I'm a few days behind updating this...I had two busy call days (Friday and Sunday) and have been putting together presentations for the past two Tuesday morning OB lectures.  So no worries, I'm really not slacking off here! 
The variety of OB cases continues to be impressive.  As an example, take my 24 hour call shift on Sunday (which was actually not my busiest call day): managed 1 breech delivery, 1 vacuum delivery, 1 set of twins, not sure how many semi-normal deliveries/inductions, one postpartum eclamptic seizure, one postpartum septic endometritis, did a D&C of a 16 week molar pregnancy (that showed up in shock with a hemoglobin of 5.0), and removed one vaginal leech (yes, that's a real problem here...leeches have no boundaries). 
The best part of the job is getting to work with the doctors here.  I've enjoyed being a part of a training program with the constant focus on good education.  Both the junior and senior doctors have welcomed me onto the team, and have all been so willing to teach me Bangladeshi obstetrics.  From laughing around the rounds table in the morning to having iftar (breaking of Ramadan fast) at their homes in the evening, they've become good friends.  Besides my interactions with patients, the staff here have given me a solid one month introduction to Bengali culture. 
I'm really looking forward to sharing cases, pictures, and experiences when I'm back in Greeley soon!

Bangladesh, Part #2

It's been a full week at LAMB - I'm staying busy either doing ultrasounds, rounding on antepartum and postpartum patients, and working on the labor & delivery unit!  I had two 24 hr call shifts this week with lots of interesting patients.
I've also been introduced to the difficult concept that female infants are considered a liability.  A few families have been disappointed this week because they delivered females, and one family refused a C-section for a very distressed infant because they knew it was going to be a girl from an ultrasound they obtained elsewhere.  Here, we don't tell anyone gender on ultrasound because of this phenomenon.
It's also interesting to be the second or third hospital that people come to for care.  Last week I admitted a term severe preeclamptic (BP 190/110 with headache and significant edema) who had been treated at a clinic for high blood pressure...3 days before.  The clinic had actually given her a shot of magnesium and sent her home.  Incredibly, the baby was still OK.
On my most recent call night, a woman came in with severe abdominal pain and a very small amount of vaginal bleeding after 2 months of amenorrhea.  She gave the odd history that she had 2 prior D&Cs, both done in outside clinics.  She was awake for the first D&C and no product came out - the doctor simply told her that the baby must have already passed despite having no bleeding.  After 2 more weeks of pain, she had a second D&C at the same clinic.  And now she came to us with exquisite abdominal tenderness.  I was surprised by the ultrasound to see products of conception and a fetus (without heartbeat), but also saw fluid and irregular masses everywhere.  I called Dr. B who agreed this was a very strange ultrasound. We discussed the possibility of uterine perforation vs ectopic.  After overnight antibiotics, we took her to surgery yesterday and found an abdomen full of blood clots, swollen adnexa & tubes, and a huge ectopic pregnancy in her right ovary - it was actually difficult to find the tiny uterus in the midst of the mess in her pelvis.  Learning point...if you  can't get the products out on D&C, the fetus is probably somewhere else!
I have been so impressed with the quality of medicine that is done here at LAMB with relatively few resources. The guidelines that the hospital follows and teaches the residents are evidence-based and up to date, the facilities are very clean, and everyone is constantly looking for ways to learn and improve.  It's definitely a model of missions hospital that others could learn a lot from.  I've felt so welcomed and have been working with the best people - both the Bangladeshi staff and missionaries.
Feel free to email if anyone has questions :-) I'm looking forward to sharing more when I get back!

Hello from LAMB Hospital, Bangladesh!  It's hard to believe that I arrived here a whole week ago - it's going quickly!

First a brief overview of LAMB - it's an impressive hospital and community health system, and the hospital compound where I'm living and working is also home to an elementary school, nursing school, and midwife training program.  In communities around the hospital, LAMB has 28 clinics, including 18 safe delivery units.  The community activities include not only health related activities, but also community development and disaster preparedness.

LAMB now has more than 1000 staff – mostly Bangladeshi, but with approximately 25 foreign staff to bring additional expertise and training capacity.

I'm working in the obstetric/gynecology unit along with Bangladeshi senior doctors and residents and one Swiss physician, Dr. Ambauen, who has worked here for a number of years and heads the department.  I arrived Sunday evening and my introduction to the hospital started Monday morning with a retained placenta - 5 hours after delivering the baby at home, the patient had sustained huge postpartum hemorrhage and was in hypovolemic shock.  By noon, I found myself in the operating room again doing a C-section, and assisted a molar pregnancy D&C that afternoon.  So it was a solid start to the month here!  I was put on the call schedule as a senior doctor, which made me a bit nervous on my 3rd day in a country where they talk about "normal ecclampsia" (when mothers seize but recover without complications).  Fortunately I had a back-up in case of emergency and honestly, things went smoothly on my first call day Wednesday.  The midwives handle all low-risk cases - I'm still getting used to not knowing about all the deliveries!  Junior doctors have a range of experience from 1 month to over 2 years.  I've been working with the youngest junior doctors on suturing the fascia in the OR and doing basic growth ultrasounds.  The experienced junior doctors can handle most things themselves, but call about decision making or any complicated cases.  Many women here deliver in SDUs (safe delivery units) that are midwife-staffed.  I visited one of these this morning and was impressed with the services offered there.  If there are problems, the women are sent here to the hospital.

Friday was particularly interesting- we hosted "Fistula Camp" and operated on 7 complicated fistula cases in a single 13 hour day.  A well-known fistula surgeon flew in for the day from Dhaka and I got a crash course in assisting fistula cases.  It's mind-blowing to think of 2 million women worldwide suffering from constant leaking and the stigma that goes with fistulas, and with poor access to labor care, more women are developing these daily. It was a great learning experience to assist on these repairs, and meeting these women was a reminder of how critical it is to have access to proper intrapartum care.

And just like that, I have reached my last day at LDL. This week, I have gotten to see a few repeat patients and it has been fun to have some continuity in my short time here. Both were newly diagnosed CHF patients that are undergoing diuresis and it has been so satisfying to see how much better they are doing with just a week or 2 of treatment. As I reflect on my time, I remain so impressed by the work that I see the long term missionaries doing here. I would have a day where I frequently got interrupted and would be annoyed, then I would go interrupt my preceptor, who would be interrupted about 4 more times during my interruption and just take it in stride. More and more patients are accessing the hospital from outside of the local area because they don't trust the care elsewhere, or the cost is too high. These providers continue to prioritize their local patients, but they remain patient focused when they turn people away or when they make exceptions for outside patients. At their hearts, they want to serve their community the best they can. I am impressed by the skills of the different providers. It has been especially inspiring to watch the teamwork that occurs when more acute issues come up. I have seen firsthand how everyone comes to code blues and rapid responses, all troubleshooting together. I have been a part of 2 complicated deliveries where people rallied to create both neonatal and maternal teams. Yesterday, a patient around 35 weeks went to section. She had been admitted for several days of monitoring because she initially presented with maternal fever and fetal tachycardia in the 200s that converted with maternal dioxin. She was induced after her NSTs showed late decelerations with contractions and her temperature again began to rise after discontinuing antibiotics. When she developed persistent fetal tachycardia with minimal variability, she went to section. I was there to help with the baby's initial resuscitation along with 1 family medicine and 1 ER doctor. With the baby stable, I went to finally share lab results with a clinic patient that had been waiting for a couple of hours. While there, I heard calls for the pediatrician and figured something had happened. As I wrapped up with my patient, I was approached by one of the nurses to help with another clinic patient whose provider was in the same cesarean delivery. I was able to pop my head in and discuss the patient with him, then begin to work on her counseling and medications before she headed back up the mountains. When her appointment was completed, we went back to see the baby. I watched the pediatrician guide the family medicine doctor on his umbilical line placement. I heard the ER doctor confirm the appropriate dosage for the medication. I watched the nurse run to the pharmacy to evaluate which IV antiarrhythmics we had in stock. The tech came in to perform the chest x-ray to check line placement. The baby had initially received adenosine, but the heart rate remained in the 250s. The 2 family medicine doctors, pediatrician, and ER doctor discussed what medications we should try next and at what doses. It was decided to repeat adenosine because the umbilical line was initially too distal. The dose was also increased. The baby converted immediately. The decisions and treatments happened as a team and were wonderfully successful. I am not sure if international medical mission work is something that I envision for my life fulltime, but it has given me an opportunity to see how important it is for the long term missionaries to have providers that can come to help lighten the load when a long term member leaves on furlough. It has been a pleasure to be a temporary team member here.