Rising M2, Emma Lawrence, shares her Summer 2012 experience in Ghana
Unlike past trips to Ghana, my primary responsibility this summer is research. Along with a University of Michigan undergraduate student, I am based at Komfo Anokye Teaching Hospital, a large tertiary care center in one of Ghana’s busiest cities. The hospital is a maze of crowded wards, hurried health workers and an unrelentless inpouring of patients. I spend my time in the “A ward”, a 4-floor block dedicated to OBGYN. The high-risk antenatal ward, where I recruit patients and follow up on their care, is constantly hovering at the brink of barely controlled chaos. Physically, the room is bursting at the seams with laboring patients; hospital beds are always full and the doctors weave among the extra mattresses squeezed into every spare space, attempting to hang IVs from window sills and examine the women as they lie on the floor. Women are rushed from nearby hospitals in the throes of eclamptic seizures, with blood pressures at impossibly high levels, and with obstetric histories full of loss. Last year, the hospital averaged 33 deliveries a day, a staggering number by any account.
My research involves the implementation of cardiotocograph monitoring, a form of electronic fetal monitoring that is routinely used in the United States. The 20-minute test produces an EKG-like print out and the strip can be interpreted for characteristic patterns of fetal heart rate, fetal movement, and uterine activity that suggest fetal acidosis and hypoxic distress (basically, blood flow to the placenta is reduced and the fetus is not getting enough oxygen). In an effort to reduce the staggering number of stillbirths at Komfo Anokye, the monitors give an inside look into the health of the fetus and allow doctors to take action, by inducing labor or performing a c-section, in the critical period that precedes fetal death. My research is focusing on women with Pregnancy Induced Hypertension, Pre-Eclampsia and Eclampsia to analyze whether the presence of cardiotocograph monitoring will improve birth outcomes. I am pulling data from hundreds of patient charts from March, April and May, which will serve as historical controls for the monitored patients in June and July. The charts are mismatch piles of laboratory reports, doctor’s notes and nurses records; an agglomeration of discrepancies and indecipherable handwriting bound together with staples and green twine.
My work has been both fascinating and challenging on every level. We started with a bare room and a hospital staff largely unfamiliar with the indications and interpretations of cardiotocographs. After countless phone calls and meetings, endless trips to the ATMs, and an impressive battery of stabilizers, surge protectors, voltage transformers, and socket adaptors, the “fetal assessment center” is newly equipped with patient beds, privacy screens, 3 cardiotocographs, and an ultrasound machine. An additional 15 cardiotocographs have been distributed to OBGYNs in two of Ghana’s other major teaching hospitals and to 6 district hospitals.
After the physical parts of the center were completed, we moved to the more challenging aspect of the project: integrating a new technology into the care, referral and reporting protocols of already overextended physicians, many of whom have never experienced cardiotocographs apart from a diagram in a textbook. I am working closely with a senior OBGYN specialist here at Komfo Anokye whose training at Michigan’s perinatal assessment center I funded through a global health grant. Building upon his experience at Michigan, similar training experiences of 2 other Komfo Anokye colleagues, lessons learned from a similar center in Ghana’s capital city, my own shadowing at Michigan’s perinatal assessment center, and the pages upon pages of textbooks and articles and bulletins that we collectively read, we began to piece together a comprehensive protocol. The protocol combines evidence-based practices from leading OBGYN groups in America and Canada with the terminology and resource-constrained realities of Komfo Anokye. It links specific combinations of indicative patterns of fetal heart rate (described in terms of baseline, variability, accelerations and decelerations) with practical care interventions ranging from repeating a reassuring cardiotocograph in another week, to a women being rushed into an emergency c-section.
In the past weeks, we have created a comprehensive training and protocol manual, led a lecture at Komfo Anokye’s OBGYN “morning meeting” for 45 doctors and residents, led a day-long, hands-on training for district hospital OBGYN and nurse midwife teams who received cardiotographs, developed and made countless revisions to physician referral and reporting forms, invited groups of nurses into the center to learn about the technology, organized small group teaching sessions for over 60 clinical medical students, and trained an employee to run the center and continue to collect data after we leave in August. Despite the strides we have made, we are just scratching the surface.
Doing this research and working with patients has been a clash of emotional highs and lows. I've shared in the joy after finding fetal heart beats for women whose doctors cannot pick them up with basic fetoscopes, and exchanged hugs and laughter with women who bring their new babies back to the fetal assessment center to visit. After running close to 100 strips, I still dread the feeling of sitting across the room and hearing the mother’s cries through a contraction closely followed by the terrifying slowing thump of fetal heartbeat; a pattern I’ve learned to identify as indicative of fetal distress. With my own heart racing, I check the on-duty schedule for doctors who understand how to read the strips, knowing that more often than not I will be rushing into the operating room in search of a doctor. On a daily basis, I struggle with the ethical dilemma of my own place in the hierarchy of medicine (as a rising second year medical student with no business making critical care decisions) and the conflicting realization that the doctor I’m sharing a strip with might not understand the importance of the lines and wiggles and black marks that now mean so much to me.
After finishing my first year of medical school with a short sequence on embryology, words like “spontaneous abortion” and “intrauterine fetal death” conjured images of blastulas and gastrulation and balls of implanting cells that seemed only remotely connected to the idea of life and birth. However, as we began to monitor patients, these words and numbers that we pull from patient charts and enter into our data collection forms have taken on a new reality. During our first week, I was doing a repeat cardiotocograph on one of the few women who spoke enough English to carry on a conversation during the 20 minute test. We were joking around and chatting about her new shoes as I moved the transducer around her abdomen to locate the fetal heart beat. At first, I attributed the lack of heart beat to my own poor skill. I could feel the baby’s back and the head firmly under my hands. And I could remember the reassuring flutter of her baby’s heart beat last time we met. I slowly and systematically moved the transducer across her abdomen, willing the monitor to turn green produce a reading. Finally, I called a doctor to confirm the death via ultrasound, and watched, frozen, as he shared the devastating news with his patient. 176 charts later, even with women who I only know through a messily scrawled history, I still get a lump in my throat when I read those same words.
When I stop by on the weekend to monitor a single patient and end up leaving 8 hours later, I leave exhausted and invigorated and emotionally drained and so deeply amazed at the dedication and fortitude of the physicians here. I know that medicine is never easy anywhere, but I cannot imagine that most doctors in America will have to help a women deliver in a chair because the labor beds are full or manually squeeze bags of saline into a women dying of septic shock or induce labor in an eclamptic women to save the mother’s life, knowing full well that the baby will die here in Ghana because of the limited capabilities of the NICU.
I have grown enormously from this experience. Despite the amount of information I seem to have forgotten just days after our medical school exams, being here has allowed me to appreciate the enormous gain in understanding I have made in the past year. Whether it’s watching the surgeons suture layers of fascia after a c-section or quizzing the Ghanaian medical students as they study for their clinical exams or sorting through the previously unknown “alphabet soup” of the patient charts, I realize both the remarkable gains in knowledge my classmates and I have made, and the enormity of what I have left to learn.