Day 10: Vaginal Tears

Today, Dane, Lidia and I did morning rounds in the medicine ward with Dr. Stanley, the head doctor of the hospital.

Top 10 Diseases and Drugs

Infectious diseases dominate the “Top 10” diseases in the Medicine Ward, Amana Hospital.

Dr. Stanley was sharp, and if he didn’t always know his stuff, he sure seemed like he did. One intern doctor presented a patient whom he’d diagnosed with anemia secondary to peptic ulcer disease. Dr. Stanley ruthlessly questioned every aspect of the presentation. What else could possibly be causing the anemia? Was the patient passing black stools, suggesting a bleeding ulcer? What exactly did the intern do on the initial physical exam?

Dane doing a physical exam

Dane examining a patient in the medicine ward

I was surprised to learn that endoscopies are available at Amana Hospital for the bargain basement price (by Western standards) of 100,000 shillings (~US$45). It’s the best way to determine the exact cause and location of an upper GI bleed, but its price tag put in the same category as most other diagnostic tests – nice to have, but too expensive for your average patient at a Tanzanian government hospital.

Patients crammed into the medicine ward

Patients are crammed close together in the medicine ward, Amana Hospital

I’ve heard over and over again in Tanzania that doctors here rely on their brains and physical exam to get the right diagnosis rather than rely on high-tech tests like in the West. I’m pretty sure that a good number of patients in Tanzania are also misdiagnosed for this very reason. There’s very little accountability to get the diagnosis right. Patients die all the time, and whether it’s due to the wrong diagnosis, poor prognosis or lack of resources, no one really knows. With no confirmatory tests or autopsies after death, who’s to say the diagnosis was correct in the first place?

Dane and Lidia wearing N95 masks

Dane wearing his N95 mask. Lidia would soon change into one.

We wore N95 masks the whole time we were in the medicine ward. Many of the patients are immune-compromised and suspected of having active TB, so N95 masks (so named because they block 95% of particulate matter) seemed like a sensible precaution. We got quite a few looks of ridicule from the doctors and nurses in the ward, but catching TB here could mean taking a year or more off from medical school for treatment.

Horror in the Labor and Delivery Ward

We later joined Ismat in the labor and delivery ward. Ismat had spent most of the week in this ward, which I had avoided all week. It’s hot, cramped and dirty. There were feces splattered on the curtains from an explosive delivery. Blood was smeared everywhere. The air was a cacophony of fetid odors.

Amana Regional Hospital hosts anywhere from 60 to 100 deliveries a day. With only eight beds in the delivery room, there’s a constant turnover of round-bellied women hobbling onto the thinly padded beds.

Delivery room, Amana Regional Hospital

Delivery room, Amana Regional Hospital

Ismat wanted to deliver a baby all week and now was her big moment. One woman was “crowning” – her baby’s head was visible. Ismat rushed over and got into her delivery position.

Ismat ready to deliver

Ismat prepares to administer oxytocin, a drug that induces contractions

Judging solely as a layperson (I have no OB/GYN training), the woman’s vagina wasn’t wide enough for a baby to get through without major tearing. Ismat and Kiah, an American volunteer, thought the woman needed an episiotomy, a preemptive slicing of her perineum, to make room for the baby. An episiotomy is much easier to repair than a spontaneous tear during delivery.

The doctor and nurse didn’t agree that the woman needed an episiotomy and instructed Ismat to proceed with delivery, which went smoothly until it was time to deliver the shoulders. Ismat was making no progress pulling and tugging the baby’s head. Fearing she’d pull the baby’s head off, Ismat stepped aside and let the nurse finish the delivery. With a twist and a jerk, the nurse got the baby’s shoulders, and the rest of its body, out of the woman’s vagina.

The baby was fine. The problem now was the woman’s vagina. There was a two inch tear below her vagina, through her perineum, almost to her anus. The doctor palpated the tear with gloved fingers and declared it a “third-degree tear.”

Preparing to suture the vaginal tear

Preparing to suture the vaginal tear

Ismat, Kiah, Dane and I traded knowing looks of “We saw this coming.” The woman was shrieking in pain and needed sutures to repair her vaginal tear.

The doctor gestured with his bloody hand for a suturing kit and some lidocaine (injectable pain killer). But the supply cart only had 1/3 of a vial of lidocaine left – about 3.5 mL. The usual dose is 10 mL for this procedure. The doctor took the partly filled syringe and injected the tissue around middle part of the tear with the lidocaine as the woman screamed in agony. But there wasn’t enough for the whole area that had to be sutured.

We asked around desperately for some more lidocaine, as the doctor looked quite content to start suturing without it. None was in sight. “We can’t wait,” said the doctor, eager to get going.

He began stitching the woman’s torn vagina from bottom to top. The woman screamed every time the suturing needle penetrated her raw, torn flesh, except when the doctor stitched the middle part of the tear, which had received lidocaine.

It took three of us to hold the woman’s arms down and legs apart as the doctor sutured. “Mama! Mama!” were the only words I recognized from her mouth. I felt her pained grip in my hand as the doctor scorned the woman for squirming as he tried to suture.

This tear required two layers of stitches to close it – one deep, another more superficial. After 20 agonizing minutes, the suturing was done. It wasn’t the most elegant stitching job, but it seemed to do the trick. I took off my gloves and apron, rubbed some alcohol gel onto my hands and took a deep sigh.

The image of that woman’s vagina being sown up as she lay completely naked on the table, the air ringing with her blood-curdling shrieks, would haunt me for the rest of the day.

Why didn’t the doctor do an episiotomy when it was clear the woman would tear? Why was the delivery room down to a fraction of a vial of lidocaine? Many things in this hospital don’t make any sense to me. I don’t know if I’m more disturbed by the lack of basic medicines, or the apparent apathy of the doctor and nurses to their patient’s suffering.

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