Arrival in Mauritius

"I am writing this note 'standing' as I have not had time to sit down."

That is an excerpt from a handwritten letter from my great grand-uncle, Father Jack Egan, to his brother and sister-in-law, my great grandparents. It is dated September 1935, but I feel as if I could be writing those same words to my family today after the past week. Several days ago, my wife Megan and I arrived in Mauritius after a lengthy travel itinerary originating in Colorado, involving stops in New Jersey and Paris, and terminating on this small island in the Indian Ocean. It has been a tiring week, but we are grateful to have arrived at our destination safely. I am grateful beyond measure to all at North Colorado Family Medicine, my family, and everyone here in Mauritius who has made this trip possible.

When informing querying parties of my summer plans to travel to Mauritius over the past few months, I was frequently met with looks of bemusement and the common question, "Why Mauritius?" These unfortunate individuals were then met with a long, detailed explanation that involved an account of my genealogy, tales from a newlywed year spent in Ireland, and finally, the explanation that my great grand-uncle, the aforementioned Father Egan, was a priest who lived in Mauritius for approximately 30 years of his life. He died here about 50 years ago, and he is buried at the parish church of St. Julien in eastern Mauritius. Ever since I heard about Uncle Jack as a young boy from my grandmother, his tale captivated me. He seemed to be a man of great principle and devotion who was willing to move far from his home in pursuit of a greater, higher cause. He was born in rural Ireland in the early years of the 20th century. Later in life, he entered the seminary in Paris and was eventually ordained as a member of the Congregation of the Holy Spirit, a Roman Catholic order of priests. Shortly after his ordination, he was sent to preach and serve the people of Mauritius, where he would spend the rest of his days as a true man of the people. My mother recalls meeting him several times when she was a young girl and he came to visit New York, and her vague memories endorse the image of the gregarious, spirited, humble man I have encountered in the letters, documents, and stories I have gathered over the years pertaining to his character. 

I must, unfortunately, bring this post to a premature close, as the hour is growing late and I am to arise early to attend surgical cases tomorrow morning. I find my time limited these past few days, as if I have "not had time to sit down." I will end with a brief description of the past few days and what I hope to accomplish over the next several weeks. I have now spent several days working at the Clinique du Bon Pasteur, a private clinic in Rose Hill, Mauritius, where I will be completing my international clinic elective. In the few short days since I started, I have worked in the emergency department, operating theater, and with the community outreach team. I have already encountered skilled physicians who very graciously have taken the time to teach and mentor me. Over the next few weeks, I hope to explore this faraway island and learn about the practice of medicine here. I hope to learn a great deal from the physicians with whom I am working and the patients who come to the clinic seeking care. And of course, I am hoping to better understand my uncle, Father Jack Egan, to hear stories of his life from those who might have known him, and to behold the grace and resilience that enabled him to leave his home in order to serve where he was needed.

A bientôt,
Tom

Below, some photos from what Megan and I have been up to over the past week. In order:

                                   Beautiful church on the water where we attended Mass last weekend

                                        Clinique du Bon Pasteur, where I have been working

                                         Terre de Sept Couleurs, national park in Mauritius with volcanic remnants

                                        Beautiful view of the Mauritian coast

                                         



        Église de St. Augustin, one of the church construction projects Uncle Jack was involved in on the island

Bangladesh Update #4

After an incredible month, I’m headed back to Colorado now.  I finished by squeezing in a twin C-section the morning I left (and running from the OR to catch my car to the airport). 

I certainly saw a lot of unforgettable things this past month, met several doctors who quickly became role models, and gained a valuable experience in adapting to a very different obstetrics environment!  Babies really do come out the same general ways regardless of where you are.  But the amount of antenatal care is drastically less.  First trimester scans are rare and dates are generally uncertain.  The way people communicate about labor progress is different – I learned to judge effacement by centimeters instead of percentage and station by feeling the pelvis, not by cervical exam.  In fact, I gained valuable examination skills in so many areas – with little advanced testing available, physical exam is critical to making good clinical decisions.  Breech babies don’t always come out by C-section here.  In fact, transverse lie babies sometimes come out vaginally too if they’re small IUFDs (shoulder first?).  Eclamptic seizures happen.  Sometimes a patient comes in with an IV from some village clinic with who knows what prior treatment. The partograph system for plotting labor curves that I’d only witnessed in action a few times before is used in every labor here – figuring out the advantage of this system, its pitfalls, and how to use it clinically was really important!  I’m still working out the nuances of this, but as the partograph is used worldwide, I know this will be a very useful skill.  C-sections are basically the same…just with different clamps and different needles in a different operating room. I’m certainly a better surgeon after this month for having learned to be flexible with equipment.  

And there are the more general skills – learning to work with a new team that involves various levels of doctors & midwives, changing my personal patient organization system to fit the quantity and constant movement between beds, figuring out a successful communication style with my limited Bangla.  And learning to emotionally cope with tragic outcomes and higher rate of IUFDs than we would typically see in the US with all of the monitoring and testing that is able to be done.

So again – I can’t say thanks enough to the amazing LAMB team who took me in and taught me so much!  I’d certainly love to go back someday to LAMB or a similar setting, and despite the challenges, feel that my interest in going long-term to a hospital in a low-resource area overseas has been confirmed this month.  I’m looking forward to sharing more details & stories when I get back to Colorado!

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.

Today was a sad day in LDL. I was planning on sharing about this pair of patients, but I was hoping it would be a better outcome. A patient, K, that had been staying in the discounted housing near LDL for the last few weeks delivered on Tuesday night. She has sickle cell disease and was having multiple sickle cell crises throughout pregnancy. Then she had the misfortune to developed severe preeclampsia and possible HELLP syndrome at 30 weeks gestation. LDL has never had a baby under 30 weeks survive, and few below 3 pounds survive. K was counseled on her risk and her risk to her baby. I placed her cytotec on Tuesday night and we started her on magnesium. There are only 2 nurses and 1 CNA at LDL overnight covering the entirety of Med Surg, Labor and Delivery, and the ER. We discussed that for safety reasons, one nurse would have to be committed to Labor and Delivery. If they were overwhelmed, they would have to call in a second nurse or call me in. She did well overnight and made it to the following day with little cervical change. K was also severely anemic and had a rare antibody that was being explored that made any transfusion highly risky for reaction. The decision was made to perform a cesarean delivery for K. I watched the providers at LDL work together to coordinate the delivery of blood for K from the Red Cross across the country, a process that required the blood to be flown and then driven about 1.5 hours. LDL also doesn't have surfactant, but they were able to get it from the town 1.5 hours away because they were anticipating this delivery. As soon as everything was available, we proceeded with the cesarean delivery. The team included 3 operating providers, one provider administering anesthesia, one scrub nurse, one nurse primarily for the baby, and 4 providers committed to the baby's resuscitation. I watched the ingenuity of the baby's providers as they prepared a bubble CPAP using a canister of water, tongue depressors, and a Y connector for oxygen. It was one of the fastest sections I've seen and it included a tubal libation per the patient's request. She is 25 and this was her first pregnancy, but she decided that a repeat pregnancy would be too high risk, despite knowing this baby had a probable less than 50% chance of survival. Her suction canister had no more than 100 cc of blood in it. The baby had an initial Apgar of 0 and was briefly intubated, but was able to be transitioned to CPAP. He was placed in a Ziploc bag for temperature regulation. He had an umbilical line and NG tube placed. He received his surfactant. He weighed just over 2 pounds. The team was hopeful but cognizant of their last early premature infant that died at 48 hours of life. LDL doesn't have the luxury to ship babies to a different hospital because they are not a level III NICU and cannot take babies under a certain gestational age. So they get creative and work as a team to do everything they can to give baby J the past chance he can get. He was undergoing phototherapy on Thursday. He was stable on CPAP and maintaining his temperature with the warmer alone. He was strong with an opinion. He made it past 48 hours. But this morning, the nurses called a code blue. When I walked in the room (the first provider to arrive and probably the one with the least amount of NICU experience), his oxygen saturation was in the 40s despite bag masking him. He had likely become apneic and there wasn't a quick enough or adequate enough response despite one-to-one nursing. We struggled to get his oxygen above 70% and it was often below 50%. Blood prevented adequate visualization for intubation. His heart rate started to slow. A tech was called in for a chest x-ray. They attempted needle decompression for possible pneumothorax. He got fluids and epinephrine. They had caffeine ready. But he wouldn't breathe on his own and we could barely maintain his saturations even with good chest rise. He was finally intubated but with no improvement. So we took out his tubes and his family came in to hold him as he died. Would he have died in the states? I don't know. I watched heroic efforts and creative thinking. I watched a team commit to this patient. It was beautiful and tragic. I hoped to talk about how well he was doing with his limited resources. I still think incredible work happened for him. But would he have died in the states?