Monday, December 14, 2015

Culture Clash



Last week, I ran smack into a very difficult culture clash that broke my heart.  I arrived at the clinic to start work.  We began to see patients when Dr. Sana got a call to run to the next village to see a patient.  He left me there to continue on my own. As he was leaving, he said, there is a pregnant girl out here who is suffering with pain.  Her paper was already in the stack of waiting patients.  I saw another patient, but then decided to move her ahead in line. 

I wasn't super worried about her.....We see lots of pregnant women with low belly pain due to STDs.  She was only 17 years old, 7 months along and this was her first baby.  I called her into the office and registered her in the book and began asking what the problem was.  Her pain seems more intense than an STD and she said it had started the day before.  As she lay down on the exam table, I asked if she was having any "white water" - the term we use for discharge.  Yes, she replied.  A lot? I asked.  Yes, like I peed.  That had me concerned. 

I checked her stomach and she seemed to be having contractions.  Baby's heartbeat was nice and loud.  But mom also had significant edema/swelling in her legs, she was complaining of a headache, and her blood pressure was 160/110.  I did an exam and she was dilated 1 cm.  Since no one here checks for that during prenatal visits, I had no way of knowing if that was new.  I wasn't sure what to do....I kind of wanted to send her to the hospital, but that was a 2 hour motorcycle ride away on rough roads.

I called her husband (about 18 years old) and father in and told them...I want her to start taking medicine and rest here for the afternoon.  We will see if her stomach calms down - and then we will have a better idea of what to do.  They were good with that and the dad went back to their village to work on the farm until evening, when he would return to pick them up.

I started her on antibiotics and gave her a shot for the pain.  We mixed up Gatorade and she started drinking it.  I had her lay down in a quiet room, and continued to see other patients.  I checked on her throughout the morning.  The pain wasn't getting better, but it wasn't getting worse either.

By this time, I was way past my time to go home (most days I only work in the morning), but Sana wasn't back yet and I felt uncomfortable leaving her alone.  I continued to see patients until everyone was seen.  Still no Sana.  I was getting fussy.  I was hungry and had a boatload of stuff that I had been planning on doing that afternoon.  I thought about leaving her at the clinic and running home to grab a bite to eat.  Sana's wife was there (their house is right beside the clinic) and she could call me if there was a problem. 

Something told me to stay put.  It was 3:30 pm at this point and I knew that we were going to make a decision about what to do with Dyama (the patient).  Her headache was worse and the pain shot wasn't working.  I finally was able to call Sana to ask where he was.  He said that he was on his way -which means anything from....be there in 10 min to showing up several hours later.

Thankfully this was a 10 minute delay.  He pulled in on his Moto and looked at me with a question on his face.  I pointed to mom, who was standing in the hall.  Is she in labour, he asked?

I think so, I replied....but she is only 7 months along.  And I think she has pre-eclampsia.

He headed over to his house and I decided to check and see if she was dilated more.  As I went to get gloves, I heard a loud scream from the other room.  Not good, I thought.

I grabbed gloves and laid down an old plastic tablecloth - our attempt to reduce tetanus.  I told mom to lay down.  As she did, I could see the umbilical cord sticking out.  I ran out and told Sana that I needed help.

We discovered that baby was breech when the first body part we could find was a foot.  Sana's wife Dena came in to help when she heard the screaming.  What followed was about 20 exhausting minutes of.....

-Dyama screaming and begging us to stop....having never had a baby, she had NO idea what was happening....she wouldn't lay still, making our job SO much harder.
-Dena chastising her...telling her that there were men outside the clinic who could hear her screaming
-Sana and I taking turns trying to reach in for feet and arms to try to get baby out - his little arms were stretched high above his head....and the cord was part way out so his blood supply was cut off.  Sana said...no way this baby is going to survive...but I was hopeful.

Finally we got baby delivered - strangely, the placenta came out with baby- having already detached.  He was a good sized, beautiful little boy.  He was not breathing and had no heartbeat.  I was going to try to revive him, but my delivery bag was at home with my ambu bag and I felt certain it was already too late.  I reached for him, deciding to try anyway, but Sana stopped me.  I knew he was right.

So there we stood, looking down at the mom and her baby...I had no idea what to say or how to handle it.  I was opening my mouth to tell mom how sorry I was when I saw her looking at the baby.  She said something about whether or not it was breathing yet...and I realized that she didn't know it was not alive.  Ok, I thought...let's see how Sana breaks the news.  But he just brushed her off and said, we will take care of it.  Wow, that was not what I was expecting.

We called in a distant relative - a woman for our town - and explained what happened.  We got mom cleaned up...baby laying next to her the whole time.  Finally we moved mom into the next room and wrapped baby in plastic and laid it out of sight.

We went to the office and Sana called the husband in.  He said, I want you to go to your village and get your family.  The husband said, you are scaring me.

Sana said, nothing to be worried about.  Just go get your family and we will wait for you here.  The husband left.

I was stunned ....nothing to be worried about? Seriously?

Sana said, they are both very young.  We cannot tell them about the baby until their parents are here.

Now, before you wonder about me and why I didn't go with my instincts to tell mom and  comfort her, you need put yourself in my shoes. We are guests here in this country and there are a million things about the culture that I don't get.  Breaking bad news to someone is one of them.  I have seen people lie to the face of another (there is nothing to be worried about, for example) until they feel the time is right to break the news.  We rely HEAVILY on Sana, Dena, and our other friends to help us know the correct cultural way to approach things like this.

So I shut my mouth and waited.

After about 30 minutes, I decided to go and check on mom.  I wanted to check her BP to see if it was going down.  I went in and laid my hand on her shoulder and ask how she was feeling.
Better, she said.  But where is my baby? Did that lady relative take him to her house?

I couldn't look her in the face.  I mumbled something and left the room, forgetting about taking her blood pressure.  It was awful.

I wanted SO much to sit with her- but I knew I would not be able to avoid her questions so I sat outside, tears running down my face.

It is cultural no-no to cry like that.....Sana asked why I was upset...Since it was God who had decided that the baby would not live. 

After about 45 min, the husband returned with his in-laws and a few other people.  I was still crying but trying to get it under control.  We all went into the office.  Sana explained how she had come because she was sick but that it had turned into a delivery.  But that baby was too small and didn't survive.

The dad was the spokesman for the group.  He said that he had heard, and that they were grateful for all we did.  He knew that we tried.  He then said something that surprised me....He said, "Gulunga (me) stayed here the whole time.  She never left Dyama alone.  And we thank her for that."

I was surprised, because the 18 year old husband was the only one from that group at the clinic that day....He must have been the one who told them that I had been there the whole time (made me SUPER glad I didn't run home for a bite to eat).  It never occurred to me that it would make the impression that it did.

Sana took the family to see the baby and then we all went into the room where the mom was laying .  There the dad officially told the baby's parents that the baby didn't survive (even though the baby's dad had been in the office with us and already knew).

The family thanked us again for our kindness and for me staying with her the whole time.  After a short while, all the men left, except the husband.  I went in to be with mom for a bit and to tell her how sorry I was.  A group of women were sitting there with mom, talking.  One of them said, was this her first baby?  When they replied that it was, she said, first babies are hard.  They are often taken from their mom's hand (meaning that they died).  Everyone agreed.

That might be reality but it made me angry.  I wanted to shout - but it doesn't have to be that way!!!!!  It is not like that everywhere.  That is not to say that it doesn't happen.....but it is certainly NOT the norm.

I was able to talk to mom for a few moments...telling her how very sorry I was and prayed for her....that God would bring comfort to her heart.

I went home broken hearted that day....feelings like I had failed my patient and her baby.

I known that in will never understand all that is involved in breaking bad news in this culture.
My hope and prayer is that the families will see my heart for them, and through me, Jesus's love and concern as well.....no matter how the news was delivered.