Donors

This morning, before my fellow med students had even cracked an eyelid, I was off on my own personal clinical adventure: the maternity ward at Kamuzu Central Hospital! I’d been on a tour through the labor and obstetrics floors with the rest of the group a week or so ago, but this time, I was going to be more than a tourist – I was going to go behind the scenes. Dr. Sethi happens to know an American physician, Dr. Chambers, who’s working as an Ob-Gyn at KCH for a year. Since Dr. Sethi knows my heart of hearts isn’t really into this whole skin thing, she arranged for me to spend my last full day in Malawi tagging along with Dr. Chambers and seeing what the day-today life is actually like for an American physician integrated into the Malawian system.

As it turns out, the day-to-day life of Dr. Chambers…appears to be a bit like living in a Kafka novel. I caught her on her post-call day; she’d spent the past 24 hours living at KCH, taking care of all the overnight emergencies on the antenatal/labor/postnatal wards. So the hard part should’ve been over, theoretically – the rest of the staff was back to help out and take over from her.

Things proceeded efficiently at first. The turnover meeting, where everyone talks about the patients together and gets on the same page, actually even started on time. I recognized the whole procedure all from the US system, with the exception that there’d been a maternal death the night before (almost unheard of back home).

But from there on, the system started to show its flaws a bit. The first patient for us to see that morning was essentially the victim of a botched C-section at another hospital; she obviously had some big collection of fluid in her left belly that was causing her a lot of pain. From the limited view available via ultrasound, the docs suspected it could basically be either blood (from an injury from the surgery) or pus (from an infection) – either way, she’d need a second operation. And this when she’s still knocked out quite a bit from the first surgery and is trying to take care of an infant (who had his own tiny pile of blankets next to her in the patient bed. Aw).

But still, that was the fault of doctors elsewhere, not the big fancy central hospital. I could compartmentalize that….until the next task of the morning, in which we tried to find someone to sign off on the plan of care for a woman with widespread tuberculosis (TB) and a planned C-section. There is a dedicated TB ward at KCH, so this seemed straightforward to me. We walked across campus, right up to the TB office: empty. We asked across the hall – donde estan los TB officers? Not in yet, came the response. They usually come late. But we could leave a message. Did we have the Official Consult Form and the patient’s file?

We did not. We walked all the way back, found the required form, and realized that if we took the patient’s physical file with us, the anaesthesiologists wouldn’t be able to have it in THEIR official pile and would cancel her C-section. (The “patient file”, mind you, was just a loose pile of papers. No one had bothered to even put it in a folder yet, let alone organize it.) So we returned with just the consult form….only to find that both the TB officers AND the folks across the hall were now missing. Patients lined the corridors, waiting, but no doctors to be found. A nurse told us we’d have to go see the general medicine physicians upstairs; another 5 minute walk led us to discover that they, too, were not in their clinic. Back downstairs. Someone finally picks up a phone and calls in the TB officer. Great! We establish a plan in two minutes for the baby’s medicines – but he won’t give us the medicines now, or write down instructions for what the dosage should be. No, he’d rather the extremely sick patient and her newborn just come across campus to this office after the C-section and he’d see to it then. No doubt he’d be in his office – eventually.

The next adventure was more of the same. Two patients in the postnatal ward were in extreme need of blood transfusions, but two major things seemed to stand in their way. First, they needed blood samples drawn so that we could make sure they got the right type of blood; theoretically this had happened the night before. Second, there had to actually BE blood to transfuse. (Not a barrier I often consider in writing my US patients for transfusions, really.)

Trying to work out this bloody (heh) situation got increasingly ridiculous. First, turns out there were exactly zero pints of blood for adult patients in the whole of KCH. Not a single one. The national blood transfusion service had taken the day off yesterday, and were taking their time getting running again this morning.

So we decided to try to work out the blood sample in the meantime. We walked to the lab; the lab claimed to somehow have only received one of the patient’s blood samples and required a second. We walked back to the ward; the nurse on duty claimed it had been sent. Back to the lab; some half-hearted searching for the blood tube and coming up empty-handed. Back to the ward, awkwardly lugging a freezer box full of three units of commandeered pediatric blood for the most needful patient, who had the lowest blood count I’d ever heard for a living human being (hemoglobin of 2, med school friends. 2!). Back to the lab to return the freezer box and bring the new sample for the other patient. This all took about 90 minutes altogether, and still no sign of any adult blood units from the transfusion storage folks. As Dr. Chambers stated matter-of-factly on our 11th or 12th walk, “I’m pretty sure most of what I do here does not require a medical degree."

Because what she does, essentially, is follow through. The American medical system ingrains it into all its physicians: your patients are YOURS. You must do what you need to do to make sure they get care. In truth, the American system probably takes it too far – this is how medical residents end up working 100+ hours a week and making sleep deprived mistakes. But on the other hand, no US surgeon would ever refer a pregnant patient to another hospital for a C-section because he was “tired” and “didn’t want to do any more C-sections today”, a note Dr. Chambers recalled from a recent referral. She says she struggles daily to find a balance between making sure her patients get what they need and not doing the hospital staff’s jobs for them; there’s no incentive to find your blood samples, follow up labs, or actually take your patients’ temperatures, if someone else will always do it for you.

For someone trained in the American hospital system, I think this could quickly make you insane – so much inefficiency, and so much feeling that you can’t rely on other hospital staff to consistently do their jobs. Dr. Chambers apologized throughout the morning for being “cynical”, but said that she tries to keep in mind just what it’s like to be trained in Malawian hospitals: for the most part, extremely sick patients don’t do well. Working harder for your patients might not really make much of a difference. It’s hard to stay motivated and driven when the guy next to you, who just sits around and plays tetris on his phone all day, has patients that do just as well as your own.

So, despite not seeing a single birth or C-section today, I actually felt like I learned a lot more today about what it means to be an Ob-Gyn working in a resource-poor hospital. You make some clinical decisions, yes, but a significant part of your day is spent simply trying to keep the momentum moving forward, personally seeing that each small step in the process happens and generally fighting inertia. Very eye-opening. Part of me feels like I would be quickly beaten down by that daily existence, and that I should focus my future global health efforts on the policy or research level rather than the clinical. But I admit – part of me also sort of likes the idea of being the one who sees things get done, crossing all your own Ts and dotting your own Is. Saving lives, for sure.

In the meantime, I figured I could at least try to help kickstart the blood service again – my fellow med student Laura and I stopped on the way home to donate a pint each to the Malawian Blood Transfusion Services. (Just like the experience at the Red Cross, but with squash juice!) Dr. Chambers says she’ll be on the lookout for them in the maternity ward.