you cervical cancer.  Is it true?"

"When you get the contraceptive implant taken out, I heard that your next period is really heavy.  Is that because all the blood builds up inside you when you use the implant? 

A couple questions seemed to come out of left field.  They reminded me that there are a wealth of myths that exist about birth control, many of which paint contraception as scary and dangerous.

 "I heard that if you use birth control pills, they will all collect in one area in your body, and you will eventually need to have a major operation to remove all the pills.  Is it true?"

" I heard that the IUD can leave your uterus and travel to your heart.  Is it true?"

These women were very engaged with the talk and had numerous questions.  They all took the handout that I had made, and many requested one or two extras to give to a friend.  The interest in contraception is definitely present, but they have little to no access to accurate information or to the contraception itself.  Kenya is fairly advanced when compared to its peers in Subsaharan Africa, but it continues to foster a society that values men above women and relegates women to the role of child-bearer and mother.  I learned from a Kenyan med student that even among progressive families, a dowery is still paid by the man when he marries a woman - an act that, even if ceremonial, defines women as property.  Today the husband of a patient on our team refused to consent for a biopsy of a liver mass for his wife, stating that a relative of his died from a biopsy and he "doesn't want to lose her and the money."  Why does he mention the loss of his wife and the loss of money as if they are of equal value?  As we tried to explain to him the risks and benefits of the biopsy and the risks and benefits of doing nothing, and as he continued to interrupt us and refuse our explanation, I couldn't help but think that if this was his son or his brother, he would have consented in a heartbeat.  I felt anger and frustration at the injustice I was witnessing.  Yes, there are women in more progressive (and likely more wealthy) families who are loved and supported and encouraged to pursue their dreams.  There are quite a few female physicians and med students, and I see women around town who run little street-stands and seem quite independent.  But there are still many women here who live within a constrained set of societal rules that value men over women.

Witnessing this sexism and the second-rate status of many women here has been challenging.  It also added yet another item to the growing list of things I am grateful for: the fact that I am a 26 year old unmarried woman without children who is supported and loved by her family and friends.

On the back of a motorcycle...

A lighter view of my time here.

Here are some of the more impressive things I've seen on the backs of motorcycles:
- a goat
- a full sized ladder, held by a man eating a corn cob
- a coffin
- 8 twin-sized foam mattresses
- a meat locker
- a meter-tall stack of wood
- a car-sized windshield
- a couch and 2 chairs
- 2 bicycles

And on top of a matatu (a 12-person van):
- 30 chickens, not in cages, strapped to the top with some rope.

Kenya, I am duly impressed.


And some pictures:

 In Kaptagat forest with "Big Daddy" - a 1000 year old tree

 Kenyan lunch: Chapati, sikuma wiki (kale), ndengu (mung beans), some soup, and a banana.  This cost me 80 Ksh, which is less than $1 USD.

 Some lovely Samboro women from near Maralal, Kenya.  They laughed when I showed them their picture.

The front of the hospital.

 Jon and I at Kruger Farms - a large farm that has a conserved area where 9 to 12 giraffes live.

Twiga! (giraffe, in Kiswahili).

Dealing with death

Warning: this post is about death.  It is not cheery.  Read on at your discretion.

Today I held a patient's hand as she took her last breath.  She had been found down and brought to casualty (the ED) by a good samaritan.  We don't know if she had family or if she was homeless, but we knew she had had a rough time.  She was non-responsive, her right leg twisted inwards at an impossible angle, and she was crawling with lice.  She was 28.4 degrees C when we rounded on her (83.1 F).  An initial workup had been started last night, and she was put on empiric broad spectrum antibiotics, but she was too unstable for surgery.  This is patient who would have resuscitated and warmed in the ED, sent straight to the ICU and had a surgery consult within hours in the US, but here she was sent to the wards bradycardic, hypoglycemic and hypothermic, where she sat until we rounded on her at noon.  She was put in the back corner of the wards, despite being our sickest patient, so we didn't know about her until late in the morning.  After an ICU consult, we decided to treat her palliatively with morphine.  Her chance of survival was dismally low, and without family to supply funds there were very few interventions we could give her.  The nurse called me when her breathing became agonal.  I placed a gloved hand on her shoulder and watched as her breaths slowed to 4 per minute, then 2, then none.  One last gasping breath, and she was still.  Her chest sounded vacant, her eyes were fixed and empty.  For the second time, I declared a patient.

I have seen more death here in 4 weeks than I saw at home in a year and a half.  Last week was especially hard.  We lost 4 patients during the week, three within a 36 hour period.  Three of the four were my patients.  One was a 28 year old mother of three who grew up as a street kid.  She came in in septic shock, but had improved over the week.  When I came back from the weekend, she had passed.  I had tried for 2 days prior to the weekend to get her an abdominal ultrasound to rule out a surgical abdomen or abscess, but time and again watched as stable patients were taken to the ultrasound before here.  The second was an elderly woman with pulmonary TB and likely Guillan-Barre syndrome.  She was paralyzed up to the waist and tachypnic, but had been stable for several days.  When I came to work Thursday morning, she had died overnight.  The third was another 28 year old.  She was HIV+ and presented with a 1cm partially organized pericardial effusion, which was suspected to be TB pericarditis.  She had also been stable for days.  Thursday morning, just after I learned that the woman with TB had died, she started acting out, standing up during the middle of rounds, lying on the bodily-fluid covered floor and periodically yelling.  She was desatting but refused oxygen. In the afternoon a nurse brought her back to her bed and tied her hand to the metal bed post with a spare jacket.  I walked to the nurse's station to write a note, and when I returned the drapes were tied around her bed.  She lay on her bed, her right eye and mouth open, as if she had died in motion.  I asked the nurse about what happened, and she said, "She just passed," not looking up from the medications she was sorting.  I examined her, acutely aware of the difference between a live person and a dead body.  She was the first patient I declared deceased.

The last patient, B, was the hardest for me to lose.  She was the 19 year old wasted girl I mentioned in my last post.  I had researched causes of wasting, consulted oncology (who assured me that her prior diagnosis of paraganglioma could not cause the degree of wasting that she had), searched for her prior chart.  I presented her case in morning report and got input from my colleagues and attendings.  The medicine team leader even offered to pay for an abdominal CT if her family couldn't afford it.  Later that same day I got the results of her abdominal ultrasound: a massive neuroblastoma (related to paraganglioma) extending from her epigastrum to her pelvis, with a met on her IVC.  Her chest x-ray showed massive cardiomegaly and numerous nodules - also suspicious for mets.  It was crushing news to receive.  She was tachypneic when I went home that night.  The next morning her bed only contained her bed-mate; B's end of the bed was conspicuously tidy.  My heart sank, and sank again when the nurse confirmed the worst.  I felt both sadness and anger.  Sad for the loss of this sweet girl who had found her way into my heart, and angry at the injustice of her death.  Her old file was found hours before she died.  It revealed that she had a long history cancer and that she had not gotten chemotherapy when the tumor was smaller because her family couldn't afford it.

This is the hardest part about death here.  That most of the patients would live if they were in the U.S.  It can make me feel pretty helpless at times.  For each patient I ask myself if I missed something.  Was there another intervention I could have done?  Another investigation I could have ordered?  And here, in Western Africa, the answer is always yes.  There is so much more I wanted to do for each of these patients, but this place and these people simply don't have the resources.

When I learned about B's extensive tumor, I walked into the procedure room and cried.  A nurse came in and asked me what was wrong.  When I told her, she put her hand on my arm and thanked me for my empathy.  Empathy is what keeps us human - what prevents me from being just a doctor, and prevents B from being just a patient.  I know I can't dwell on the people that we lose, but I also never want to lose that feeling of loss when a patient, a person, dies.  I will allow myself a moment of sadness, a taste of the pain that their family feels.  And then I will turn back to the living and see what good I can do.  I will think about people like E, a 16 year old girl who presented with septic shock and now walks around the ward playing with blown-up glove-balloons.  For patients like her, I will feel happiness.

Humanity among chaos

I've been here over one week now, and am starting to get used to things, but a lot of it is still a mystery to me.  I continue to be amazed and frustrated by the chaos and inefficiency of the hospital.  Rounding each morning is a trial of my patience.  We have to figure out whether each patient has been getting their medications for the last 24 hours, including a patient on anticoagulants for a stroke secondary to cerebral sinus thrombosis, a patient on antimalarials, and patients getting empiric TB treatment.  Patients on critical medications only sporadically receive their doses.  The pharmacist from our team has taken to getting the meds from the pharmacy herself and giving them to the patient to self-dose.  

At the end of rounds one day we had a lab slip for some blood-work.  I still haven't figured out who these pieces of paper go to - there's so much paper floating around the wards it's amazing that any labs get completed at all.  I asked one of the 6th year Kenyan med students (they have 6 years of med school instead of 4) what to do with the paper, and she shrugged and said she didn't know.  Someone who has been in the hospital for 3 years doesn't know what to do with the lab slip after the phlebotomist has come through for the morning.  It took asking 3 more people to figure it out.  Nurses don't know where sterile urine cups are.  No one can find the sanitizing gel we use before doing LPs.  No one seems to know how the hospital runs, even the people who help run it.

With this constant barrage of chaos, I have found it easy to get lost in feelings of frustration and inutility.  So I try to find the positive moments among the chaos.

We have one patient who is encephalopathic, likely due to TB meningitis or toxoplasmosis. We'll call her E. She now occasionally opens here eyes to her name, but still doesn't speak or move much and needs to be lifted into sitting position, supported, and spoon-fed.  Her mother is by her side every day, without fail.  She shares the bed with another woman who is being treated for bacterial meningitis.  Several days ago, E's mother sat her up and sat behind her to keep her upright, reaching over her shoulders to try to feed her.  The other patient in the bed got up, without being asked, and took the spoon and cup from E's mother and began feeding E.  I almost cried.  Time and again the patients here help each other, from feeding each other to telling a doctor how the patient has been doing to wiping sweat off their foreheads.  They are in horrible conditions getting poor medical care, and yet they never complain and are always willing to help each other.  They never forget their humanity.  What a beautiful thing to witness and to remember should I ever be in a situation half as dire as theirs.

Mzungu = white person

Here is the first of (hopefully) many posts that I will write about my time in Eldoret, Kenya, where I am spending 2 months working in a teaching hospital.  FYI, I'm going to be including some medical speak in here - sorry to those of you who aren't familiar with it.  Thanks for reading!

Driving into Eldoret, it is clear that I am in a 3rd world country.  Tin-roofed shacks line the side of the road.  There are plastic bags littering the ground.  There is a woman wearing a business skirt-suit trying to get her cow through a gate.  And the driving is insane.  The road is just wide enough for 2 cars to pass, with a several inch drop off of the pavement on either side.  Along with private cars there are pikipikis (little motorcycles) packed with 2-3 people and matatus (large vans designed to seat probably 9-12 people, but which always carry more than that - notoriously dangerous).  When the traffic is slow, the matatus drive off the road and drive along the path where people are walking.  In the 20 minute ride from the airport, I see a matatu side-swipe a bicyclist - not a horrible accident, but not a good one either.

 The hospital I'm working at is called Moi Teaching and Referral Hospital.  The hospital itself is comprised of several separate buildings, connected by a central outdoor walkway covered by a tin roof.  I am working in the inpatient medicine wards, which shares a building with pediatrics. I am working in the women's ward - a hallway with six "cubes"attached to it (3 per side).  A cube is an open area about the size of 2.5 standard private US hospital rooms.  Each cube has 8 beds, and each bed has 2 people who lie head to toe.  There are a few curtains that are knotted out of the way and no privacy to speak of.  I've seen a patient squat in the 2 foot space between beds to urinate into a bucket.  The ward has an overlying smell of body odor and illness, with occasional wafts of feces or vomit.  It can get pretty stifling with the smell and the heat, especially during visiting hours when more than 30 people can be packed into each cube.

The hospital is a mess of disorganization and inefficiency.  The paper charts are held together with string and are strewn about the nurses station in no particular order.  Labs often don't come back for 3 days. Xrays can take days to be completed.  Currently, the CT scanner is down, so our patient with a suspected subarachnoid hemorrhage will just have to tough it out.  We don't have spinal needles, so we do LPs (lumbar punctures) with IV catheter needles, after 'sanitizing' the site with hand sanatizer, and without using lidocaine first.  There is no vancomycin or cipro available in the hospital.  Gloves run out on a daily basis. When we order 3 liters of normal saline for a patient, they will often get 1 liter or less of dextrose instead.  There is a single nurse for the 16 patients in the cube (normal in the US is 4-6 patients per nurse), so it's understandable that things get forgotten, but it is difficult not to get frustrated.  There are also no landlines, so if you want to see if a lab is ready you have to take the 5 minute walk to find out.  On top of this, all of our patients speak swahili, so my utility feels very limited.  I'm taking lessons and will hopefully be of more help later, but for now I'm pretty dependent.  On top of all this the interns are on strike, as well as some of the residents and pharmacy staff because the government hasn't paid them in 5 months.  This morning our visiting resident was gone, so our rounding team consisted of myself, 2 senior Kenyan med students, and a pharmacist.  So, no actual doctor... Oof.

Despite all of this, my experience in the wards has been enjoyable.  The medicine is fascinating.  In just 3 days I've seen patients with cerebral toxoplasmosis, cryptococcal meningitis, likely TB, sepsis, encephalopathy, subarachnoid hemorrhage, acute kidney failure.  We have a patient with AIDS complicated by moluscum contagiosum which has covered her face in tens of large crusted nodules.  Even though I can't have a conversation with our patients, it is gratifying just to offer a 'jambo' and 'Jina langu ni Terra.  Habari yako?' (My name is Terra.  How are you?)  The Kenyan medical students are very kind and helpful, as are the nursing staff.  I am working to remember that while I won't be able to change the system or make things more efficient, I can make a difference to a few individual people.  So that is my goal.

Until next time, kwa heri!