by KIRI MACKERSEY, M.D.
All photos courtesy of Kiri Mackersey, M.D.
“How about Nigeria?” The job was at a large, long-standing maternity hospital in northern Nigeria with Doctors Without Borders/Médecins Sans Frontières (MSF), an independent, medical humanitarian organization. It was my first assignment. My role would be head of the obstetric ICU and supervisor of the local nurse anesthetists in the operating rooms. MSF’s emergency obstetrics program at the Ministry of Health hospital in Jahun, Jigawa State, Nigeria, provides obstetric care and offers surgery for women with vesicovaginal fistulas. Although other areas in the north had been devastated by the ongoing conflict between Boko Haram and the Nigerian military, the security situation in Jahun was stable. The expat compound was colloquially known as Jahun Paradise and was rumored to have the best cook in MSF. I signed up.
New York — Paris — Abuja — Jahun
I had been warned that Abuja Airport would be a goat-filled market of chaos and danger — don’t talk to anyone after the security gate and don’t walk out with anyone, even if they say that they are a policeman. In place of livestock, however, are businessmen, tourists, families coming home and a Nigerian movie star whose entourage rivals that of the Kardashians. I spend a couple of nights in Abuja receiving security and medical briefings before heading to Jahun.
The drive is about five to six hours to Jahun, depending on traffic.
The drive takes seven hours on a good day … without military roadblocks.
You’ll be driving for eight hours, depending on weather.
Are you ready for a nine to ten hour drive, more or less?
At this point, I stop asking how long the drive to Jahun will take.
ICU: India Charlie
We arrive in Jahun in the late afternoon. Finally I see the promised goats surrounded by a distinct lack of chaos or danger. My Australian predecessor wastes no time showing me around the hospital. I put down my bags and 10 minutes later I’m on an ICU round. The ICU has eight beds run by a local staff of two nurses and a charge nurse, Helene. At the start and conclusion of the round I am greeted with “The new med anesthetist! You are welcome.” At the door to the ICU we wash our hands and change from outside shoes into rubber clogs and white coats. The room is simple and functional, each bed separated by a nylon curtain. The head of the bed can be raised mechanically and every component can be wiped clean. There are several fans and two air conditioning units that provide welcome relief from the heat outside. We start the round immediately at bed one.
Bed one: an 18-year-old G3P0 with eclampsia. She was seizing at home for about nine hours before she was brought in and delivered a deceased term baby last night. BP 185/101. No hyperreflexia, no headache. Magnesium treatment is halfway complete and she’s on labetalol. The labetalol is increased. Bed two: a 20-year-old G4P1, eclampsia. Seized again last night despite magnesium. There’s a low-grade fever and she’s drowsy and incoherent. We start a discussion: is it a postictal state, a stroke in progress, magnesium or the benzodiazepines used to break the seizure? Blood pressure is controlled, pupils equal and reactive, limbs are symmetrically hypotonic. Continue magnesium, check mag levels and electrolytes, rapid malaria screen. In my head I imagine the work-up she would receive in New York: a CT head, cultures from every orifice, anesthesia team on standby to intubate. Bed three: 25-year-old G6P3, eclampsia. She has finished magnesium treatment and is on oral antihypertensives.
Northern Nigeria has one of the highest rates of preeclampsia in the world. No one knows exactly why. It could be nutritional deficiency in magnesium or a genetic predisposition, but more universal reasons, such as second marriages with multiple gestations, cannot be ruled out. The American obstetrician on our team shakes his head. He’s never seen three recently eclamptic women in the same room before. “Sahnu?” The patient in bed three nods. “Sahnu” is Hausa, the predominant language in this area. It is one of those indispensable, Swiss Army pocketknife words: how are you?/I’m fine/hello/thank you/OK/I’m sorry. By the end of my mission it forms the backbone of my vocabulary.
We move on. Bed four: a 17-year-old G1P1, jaundice, abdominal distension, renal failure, lethargy, normotensive, no seizures. Her baby is in a crib beside the bed. We stand around scratching our medical heads. One of the local doctors suggests herbal toxicity. The woman has been taking a local herbal concoction of potash and plants to speed labor — her tongue is still dark from the ash. These mixtures are usually made by traditional healers and come with a high risk of liver failure. Will the lab do liver enzymes? Our new French lab technician has recently catalogued the reagents — she is hopeful. The obstetric ultrasound confirms ascites. I move up onto her chest. The curvilinear ultrasound probe just about fits between her ribs and I see a hyperdynamic, empty heart. We start IV fluids and discuss transfer to a larger state hospital.
The women in beds five and six have recovered from postpartum bleeds and are ready to move to the step-down beds in the adjacent room. Helene calls their names out the window. The central courtyard is full of waiting aunts and grandmothers who feed, wash and transfer our patients. “Fatima … Family of Fatima! Come to the ICU.” A few minutes later, Family of Fatima is cloaking her in a long hijab and bright cloth “wrappa,” the traditional dress in this area. They scoop up her brightly bundled baby and walk across the doorway into the general ward. Here she will have her own bed for a couple of nights, then she will share her bed with another postpartum patient before returning to her own village. As they pass me, the women raise their hands and bow their heads: “Sahnu! Sahnu! Sahnu!”
Bed seven: a 16-year-old G1P1 with anemia. Her presenting hemoglobin was 2, presenting complaint: dizziness while walking. She had delivered at home two days previously and her baby is beside her. After 4 units, the hemoglobin on our bedside fingerstick is now 6. She feels good. We debate transfusing another unit. She is nutritionally deprived and is about to spend the next few months breastfeeding. I grab the obstetric ultrasound probe (my echo). Her left ventricle is hyperdynamic and relatively empty. We take a vote and the transfusers win. We also add some high-calorie nutritional supplements.
We turn to our last bed. She’s 35, G5P2 with weakness. She was brought in by her family an hour ago, unresponsive. The story is that she delivered at home overnight. She then became confused and lost consciousness in the early hours of the morning. It’s now evening. The outgoing medical anesthetist educates me: only the men drive and they may be reluctant to travel at night or in poor weather. Our admissions come in mainly between 9 a.m. and 11 a.m., regardless of the onset of symptoms. Some women travel for days, from neighboring countries, for the free, highquality care that MSF delivers. The lucky ones come by car, the rest by oxcart. Our patient flails her left side but her right side is immobile. Blood pressure is uncontrolled, Babinski’s ... I have not checked for this sign since I was a medical student. I doubt myself and repeat the test. Up-going. Her prognosis is grim. Long-term treatment facilities and rehab units do not exist in Jahun and her ongoing care will place an enormous burden on her extended family. The team is silent for a moment, deeply aware of the repercussions if no recovery is made.
The static of a walkie-talkie breaks my reverie. India Charlie, this is Oscar Tango, do you copy? We copy. India Charlie, is the med anesthetist with you? We need help in Oscar Tango. Good copy, she’s coming.
Operating Theatre: Oscar Tango
The nurse anesthetist is struggling with an intubation. I take over and, after the tube is in, find out what is going on. Uterine rupture from a combination of eclampsia and protracted labor. Extra IV lines are secured and we cover her with a washable forced air warmer. Fresh blood is ordered from the blood bank. It arrives four minutes later, still warm from donation. In Jahun, the family of the patient “repays” by donating the number of units used by the patient. There is always a line of willing husbands and fathers on the bench outside the blood bank, waiting for a spot in the “bleeding room.” The type and screen is done on a large porcelain tablet. Blood is screened for hepatitis, HIV, syphilis and malaria. Malaria positive blood is still used — in an endemic area, too many units would be wasted otherwise — but the recipient is simultaneously treated. Packed cells are available for the neonates, everyone else gets whole blood.
Hysterectomy underway, I explore the drug cabinet. It’s fully stocked with a familiar family of emergency medications. Stacks of single-use syringes and needles are neatly organized. A separate, locked shelf contains controlled substances and there is a log book in the office nearby for periodic inspections by the Ministry of Health (MOH). All controlled substance containers are discarded separately. The MOH inspector will compare the log book with the collection of vials. While I understand how narcotics and benzodiazepines made the controlled list, the reason for locking up ephedrine, caffeine and methylergometrine is more of a mystery.
I turn to the anesthesia machine. I had read the orientation pack but the chrome box is quite different in practice. The nurse smiles. “Not like the one you are used to?” It reminds me of a gramophone from 1950.
I follow a standard mental algorithm: first find the “on” switch. There are six dials and two pressure gauges on the Monnal D2. My predecessor points out the pressure dial, rate setting and pressure alarms. There’s an oxygen blender and an isoflurane vaporizer. Monnal has continued manufacture of these simple models as a service to medical NGOs — they are easy to maintain, easy to transport and difficult to break. In terms of the circuit, everything except the endotracheal tube is reusable. The sterilization room has a counter window into the operating theatre — central supply gives us immediate service!
The next five weeks of my assignment pass quickly. I’m on call around the clock and every few days there is a soft nighttime knock at my door. Sometimes I’m called to help with mystery diagnoses (a thyroid storm, an acute non-obstetric abdomen, liver failure, psychosis mimicking a stroke) or to the operating room when a spinal won’t go in easily for an overnight C-section. I use the OB ultrasound for echo often, and rapidly discover that these young women have far from young hearts. Admissions for heart failure come in two or three times a week and some have concomitant valvular disease. I dredge up knowledge from medical school, consult my pocket pharmacopeia, and ask the local doctors if this is what a malaria spleen feels like. Every day I feel humble and grateful.
How to treat burnout? Talk to colleagues, get a massage? Rest on holiday? Quit your job? Become an administrator? Perhaps. For anyone who still has the embers of medicine alight, my advice is to drop the pressures of the Joint Commission, escape the clipboards and walk away from the man who didn’t like the “feel of the pillow” in PACU. Go and treat people who ask for nothing and give only gratitude in return. I hope I helped them. There is no doubt that they helped me. ■
Kiri Mackersey, M.D., is an attending cardiothoracic anesthesiologist at Montefiore Medical Center.
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