Thursday, May 11, 2017

OB/GYN AT SCOTTISH LIVINGSTONE HOSPITAL: MOLEPOLOLE, BOTSWANA

Anuja Singh
Resident in OB/GYN at MGH/BWH
PGY3

OB/GYN AT SCOTTISH LIVINGSTONE HOSPITAL: MOLEPOLOLE, BOTSWANA 

A day at Scottish Livingstone Hospital in the OB/GYN department is a whirlwind. Scottish Livingstone Hospital (SLH) is a 200-bed facility in Molepolole, about 60 km from the capital Gabarone. There are 4 hospital departments: Medicine, Pediatrics, OB/GYN, and Surgery. The day starts with a hospital-wide morning report – a recounting of what happened in the night – given by the two medical officers and one intern that staff the entire hospital during those hours. After this update, everyone would go to his or her respective assignments for the day.
My schedule varied from day to day, echoing that my mentor and former chief resident, Dr. Rebecca Luckett. Rebecca is an OB/GYN who also trained at BWH/MGH and moved to Botswana with her family shortly after completing residency. She has now been there for a bit over a year and has become an integral part of the hospital and a respected leader there. Rebecca and Suzie Anderson, an excellent OB/GYN who started her training at SLH and completed her residency in South Africa, are the two OB/GYN attendings at the hospital. Rebecca’s phone is going off throughout the day and often the evening, with doctors, trainees, and staff from SLH and from throughout the district it serves calling to get her opinion, advice, and help. She is uniformly kind, thoughtful, and helpful, somehow managing never to sound rushed or flustered even when three people are talking to her almost at once, as she also sees a patient in clinic. 

On Monday and Wednesdays, I joined Rebecca in clinic, seeing patients referred for gynecology and high-risk obstetrics care respectively. Tuesday and Thursday were OR days. Walking in to the Sexual and Reproductive Health Clinic (SRH) on those clinic days, women, often with children would be filling rows and rows of seat in the waiting area and milling around outside. We would walk in to the exam rooms with women already lined up, ready to be seen, outside the door, clutching their health cards. After the first week or so, Rebecca and I would see patients in different rooms, splitting the 30-40 of them between us. From a woman with multi-fibroid uterus the size of a 30-week pregnancy desperate to become pregnant to the 60-year-old HIV positive woman who came in with a little bleeding and we found to have a cervical mass filling her vagina, I was challenged and humbled by the patients I saw. I was impressed both by their strength in the face of hard news and a difficult course forward and the immense amount of work, organization, persistence, and creativity required to take care of them in a world without ready access to a robust blood bank, infertility therapy, or easy access to oncology care.
 
Tuesdays and Thursdays in the OR were of course interesting and challenging in different ways. The ORs in many ways looked on the surface much like our ORs here at BWH/MGH and functioned, in many respects, similarly as well. Rebecca’s cases, too, were typical gynecology cases – from dilation and evacuations and marsupialization of cysts to myomectomies and hysterectomies. Key differences, however, made me think about surgery in new ways. First, while SLH has a blood bank, the blood bank does not always have blood. Before doing a large surgery, especially one like a myomectomy which can easily have a significant blood loss, it was critical to make sure the blood bank was aware and equipped and, finally, that they had not had to give those precious units of blood to someone else that came in overnight. In addition, while I think of anesthesia care hand in glove with ORs as if they somehow travel together, this was a definite challenge in Botswana. There are simply not sufficient trained anesthesia providers. Medical officers, in fact, are proficient in admonished conscious sedation, something I have never done after three years of residency in the US. For larger cases, however, this is clearly not enough. SLH has two anesthesiologists and one nurse anesthetist, making their call one in three nights. In this setting, it is not uncommon to have insufficient anesthesia support for scheduled surgeries come early afternoon, a challenge for Rebecca, the medical officers, and, especially, the patients, who may remain in the hospital for several days waiting for their surgery.

Friday is more flexible, allowing more time to be spent on the inpatient services. Nurse midwives largely manage Labor and Delivery, calling when they need help. The Antenatal Ward is generally the one most demanding of attention, with women there for everything for rule out labor to severe pre-eclampsia to rupture of membranes early in pregnancy and TB sepsis. Like in the US, rounds involve review of the data, patient evaluation, and making a plan for the day. Diagnostics, however, are obviously more limited and, given the tight resources, significant dedication and follow-through are required to get labs, x-rays, and ultrasounds done, particularly in a timely fashion. For instance, Interns and medical officers do all of the blood draws. While there is a system to transfer specimens to the lab, it is not uncommon to find tubes of blood in the ward cooler at the end of the day, so if information is needed, it needs to be run down to the lab personally.
The day and the week thus pass in a blur of clinic, wards, and surgery, each day full and sometimes exhausting but immensely rewarding.


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