HIV and haemorrhage

This week the government of Kenya is having a massive campaign to encourage people to have HIV testing. As part of this effort our church had a service focusing on a Christian response to HIV. They gave a good factual education of how HIV is transmitted and how it effects the body, explained the ABC (abstain, be faithful, use condoms) approach to prevention, and highlighted the AIDS Relief project in the hospital (where 5000+ people receive treatment for HIV, with one of the best anti-retroviral compliance rates in the developing world). Above all they stressed that a godly approach to people with HIV is compassion and love, not judgement. After the service tents were set up in the church grounds for VCT (voluntary counseling and testing), and all members of the congregation were encouraged to attend for testing.

I didn't attend for testing myself - but that's because my next HIV test is due in mid-January, two weeks after I finish my post-exposure prophylaxis. (I had a needle-stick injury when operating on an HIV positive patient - the truly annoying this is that I can't really blame anything except my own carelessness - it was my fourth emergency operation in less than three hours and I was rushing to finish - a moment's distraction and I had a needle in my finger, stupid really...)

It did remind me, however, just how risky my specialty is in Africa. Massive blood loss is pretty common in obstetrics, and adequate protection (e.g. long-arm gloves) is usually lacking. As I fish out retained placentas or second twins I frequently end up with blood inside my glove (even if I'm not poking myself with a needle...). Even abdominal surgery is often pretty bloody for obstetricians. Yesterday, for example, I ended up doing a caesarean hysterectomy for a placenta praevia and accreta (yet another reason why Kenya's spiralling caesarean section rate is a reason for concern). I was pretty pleased to have limited her blood loss to about 1500 mL - but you can imagine how it soaked through my non-waterproof gown before I got the uterine arteries clamped...

This came out first - a lovely baby girl.

And this came out last - a uterus with the placenta over the cervix and morbidly adherent to the uterus.

Friday night

I've just said goodbye to our three family practice residents who have been working in Kijabe for a month. Alyson has been doing obstetrics with us - truly a joy to work with and a real help, especially in the maternal-child health clinic. I had them over for mung bean curry and a weird take on bread pudding (I used banana bread and threw chocolate and bananas into the custard - not too bad surprisingly). Luthien showed off abominably, and is more convinced than ever that she is in fact the centre of the world.

There have been several tough situations this week - two women on our theatre list who turned out to have unresectable cancers, comforting a woman facing her fourth consecutive miscarriage, and another whose baby turned blue several hours after delivery and and was diagnosed with severe heart problems (almost certain to be fatal).

But there have been many moments of pure joy. One 16 year old girl with a very rare cancer who tried to bleed to death on Saturday night. I managed to stop the bleeding with a hysterectomy and then telephoned everyone on the hospital blood donation list until we had enough donors. After 8 units of blood she had a haemaglobin of 7 - and now whenever I see her giggle with a patient in the next bed or smile to greet me I am tempted to break out into songs of praise to our great God who has saved her.

And one night when I was just 'passing through' the ward to collect something I was somewhat irritated that a patient noticed me and called me to see her. But there was no complaint, she thought I would want to know that the woman in the next bed had delivered, 'since you prayed for her child this morning I thought you would want to give thanks to God.' She then proceded to update me on the entire bay - clearly she had listened to my prayers with each patient in the morning and wanted me to know 'those two delivered safely, that one had her baby come back from nursery, the one next to me had no further bleeding, and my blood pressure is much improved.' She then instructed me to pray again with each patient that God would keep and preserve them through the night - and after our time of prayer I walked home in the starlight, humbled, knowing that I had been standing on holy ground.

Getting started...

Earlier this week I sat staring in dismay at the list of 60 e-mails that really do require answers – almost all of them including a subtle chastisement for my poor communication of recent months. And though I know this is not a real substitute, I figured I might as well give blogging a try. The concept unnerves me slightly I confess, it feels slightly too exposed for my taste – but for those who are interested, I’ll see if I’m any better at posting news for all to see than answering individual messages.

So here are a few items to kick off with.

First, may I introduce you to Luthien Tinuviel?

She is a border collie puppy now six weeks old and she moved in with me one week ago. We are learning the process of living together. I’ve discovered that if I don’t have her breakfast ready on time I’m in big trouble and that a 15 minute walk is exhausting for her short legs; she’s learned that if she cocks her head just right or wags her tail she can get away with murder.

Luthien is extremely popular with my neighbors’ children who are glad to come and play with her when I am working.

Second, here is my favourite clinical story from November.

J. is a 22 year old woman in her fourth pregnancy. In August her family thought she looks a bit bigger than the previous three times, so she went to a clinic for an ultrasound scan, and was told that she was expecting twins. This is not a big deal in her community, and certainly not a reason to avoid delivering at home. So one night J. went into labour. After some time she delivered a healthy baby boy, and then prepared for the next child to come out. As they waited, J.'s mother pondered the size of the abdomen and concluded that perhaps there were two babies left inside - and two more babies could mean trouble. After some discussion they agreed to bring J. to the hospital, arriving 8 hours after the first baby had delivered. I then proceded to perform a breech extraction of one baby, delivering a baby boy. A minute later I had my hand around the ankle of the remaining child - and soon we have three screaming boys in the cot - all weighing >2kg. J. herself suffered some bladder trauma and developed a uterine infection (due to the long labour and delay between babies) - both of which resolved nicely during two weeks in hospital.

Yesterday her husband came to collect her and the infants. They will be returning to the older three children - all of whom are also boys.

So, how's that for a first attempt? (At blogging I mean...)