Sunday Morning~ Blantyre

April 9, 2017

Hi Everyone,

While waiting for the kettle to boil for tea this morning, I turned off the outside light and looked to see if the night guard was around. He’s been leaving early and not waiting for the day guard to arrive. I happened to be looking at our gate that leads to a footpath and saw a hand reach in to see if the lock was secure. To open the gate from the footpath, you have to reach in a little hole cut into the sheet metal, turn the padlock so the keyhole is pointed up, reach your hand into the square opening, insert the key, and fiddle with it until it opens. It’s a little annoying. To open it from the inside is a little easier as you can use one hand to hold the lock and one to use the key without the sheet metal digging into your wrist. But even that is a nuisance. I hate being locked in here like this. I appreciate when the guard is right there and does it for me, but often Chimwemwe is gardening, so I do it myself. I’ve often wondered why we need that padlock? There are already multiple locks on the doors of the house and we don’t leave anything outside. But this morning when I caught the glimpse of a hand coming through the opening in the sheet metal, grabbing the lock, turning it to see if it was indeed locked, which it was, then dropping it and walking on, I wondered if it was a thief checking to see if entry would be easy. Finding the gate locked I guess he decided it would be too much hassle to climb over the brick wall and deal with the razor wire on top. Hmm, I’m not sure what was going on, but I guess it’s a good idea to keep it locked.

Ugh, what a week. Twenty hours of lecturing in a week is a lot. If you just look at the number hours, it seems like half time. But considering it was my first time teaching this, the prep took up just as much time. It actually should have been more prep for me to be properly prepared. I did more winging it than I should have and it showed during the genetics unit. My exhausted evening idea of downloading some simple Genetics 101 video from youtube bombed when the internet was so slow nothing would download. In my exhausted state I figured it would work in the morning. (Being exhausted is a little like being drunk, some ideas seem really good at the time.) I tried at 5 a.m. but it didn’t work, and an hour later I was like, Ok, I’m screwed. I had to admit part way through the lecture that I really didn’t understand parts of the material myself. I vaguely remembered having to memorize some of this stuff in nursing school and as I recall, I didn’t do too well on that test. I should not have been teaching genetics. The parts of genetic counseling I do know, I was able to relate fairly well, but it all seemed pie in the sky anyway. If they had frigging water to wash their hands with I’d be happy. No one in my lifetime here is going to have an amniocentesis. But albinism is fairly common and being able to describe how it is inherited could actually have some impact. I focused on stuff like that to distract from the fact that I still have to look up the definition of chromatid. Anyway, I’ve got this afternoon to gear up for another similar week, then two more days the following week and my section will be done. My remaining lectures are topics I’m up on, so I think I’m over the steepest hill.

On Tuesday I had no lecture so went out to Machinga Hospital in Liwonde to supervise the fourth year students. Hours of lecturing made a clinical day seem easy. Elizabeth was in Lilongwe at a meeting so it was my first solo out there. It started in labor and delivery where four students were caring for four of the twelve laboring women. There are only six beds, so half were rolling around on the floor. The ones that could move. I greeted the students and asked what was going on? One, told me he was taking care of a woman having her seventh baby. I said, “OK, great. Present her to me.” This was a little after 9 in the morning and they start at 7:30. He had to go get her chart to read it and tell me her details. That annoyed me. She’d been in labor all night and he’d been there for an hour and a half. He should have been able to tell me something about her without searching for it in the chart, like, how dilated is she? Any complications? Basic stuff. Her age, maybe? HIV status? I’m not asking for her genotype, but some basics should be on the tip of his tongue! C’mon! I looked at this woman, who was skin and bones, writhing in pain, chanting and moaning. She had an IV in her hand about to come out from her thrashing around. The little tape that was used to secure it was flapping in the breeze. The IV bag was hooked on the little lever on the louver window. I thought that was good. It wasn’t lying on the bed. She had a urinary catheter in, but no bag was attached, so urine, along with amniotic fluid, was leaking all over the black plastic and she was lying in a pool of this mixture. She rolled away from me and I could see she was also lying in shit. I asked, “She’s been here all night and not delivered? Seventh baby? Really?” As he’s looking at the medical record he tells me she is going for a c-section. Whoa, what? Six vaginal births and now a c-section, why? He didn’t know, but says he can see in the chart she’s been fully dilated since six a.m. and she hasn’t delivered. He said, “It says in the chart the head is still high.” But since she hadn’t been checked since then, we didn’t really know where the head was now, did we? I pulled a glove out of my pocket and examined her. The head was about to crown. I said, “Get ready for the delivery, the head’s right here.” He put the chart down and looked disappointed that now we had to do the delivery. Let’s just say his energy was low. (To be fair, he was probably hungry. The students often don’t have time to go get water to wash, cook their breakfast, then walk the half hour to get to the hospital for 7:30. Their lives are hard.) But I was not going to let this woman go to surgery when I could practically see the head. I told him to explain to her the head was close and she would deliver soon. He translated this and then her reply to me. “She’s saying she’s too tired to push. It won’t come out. She wants a c-section.” I asked, “And do you think that’s a good idea with the head right here?” He looked at me silently, apparently searching for the answer I was looking for. I said, “Ok, I am going to answer that for you. No! It’s not a good idea! She doesn’t need surgery! Let’s help her to push!” He then tells me she has TB, so has no energy. (Ok, that’s why she’s so skinny.) I said, “So unnecessary surgery would be even worse for her, right?” He reluctantly nodded, apparently deducing from my tone that I was looking for agreement.

No one encourages women here to push. It’s just easier to take them to surgery. That gets them out of the labor ward, and someone else can have the bed. It is completely preposterous. I get that it takes a lot of energy to encourage someone to push when they don’t want to. It can be exhausting. It is much easier when there is a supportive team around and you can feed off each other’s energy. But when no one wants to do the cheering with you, ugh, it’s hard. And I’m not supposed to be taking over; I’m supposed to be teaching the students to do it. That’s another energy-sapping layer. So here we go… “What do you think might give her some energy?” Sugar. “Ok, great! Let’s get her some sugar! Where’s the guardian? Can they bring her something?” Translation. No. They aren’t here. Ugh. What other idea? He said, “I can put some glucose in the IV.” Ok, that would be even quicker but I didn’t think they’d have any. He went off to find some. In the meantime, I tried to clean her up a little, smiled at her, tried to communicate that the baby was coming; she would have it in her arms soon. She shook her head and turned away from me like she hated me for preventing that c-section that could end all this (and maybe her life). The student returned with some glucose and injected it in the IV. While we waited for that to get to her brain it was time for a pep talk! None of this was coming from him. He was pretty much just acting like a translator. I could tell he was trying to figure out what I wanted and none of this was familiar to him. Fortunately, another student came over to help with some enthusiasm. He was great. He must have eaten breakfast. He helped get her in a good position and was talking to her in an encouraging way. She responded. I poked student number one and said, “See! Like that!” So then we had a little student competition going and the energy improved dramatically. I said, “Here’s the deal. This baby is coming out vaginally. Period. We can either do this all day, or help her to push and have it out in 20 minutes.” The students looked at me blankly. I said, “Translate that to her.” God knows what they said, but she did muster some energy. I took her hand to make her feel the baby’s head. “Mwana mutu”, I said. (Baby, head) It was just at this point that the clinical officer came to take her to surgery. They were talking about her like we weren’t even there, fortunately in English so I could say in a sweet happy voice, “Oh, she’s going to deliver. Look! Here’s the head!” (which, admittedly was taking forever to come out) Without attitude, the clinical officer looked relieved and said, “Good job. Thank you.” like they didn’t want another patient either, and walked away. It was another half hour of cheerleading before that head finally emerged, as I suspected, in a less than optimal position. And he was big! I was shocked that a woman as thin as she was could produce a baby weighing over seven pounds. She was ecstatic. Her grimace was replaced with a huge toothy smile. I did a happy dance and a bunch of I-told-you-sos. She told the student that I should name the baby. That always seems a big responsibility and I never know which name to pick on short notice like that. I always feel like there has to be some significance to it. If it was a girl, I would have said “Hannah” as I was thinking about Hannah Shaw that day, the third anniversary of her death. But it was a boy and I didn’t want to use Hannah for a boy. Though the mom would have been fine with it, I thought of Johnny Cash singing A Boy Named Sue and couldn’t do it. So I said, “Well, she (the mom) is 37, born the year my son was born in Malawi and his name is Matthew. Does she like that?” Big smile. Ok, yes, this baby is now Matthew. So I thought that was rather sweet (though when I emailed this story to said son he told me he finds my writing “selfish and pandering”, though his girlfriend and ex-girlfriends “eat this shit up.” I do hope the new little Matthew doesn’t turn into an asshole like his namesake). I wrapped the baby in a chitheje and took him over to show the clinical officer where the molding was on his head. I said, “See? His head was asynclitic; that’s why it took a little longer.” He nodded, bored.

From there I went to see the three students in the antenatal clinic. One had been pregnant herself and I learned when I arrived that she’d delivered four days before. I asked the other students if they were with her for the delivery? No, they weren’t. The delivery happened during the night and they didn’t go. It’s too hard to go anywhere in the dark. I thought that was poor form, but I didn’t say that. I just acted surprised that they didn’t want to be with their friend when she delivered. (It’s too early in their career to be this apathetic!) While we were standing there talking, I saw the recently-delivered student walking toward us through the hospital grounds. The others exclaimed, “Here comes Linda!” (Her name is Linda, too. She’s the only one whose name I keep straight.) She walked toward us looking like a young bride in a strapless chiffon dress with a black bolero. She had a smile from ear to ear. I thought, wow! What a transformation. I had never seen her smile before. She must be feeling a lot better. Her friends all greeted her and then she came to me and handed me a note. I opened it and read:

To: Dr. Chodzaza and Linda Robinson

From: Linda _________

I write to inform you that I have delivered my baby on Friday the 31st of March and am requesting to have two more days of sick leave. I can return on Thursday, April 6th. I will make up the lost time during the April holiday week.

I looked at her, beaming in front of me in what looked like someone’s old prom dress. I said, “Let me get this straight. You delivered your baby four days ago and you only want two more days off?” She nodded. I said, wouldn’t you prefer to have a whole week? She nodded. I said, “I think it’s fine if you take off the whole week and rest. Don’t worry about coming back here on Thursday.” She thanked me profusely. I mean really. Some days it is so easy to please people.

Touring the campus on Thursday were two midwives from Sweden who have an exchange program going with the nursing school here. We met for breakfast and talked for hours about the state of midwifery in our countries and Malawi. I told them about my clinical experiences here and the idea we have for a faculty practice. They lit up and exclaimed that they would love to be involved in that! If we could incorporate a couple of other university exchange programs and collect some good data, this really might fly! One is the head of the midwifery department in Stockholm and had some great ideas. It was another booster shot for me and I’ll get the abstract to her for input before I submit it this week. Woo hoo! Fingers crossed.

Next Sunday is Easter and we will be on top of Mt Mulanje, a different kind of cathedral. I won’t get anything posted until at least Monday. I’ve been so bloody inactive I’m sure I won’t be able to walk after the hike but should manage to type a short account. The fourth year students have this week off but the first and second years don’t. I have no idea who designed this academic calendar. It makes no sense to me at all.

Ok, off to make more powerpoint. I’m getting pretty quick at that.

Love to all,

Linda