The follow up

It’s been just over a year since I returned from Somaliland. And it’s been a year since I’ve posted anything about the trip. People have been asking me, “How is baby Mohamed?”. My answer is usually, “As far as I know, he’s still alive.”

I think about Mohamed everyday. I’ve been putting off posting anything because it has been painful to write about that time. While I was there, I needed a way to tell the story as it was happening. When I came back to the States, I no longer had a story. I kept my head down, recovered from illness, and continued about my business as a midwife in Seattle.

About three months after I returned, I received a video from my friend, Tom. It was of Mohamed and his mother, Leyla, visiting the hospital. He was sleeping in her arms. That video was played again and again, pausing here and there to catch a better glimpse of his small face. His hat looked like it was fitting better – not loose at all. Was he thriving? Was he acting like a normal baby? There’s just no way to know.

According to UNICEF, one out of ten Somali children dies without seeing his/her first birthday, and one in six die before the fifth birthday. These numbers are for Somalia, but are probably translatable to Somaliland. Statistics. If we looked at Mohamed case strictly by numbers, he would have never made it as far as he did.

After I left, Dr. Eve, an American-born physician from Ireland, took over his care, and the care of the other preemies in the ward. Through her attentive care, Mohamed was finally weaned off of blow-by oxygen, and began to nurse without aspirating milk or his oxygen sats dropping. I was on Facebook everyday, several times a day, to check on his progress. I felt tremendous angst over leaving him during such a critical transition. I was also harassing Dr. Paul about Mohamed’s status whenever I could. My former colleagues were incredibly patient with me. He was discharged from the hospital about 2 weeks after I left. Given the circumstance, it was probably the best thing to ever happen to him.

During my time in Somaliland, I knew, without a doubt, that if Mohamed had died, I would have left on the next plane out of the country. End of story. I would have been done.

It took me about a year to reconcile the guilt I felt over possibly giving up over one baby when there were others who needed help. I felt weak. I was only there for a month before I needed to tend to my midwifery practice. I still feel weak, but I accept it now.

In spite of the terrible odds against his survival, Mohamed lived. Other babies came and went, either because they became well or died, but he stayed on. He was the tether when everything was going wrong, when there was not enough supplies, equipment, or expertise.

I wish I could say that I learned about keeping my distance and healthier boundaries. I didn’t. Things became very black and white at the hospital. Either we could or we couldn’t do something. When I volunteer in the future, inviting weakness is the risk I have to take. Perhaps there’s a better word for it, but viscerally, weak seems to cut it for me. It’s not a weak in the knees feeling, but more like a crumbling sensation in the chest, like something was breaking off and losing structural integrity.

Would I leave a post in the future because I got attached? It’s hard to say. I would like to say that, since then, it’s become more clear to me that there’s more than one thing going right at a time, and with each right thing there are hundreds of other things that happened to make that moment occur. This is not rocket science, but the recurring theme of take it day by day, minute by minute, second by second.

So onwards to posts about my practice here in Seattle. Welcome to 2014.

Passing the torch

It’s been difficult to blog in the past few days. This past week has been difficult. We were all stretched and had our boundaries tested by what we felt were preventable negative outcomes. It’s still too painful to write about.

The last few days brought a gift of pineapple juice from a grandmother who was thanking me for the extended resuscitation I did on her granddaughter, an eleventh baby who was born to an eclamptic and diabetic mother. I got to observe several surgeries with Dr. Paul in what could best be described as the fibroid factory. Then there were the brachial plexus injury exercises I taught to a mother to help her baby’s arm regain some tone – no physical therapy is available in Hargeisa for this kind of injury. This baby had a difficult birth. He was a face presentation and then had a shoulder dystocia. His mother had a third degree and a cervical tear. I was able to assist Dr. Paul in the repair.

A new volunteer arrived today from Ireland. Eve is a plastic surgeon by trade. Today we put her to work as our newest neonatal nurse. I leave this hospital tomorrow, and this day was just as intense as the day of Mohamed’s birth (the preemie I’ve been caring for). We hit the ground running as I introduced Eve to her new charges – a 1 kilo boy and a 1 kilo girl.

Mohamed had a rough day today. We pulled out all the bells and whistles, called in the calvary, and now he is stable. It was a good learning experience for Eve as she’ll be caring for him, and making sure the nurses and students follow doctors orders. It was incredibly terrifying for me. I couldn’t believe that my baby was decompensating in front of my eyes, the day before I’m scheduled to leave. He was revisiting new lows in his oxygen saturation that he hadn’t hit since his second day of life.

I lost it at lunch today. Eve and I took shifts for lunch so that one of us could be with the babies at all times. I cried for the first time at the hospital. I knew that if Mohamed didn’t make it, I was going to be broken.

And then I got it together. Four physicians – two who are regular staff and also quite attached to the little man – made a plan with us. The plan worked, and this resilient little boy, who survived beyond all odds, bounced back after five hours of intensive treatment. He was back to his old self. I felt huge guilt for not being able to figure out the problem. Now I know.

We joked at dinner that he pulled this crap so that I would stay all day next to him before leaving. Mealtime is the place where the staff decompresses. The more rotten the day, the more we laugh together.

It’s the people I will miss most from this experience. Mohamed – I can’t fathom not being able to care for him, and watch him become fat enough to be discharged from the hospital. I think about the high mortality rate for children under the age of five (1 in 5), and I pray that he’s more than paid his dues. I want him to make it out to sea.

I couldn’t have made it here without with the comraderie and support of the visiting staff and Somaliland physicians. They are so dedicated to the patients – we are all here for the same reasons. The collaboration and the help from these good people, the openness in sharing knowledge, and the exchange of ideas has been an amazing experience. In addition to lighter moments, ironic observations, the conversation at the table was always stimulating, especially discussing the ethics and limits of care we could provide within the hospital’s capability.

The following people have made my life here bearable, and in no particular order: Dr. Sayid whom Penny called “Somaliland’s most eligible bachelor”. His impish grin (he looks 16) and twisted sense of humor kept us choking on our food from hysterical laughter. Dr. Naima who did at least three resuscitations with me. As part of the new crop of Somaliland women physicians, she’s a role model for the medical students. Dr. Paul who reminded me to breathe and was an example of a dedicated and ethical physician. A good ally and friend. Tom – the poor man had to listen to me vent at least 4 times a day, possibly more, since our quarters were in the same wing. Also a dedicated soul who changed his career path after years of planning – from corporate attorney to MPH. Hosea – the gentle anesthetist who cares deeply for the babies. He is away from his three year old daughter in order to work here. Dr. Sabir whom I tortured with consultation phone calls on his day off. His cultural knowledge and experience as a teacher helped me immeasurably with my patients. I will miss them all.

And last but not least, Edna. The heart and soul of this hospital. It’s truly amazing what she’s accomplished, and her vision for the future. Such a generous and formidable soul.

I lack the time to edit as I must finish packing and go to bed. I have to check in on Mohamed tomorrow!

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Moving on

There’s little time for reflection or poetry here. I’m constantly trying to keep my head above water. Just when I think there’s time for a break, there’s another situation. It is exciting, and as an adrenaline junkie, I’m loving it. I don’t even feel an adrenaline surge over resuscitation anymore. I just do it.

Over the weeks here, it’s even more clear to me that the human body was designed to survive. The body wants to live even in spite of all the care it has or has not received. If she is born, she needs to live, and all the body processes are geared towards life. The Somalilanders are a hardy people. They are resourceful survivors from birth.

I have seen more death here than any other experience I’ve had to date. Lately, it seems like twice a day there is a mother here who is left with empty arms. Children who were born into a place where our best doesn’t even compete with what facilities in first world countries can do. Babies that die of problems that have a solution in the U.S. Even though the U.S. maternal and neonatal mortality rate is high for a first world nation, it still is miles away into another galaxy when compared to what I’m seeing here.

The hospital is making a difference in giving care to mothers and babies, no question about that. There’s only so far we can go before we’ve hit the last of our capabilities. That point comes much sooner here, and it’s tough to see on a daily basis.

I brought some finger puppets from Archie McPhee. A little boy came to visit my baby Mohamed. He got an elephant and an alien. The smile on his face and his large eyes are the bright point of the day. Oh, and Mohamed is finally back to his to birth weight of 980 grams – another highlight.

On that note, I leave you with some pictures of the felines of the mother-baby ward. A black one was checking out the kitchen – I think he’s new here. I’ve only seen him for the past couple days or so. And there was a mama kitty nursing her five energetic kittens under the stairwell. She’s totally in the right place.

Ciao!

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Down time

After last night’s postpartum hemorrhage (PPH), Dr. Paul and I decided to make a kit for those emergencies. We had some delays in treatment last night since the family has to go to the pharmacy and get the hemorrhage medications, IV fluids plus drip set, and Foley catheter and urine bag before we could begin working on the mother. It didn’t help the situation that there was no extra oxytocin or ergometrine or misoprostol on the ward. None.

Dr. Paul had tried to make the nurses have a PPH kit available at all times, but the equipment keeps disappearing, and the kit degrades into nothingness over a couple of days. I think Dr. Paul is going to keep the kit we just made in his private room.

They did a bunch of GYN surgeries today, and I didn’t have much interest in observing. I checked on my baby Mohamed, who is doing very well and completely off of oxygen. He finally had a suck reflex today. My goals for him before I go: Get to 1500 grams and get his feeding tube removed. Long term goals: President of Somaliland. He is such a smart baby.

Not much else going on. I was supposed to be ready to resuscitate a cesarean baby, but the family withdrew consent for the surgery at the last minute. It took me 15 minutes to find a bag-valve-mask in preparation for the potential resus. Those keep disappearing as well. I saw three of them the other day. Lacking something to do, I started in on the PPH kit. It contains: IV & blood transfusion kit, urinary catheter kit with bag, sterile gauze and ring forceps, sterile and non-sterile gloves, and hemorrhage medications. The basin is almost complete – we just have to scrounge up some medications from somewhere.

It’s nice to have some free time to relax, watch a horrible movie – they import all the worst American movies and show them several times a week, many of them featuring Nicholas Cage – and try to take a nap. I’m pretty used to the assault of sounds – call to prayer at volume eleven, goats bleating, people on their mobile phones at all hours of the day and night (the back door to maternity is two floors below my window), people shouting across the courtyard, cats fighting for hospital dominance, random booming noises, and the list goes on.

I’m loathe to leave the walled hospital grounds. The roads are dusty and you risk getting hit by cars, buses, and errant livestock. And as several people have let me know, there’s a warning from the British government to evacuate all Westerners from Somaliland due to a kidnapping threat from the Shabab. Edna says there’s an evacuation advisory every 2-3 months. As of the present moment, I feel safe. I’m generally too busy to worry much about anything except for the situation in front of my face.

It’s an interesting political time since the U.S. decided to acknowledge the new Somali government. This does not help Somaliland in the least. We wonder how this will play out between these two countries. Hargeisa was already leveled in the independence war, and it seriously doesn’t need another reconstruction and recovery effort.

Can anyone tell me what movie has John Candy, Meg Ryan, and Eugene Levy in it? Whatever it is, it’s really quite bad.

Autonomy or bust,
Geraldine.

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A day at the hospital

It’s hard to know what a typical day at the hospital is like since there seems to be at least one totally insane/WTF thing happening within my purview everyday. This is not to discount the other totally WTF moments happening all over the hospital at any given moment.

My saving grace here are the Somali physicians and the guest staff. Mealtimes are when we debrief about the latest crazy happening. We usually laugh uncontrollably and inappropriately about it all. And then we say Dr. Paul’s mantra – everything should be blissful, peaceful, and happy under all circumstances. Uh huh… I mean, Om Shanti – another saying we have.

Dr. Harry, a visiting U.S. surgeon based out of Kenya, told us about a surgery he did (one of 34 he did during a 5 day stint at the hospital) to correct the problems a man had from a botched appendectomy. The initial surgery was done elsewhere, and resulted in this man leaking feces through a hole in his belly. Well, as Dr. Harry says, you never know what you’re going to find during surgery in Africa. They opened this guy up, and he still had an appendix. And he had a ton of abscesses and scar tissue from the first “appendectomy”. They cleaned up his insides, removed the appendix, and now he’s good. Crazy.

Last night, we got called to the OR just before dinner for an inverted uterus. I was just tagging along for the experience since I have never seen an inversion, thankfully, and this was my chance to see one and be helpful. This poor woman had severe preeclampsia, and lost her 32 week baby during her time at the hospital. She was delivered the previous night, and was silently bleeding for almost 24 hours before someone told one of the docs. Well, we got the woman under, and Dr. Paul goes in, and finds… a placenta. A placenta without membranes or cord. A whole placenta. The duty midwife had recorded that the placenta was delivered during the previous night. Ok, then.

After breakfast, as Tom and I were heading back to the guest staff quarters, we found our path blocked by a group of five or six university students sitting on the steps. I noticed that one was slumped over. We asked if this woman was ok, and the answer we got from her friends was, no. I should remind you that the hospital is only two floors down in the same building. She was cold and clammy, had a pulse, and was breathing. All good things. I checked her while Tom went to get Dr. Paul. We carried her downstairs and got her going again. Apparently, having female students faint from “hysterics” is a very common thing. I guess I’m just not used to people passing out in the hallways on a regular basis.

I went back upstairs and changed into my uniform and headed back downstairs towards the hospital floor and was met by Dr. Paul – breech baby with head entrapment. We ran to delivery expecting the worst. The baby was already out, totally covered with meconium, limp and pale. We tried to rush the midwives into cutting the cord and getting the baby to the resus station. The little one started to come around after Dr. Naima and I worked on him for about five minutes. A fat little thing at 3.8 kg, nursing, acting like a king within an hour and a half post delivery. At lunch we were laughing over how Dr. Paul almost ran down naked to the delivery ward as the midwives called him during his shower, after the head was already stuck. Generally, the midwives are supposed to call the OB before any breech delivery.

Just after the resus, I checked in on my baby Mohamed – we’re in the process of weaning him from oxygen. He was on blow by oxygen all night on the lowest setting and we had been moving it farther and farther away from him. So far so good. A student nurse tugged on my sleeve to bring me to the new preemie (somewhere between 29-31 weeks) on the ward who was transferred from Hargeisa Group Hospital. No steroids were given to the mother prior to delivery, so the baby’s lungs were not prepped. The letter from the Norwegian doctor at Group Hospital explained the situation, and reported the weight of the baby as 500 grams with blankets. Apparently the mother had lost other babies, and wanted as much effort as was possible to save this little one.

We reweighed baby Asma, and she was found to be 820 grams, even smaller than our little tiger, Mohamed. One of the docs quoted a statistic – even with the best care, this baby has a 45% mortality rate. The baby was crying and holding her own, and we were going to support her natural efforts. There was nothing else we could offer her. We began CPAP and started monitoring her progress. I don’t even know how successful we’ll be since her mother did not get any steroids as Mohamed’s did. We’re hoping beyond hope that this will be enough.

If I had known that we were short of pulse oximeters, I would have brought three instead of one. Now I was shuttling between the two incubators to share the pulse oximeter. Since Mohamed was less critical, though in a critical period of adjustment, I had to make some decisions on what would be his key monitoring periods. Since I knew that his sats dropped with feedings, we monitored him during feeds only, and then watched him closely between, supporting him with a little more blow by oxygen because I knew his sats would stay stable in the mid-90s without having to monitor him.

The best part of the day was when Mohamed’s teenage mother demonstrated some interest in feeding her baby through his nasogastric tube. He was curled up, kitten-like on her chest, and she slowly pushed the milk in over a 30 minute period. Since she didn’t have a watch, I had her give him 1 milliliter incrementally, and then had her wait 5 minutes before giving him the next milliliter. I would check in on the other baby, and come back every 5 minutes to let her know it was time. They both did great. This is happiness.

The mother of the breech baby had quite a large delayed postpartum hemorrhage while I was busy with the babies. It’s entirely possible that she had been bleeding ever since she was put in the postpartum ward.

And now we have a small break before dinner. Who knows what will happen after? It’s no wonder that I have crazy dreams at night. It’s all crazy.

Again, many apologies over the grammatical errors. It’s hard to focus long enough to do any sort of editing. I’m just trying to be blissful, peaceful, and happy!

Apparently I shouldn’t have asked what would happen next. I got a nightcap after dinner of a postpartum hemorrhage. This lady had been transferred over from a different hospital. I expressed a papaya sized clot from her uterus. We worked on her some more, gave meds, IV fluids, and blood. She’s fine now.

And now it’s time for bed.

The hours between breakfast and lunch

At some point in the last 4 years, I stopped thinking in metaphors. I’m not sure how or why I lost this ability.

And I’m not expecting it to come back anytime soon.

After breakfast, I went to check-in on my baby. His pulse oximeter was dead. I found that they’d skipped a feeding at night, and that he had been too warm for several hours at 38C. I did an about face and barged into the nurses station, and asked why this had happened. Blank stares. Perhaps an open mouth or two. And then one student found her voice and said that the students and midwives from the last shift had already gone home. I demanded to know why the batteries on the pulse oximeter wasn’t replaced. The duty midwife said, we did replace it, it’s just broken. Lies.

I replaced the batteries, and started the cooling process. The pulse ox came back to life and showed me that Mohamed was not too worse for the wear. All of this happened after I gave a lecture to the students last night about how Mohamed needed their watchful eyes. He’s losing his celebrity status already. They’re getting bored with him, watching him thrive – as much as a scrawny, chicken-winged, less than a kilo baby can thrive. I do love him dearly though.

You probably don’t want to read any further if you are pregnant or postpartum.

Just as I was about to start his first make-up feed, a purple veiled staff midwife sauntered towards me. She said non-urgently, we have an urgent case. Where? Down here. Who? The baby. Which baby? And on it went. She led me to the basinette of the second twin who was born a couple days ago. He was grey, and there was blood running out of his mouth and nose. I listened for a heartbeat while the midwives stood over to the side. Slow in the 70s. Dr. Naima showed up and together we started a resuscitation. We could hear a gurgling sound as we attempted a breath. I took out a DeLee suction, and it became full of blood. We couldn’t stay on top of it. The pupils became fixed and dilated. Dr. Naima listened for a moment. We stopped. There was nothing more we could do.

The mother was sitting up in the next bed, looking at the wall in front of her, tears rolling down her face. I wrapped the baby and tried to let her say goodbye. It was a mistake. It is not their way. After complete inaction prior to and during the resuscitation, the midwife intervened at precisely this moment to prevent this indignity. I put the baby back in the basinette, and the family covered him up. I put my hand on the mother’s shoulder, and then left the room. Baby Mohamed needed to be fed.

I asked Dr. Naima, what happens to the body? The family will take it back home with them and bury it there. The mother and remaining twin were discharged after the death, and by the time we did rounds an hour later, the room 4 was empty – they were gone.

After rounds, Dr. Paul rang me to let me know that I’d be needed for a potential resuscitation at a twin breech delivery. I set up a resuscitation station in the operating theatre, and waited for the action to begin. I held the mother’s hand as she started to have an uncontrollable urge to push. Of course, no monitoring of the babies were done at this point. The mother was quiet in her efforts, and grinning at me between contractions. She bore the poking and prodding stoically, never complaining. After the second push, we started to see a foot. Then the other. Another push – the whole body except for the head came out. And finally the head came, and I received the baby in a bit of cloth and started rubbing him down. He had a great heart rate, but no respirations. I gave him a few puffs of air, and he started crying lustily, indignantly. He was wrapped in a thick blanket, and as soon as he was stable, we gave him to the father.

The second baby came head first a contraction or two after Dr. Paul broke the mother’s bag of waters. Instead of amnihooks, they use a small razor wedged in a hemostat to break the water. Enough said. If I had known, I would have brought one from the supply stash in my room. A huge wave of fluid almost hit Dr. Paul in the face. This boy came out vigorous and squalling. We wrapped him up and sent him out to his father.

A quick change of clothes, and then it was time for my follow-up neonatal consultation with Dr. Pollack in Ethiopia. We only got disconnected once. I asked him about the baby that died, and he reassured me that nothing could have been done for him in this situation. Not with the (un)available resources.

Walking back downstairs, I checked in on the twins that were just born. I parted the curtain into bed 1, and saw their beautiful mother. She beckoned to me and grabbed my hand, turned it over, and kissed it. I turned our handshake over and kissed her hand. I had seen this handshake on my second day in Somaliland, but did not know what it meant.

The babies were sleeping in their basinettes. Pink and healthy. Breathing easily. No need of any MacGyvered CPAP devices here.

Time for lunch.

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Balance and emotional incontinence

I suppose when things better and worse than expected, they kind of cancel each other out. Or it’s really all the same. I just can’t help but feel that the crap happening here is canceling out the small victories we live by day to day.

After I went back on duty – I was horribly ill for two days – I found my 29 week baby (almost 6 days on land) off his CPAP, on too much freeflow oxygen, and a lower heart rate. Who knows how long he was like this, who did this, or why someone would do this. With the help of Dr. Paul, I restarted the CPAP, and got the baby situated again. We gingerly got rid of the heavy-duty tape that someone put on his forehead to secure his new feeding tube. I broke out into a sweat as the adhesive began to rip away some of his hair.

What was going right: About half of his feeds were breastmilk, and we were on track to meet the feeding goals of the day.

It was just after this point when a student nurses tugged my sleeve to check in on twins who were born at around noon. Twin B had been grunting -a sign of respiratory distress- for 3 hours by the time I was brought to him. He was also cold at 34.2 C / 93.6 F. I called the on-call physician to check on the baby. CPAP ordered for this baby. He also checked in on a baby that was born last night after a prolonged resuscitation. CPAP ordered for that baby as well.

Here’s to hoping that these babies stay warm and safe.

Day 6

After 2 plus days of cyclic fevers and generally feeling like crap, I’m mostly back, and completely terrified again. I had the craziest physician consultation of my life today with Dr. Lou Pollack, a Seattle neonatologist who is finishing up a month-long stint in Addis. And by his own admission, this was the craziest phone consult that he’s ever had. It took a while to reach him because the phone number I got for him had too many numbers. I pulled aside one of the Ethiopian volunteers to fix the problem for me – which one of these numbers do not belong?

And it went like this: Doc basically said that this baby should not be alive. And that we’re over the edge, and that Mohamed defied all odds by staying with us for so long. Basically with his stated gestational age, around 29 weeks, could be more/could be less, he’s SGA (small for gestational age) based on the birth weight of 0.98 kg. I can imagine that the little one was growth restricted due to the severe preeclampsia.

I got my shiny new marching orders, and I’m going to put on a damn mask and implement them after lunch. I’ve been away from my baby too long. And I’m incredibly anxious to increase his feeds. I can only hope that the midwives and student nurses were diligent about having the mother pump while I was gone. What if her supply tanked?? What if they skipped a feeding? What if he’s not well. The list of what-if’s goes on, and on, and on… It’s like what Anne Lamott describes as the radio station in her mind: K-FKED.

If the baby starts to have troubles, I was advised to let him go. I really hope it doesn’t come to that because I don’t know how I’m going to deal. I guess I could start a khat habit. But I also hope that this kiddo isn’t going to live life with crazy neurological deficits based on my frankenstein neonatal nursing in the desert.

We have clear goals for the little man for today, tomorrow, and the day after that, and hopefully I’ll have something positive to report to Dr. Pollack on Wednesday at noon, before he leaves Addis. He made me promise to check in as he can’t get this little guy out of his head.

My Somali mobile phone ran out of minutes as I was talking to the good doctor. I tried my usually non-existent Skype connection on my iPhone, but through the grace of whatever, I was able to have a clear connection to finish the consult. Thank you. Thank you. Thank you.

Non-infectious, anxious, and generally pissing myself in Hargeisa,
Geraldine.

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Day 3?

I’m using a brand of passed on shampoo called “Wistful”. Definitely feeling wistful here as I discover that there is no lather, and that my hair is the same greasy nastiness that it was before… except with a much better fragrance. It’s good to count the blessings, right?

It’s surprisingly cold here. I’m sleeping with two blankets at night, and feeling chilled all over as I’ve gotten some sort of sickness. Flipping through channels in Somaliland goes like – BBC Middle East, TV Mauritania, Korean Broadcasting System World, Al-Jazeera Children, and all sorts of other channels around North Africa.

I believe it is almost day 3 of our 29 weeker still being here with us. Before the other volunteers left, they showed me a McGyver version of a neonatal CPAP (continuous positive airway pressure) made with a plastic water bottle with a 5 cm orange razor blade sheath (found on the OR floors) taped to it, and a torn apart and reassembled-with-duct-tape adult nasal cannula. Liz and Penny, the now departed volunteers, learned it from an Australian physician who specializes in bush medicine. Using the pulse oximeter that the donations bought, we’ve been making sure that this little man who weighs less 0.98 kg/2.1 lbs is sufficiently oxygenated.

Of course, I’m terrified, and in the deep end. I’m a midwife for God’s sake, not a NICU nurse. And I desperately wish I were a NICU nurse. Too late for that. Working with the visiting obstetrician and internist, we have a plan to try and keep this baby with us. It’s difficult to titrate this plan, as I’m feeding this baby a diluted, powdered infant formula mix which has been measured out by the scoop that came with the can. As close as we’ve figured out, he needs a half scoop in 30 ml of water. We’ll be increasing his total feeds about 5 ml more per day, as long as he doesn’t have gastric distention.

Definitely had some anxiety last night at 6:30 when I found that his sats were in the 70s. The volunteers warned me that the tubing sometimes gets compressed in the door of the incubator. That wasn’t the problem. I followed the line for kinks, and found that the tube was disconnected from the oxygen tank. Once that was resolved, his sats came back to the 90’s. I suctioned him with a DeLee anyway, fed him, checked his “diaper” -pocket tissues I brought with me- and found that he had a large meconium and void. Success! It’s these small victories.

At 10 pm, baby Mohamed’s temperature had a spike – 37.5 C / 99 F Not quite a fever, but the highest he’d ever been. He felt hot to the touch. The incubator was roasting. We turned the temp down, unwrapped him a little bit, and started more hydration. I left strict instructions to the dedicated nursing student to call the on-call physician if his temp got to 38 C, a possible sign of infection.

There are definite challenges to caring for this baby. There is no soap in the ward. We posted a hand washing sign in Somali and English on the incubator. There are green nursing students as well as more experienced students. It’s on-the-job training for them. Edna gave the students a motivational speech about the importance of good care and how much this baby needs them. It seemed to have a direct effect on the night shift.

Mohamed’s mother had severe preeclampsia that was uncontrolled, and the decision was made to section at 29 weeks when the anethesiologist from Nairobi came into town. Dr. Paul, the visiting OB, did 3 surgeries that day – the delivery and two hysterectomies. At day one post-op, her BP was still 200/110. Her pressures are finally under control. She finally came back to herself around yesterday, and we began to hand express colostrum from her breasts.

She didn’t like it.

I’ve been showing the student nurses and midwives some hand expression techniques. We started syringing up 0.1 ml of colostrum at first, and the quantity kept increasing over the next 24 hours. Today we have milk, and was able to feed the baby 1 ml in addition to his formula feed. I asked the students, why is colostrum so important for the baby? It’s a good teaching moment, and I try to have them translate to the mother that her milk is like good medication for the baby. We’ve also been using this Chinese bicycle horn/breast pump that has this clown nose suction bulb on it. It’s been less painful for the young mother, and she seems a lot more willing to assist us.

The women in her family are camped out in the ward, taking their meals, and sleeping on mats or on extra beds in the room. There is always someone with the mother. She is never alone. We did have to kick out a coughing relative, but otherwise, there’s a constant flow of veiled women who are holding vigil over mother and baby.

Sorry for the typos and lack of syntax. Feeling overwhelmed with the situation, being sick, and using Wistful shampoo. It’s enough to cause delirium and this stunningly named disorder called PBA. Look it up. Thanks, Ting-Ting, for giving me that laugh before leaving. It’s the gift that keeps on giving because I now have it.

Signing off from Hargeisa on the day of rest.

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Somaliland’s only terrorist

Before I explain the title of my post, I have to say that I did finally end up in Hargeisa after a 13+ hour flight to Addis Ababa. I hope to never be on a 13 hour flight ever again, but I do need to get home at some point. Some of you know about my Ethiopian Airlines fiasco about having my flight times and flight numbers changed multiple times, sometimes twice in a day. Last I checked on the morning of my departure from DC, my flight to Berbera was supposed to take off at 10 am and arrive at 11:50 am. When I rechecked my boarding pass in flight over Libya, I found that my boarding time was at 7:45 am. This was a bit problematic since we had departed 1 hour late and would be arriving at 8:30ish. Well, to make a long story short, I arrived in Berbera at 11:20 am after we were herded into one gate and then lead to another for boarding at a totally random time. It’s true – don’t read the posted gate numbers at Addis. Ask people. Multiple times. And repeat.

The drive to Hargeisa was two hours and stunning when I wasn’t passed out and slumped over my bags. Camels and goats everywhere. I think I saw a warthog – hard to say, it was a bit dead and squashed in the middle of the road. And I saw people walking in seemingly desolate stretches of land without any homes in sight. Obviously there were huts we couldn’t see, but it was so strange to see people in the middle of nowhere, clearly going somewhere. Their landmarks are different than ours. I saw children playing with a makeshift shovel throwing sand off the road and at each other. There were other children, singly or in pairs, dotting the landscape.

The traffic situation in Hargeisa reminds me of Kathmandu. It’s a fluid thing. You can pass people, drive on the wrong side of the road, honk as friendly communication, and blithely weave your way between people, animals, large potholes, and other vehicles. Hargeisa is home to over a million people. Yes, people of Seattle – that’s way more than we have. And there are no traffic lights in sight. As Edna drove us to and from dinner, seatbelt light flashing, like a pro. It was amazing. Even more amazing is that everyone really does know Edna in Hargeisa. At all the police checkpoints, Edna would turn out the headlights, turn on the interior light, and wave to the police officer. And in every instance they would peer in, recognize her, smile, and say “Edna”, and wave us though without incident. Everyone knows her. I’d say she’s a good person to know while here.

A consummate storyteller, Edna told us about her time as a Somaliland cabinet member, and how she was dubbed by her entirely male counterparts as Somaliland’s only terrorist. She’s feisty and she gets things done.

Communal breakfast tomorrow at 7:30, and rounds commence at around 8:30. I observed an antenatal nursing training class today until I was too sleepy to finish – jet lag and exhaustion finally caught up with me. And I got my headscarf technique down pat. It just got too embarrassing at dinner as I kept fidgeting with my scarf. The volunteers here are amazing, and doing some great work. I hope I can continue what they’ve started in the education department. I’ll be using this week to get a better idea of what needs to be done and what my place in the hospital will be.

Signing off,
Geraldine