Tropical Ulcers (Mostly a completely medical post)

Tropical ulcers. Pretty much a small epidemic in the wet seasons here. Stage One- a pustule, or neglected cut. It seems that any tiny wound like a blister or deep scratch which flies are immediately attracted to will become an ulcer. Stage Two- progression of the pustule to form an acutely painful ulcer with a raised, thickened, and slightly undermined edge. This ulcer grows rapidly for several weeks. A bloody discharge covers the grey slough on its floor, the skin around it is dark and swollen, and muscle, bone, and tendon occasionally lie exposed in its base. Yuck! After about a month or two, the pain, swelling, and discharge improve, and it either heals, leaving a thick scar or it goes on to the next stage. Stage Three- it becomes chronic, and resembles any other long-standing indolent ulcer which over time can cause permanent physical problems. 

Most of the kids in Lormoruchbae (and I would be so bold as to say most of Karamoja) have at least one of these and, like the photo above, some have four or more. I really believe it has to do with the flies. Poor hygiene contributes to the problem but I've had two of these wounds and I use antibacterial soap. However, I don't always get little cuts or blisters covered right away and within minutes the flies on it are enough to drive one insane. I've learned these ulcers are disproportionately painful for their size and I now have a lot more sympathy for my patients. I've also learned (through trial and error on myself mostly) that wet-to-dry dressings are the most effective. (And before any of my nursing friends start to leave me a heated note in the comments section I would like to say I am actually aware that improving practices are telling us that there are much better alternatives to the old school wet-to-dry dressing but please keep in mind that I live in a place where most people still consider penicillin injections to be revolutionary and I don't have access to better options.)  But these dressings need to be changed at least twice a day. When I started doing just a few bad ones last time I was in Lormoruchbae I did 29 wounds before I ran out of supplies. And that was just one morning! 

So, I went out and bought gauze and tape by the kilo. (Literally. You can't get 2x2s or 4x4s here. You get a 1, 2 or 5kg roll of gauze and cut it how you need it.) I packed sterile saline squirts, antibacterial soap, and everything a person needs for a week of dressing changes in a bag. I haven't gone back up north again yet but I plan to run all of this by the VHTs and see what can be done about this little epidemic. It may be a complete flop but it might work.....

Now I spend my free time making 2x2s for wet-to-dry dressings for legs. 

Mud

How is it we are nearly finished with rainy season and I haven't complained about the mud yet?! I guess I'm getting used to it.

Can't believe I got stuck in this tiny mud patch between Nakayot and Lormoruchbae but my tires are pretty worn so they tend to slip down into the ruts and just spin.  And the ground on either side of the road is just too soft as evidenced by the last time I tried to pass through here.  

But this kid helped me toss some sorghum stalks under the tires and that little bit of traction is all it took to get out. I love it when there is no pushing required.

Got out and waded through this one to look for something for the tires to grip.  My translator was being his normal helpful self by playing with my camera while waiting for me. 

If this is all I'm stuck this season I'm quite happy with it. 

Happy Mother's Day!

I know! I'm like a week months late but computer time has been limited. I actually spent mother's day packing birth kits for the midwives in Nakayot.

A huge thanks to all of you (specifically Dar VanOveren) who gathered supplies for me, bought baby blankets, or knit hats and sweaters. The plan was that each pregnant woman in Nakayot would receive one of these to use at birth.  Unfortunately, they deliverer far more babies in a week than I can supply kits for but I know that each kit has extra gloves, the midwives save the antibacterial soap and boil the razor blades so each kit serves several deliveries. 

Traditional birth attendants training

I don't have any good pictures for this post because the TBAs (traditional birth attendants) seem to hate it when I bring out the camera so you'll just have to tolerate these internet ones.
This post is about the most recent training. The TBAs have no problem telling me they think I'm FoS sometimes and this week was no exception. But it is good because at least I know where I'm at with them. The topic was measuring fundal height to estimate fetal age, or "counting the belly to know when the woman will produce" which is roughly how it was translated. The very first thing I needed to establish was that all pregnancies are nine months long. Nope. I clearly have no idea what I'm talking about. 30 minutes and two personal accounts of pregnancies of 11 and 13 months later, I finally just moved on.
We discussed how at 4 months the top of the uterus is two finger widths below the belly button and how each month adds two fingers. I had wandered the village before we began and asked 3 pregnant women to join us. They practiced on these ladies and got it with no difficulty. Then I took it one step further and explained that because we know they will be pregnant for 9 months, when they measure 8 finger widths above the belly button the baby is about to come. They were still not convinced. I suggested they watch the women we measured and see if I was close to right. Next training we will discuss.

But I took it one step further and got out tape measures and told them they could get even more specific. That women gain 1 cm per week and that the numbers correlate so if a women measures 28 cm she is 28 weeks (+/- 2 weeks). Clearly I'd lost them and suddenly it hit me why. "Who knows how many weeks are in 9 months?" Blank stares. "How many weeks are in a month?" Some discussion in Kjung. 2 to 5 depending. Ummm. I tried explaining there are consistently 4 weeks in a month. They didn't completely buy it but they let me continue. I tried explaining that pregnancies are 38 or 39 weeks long so that a woman who is putting on weight normally can be expected to deliver when she is about this size. The whole purpose of this training was to help them see that if they are measuring women over the course of the pregnancy and they are not growing as they should they need to refer them to the clinics. I'm not sure they completely got my points but the discussions were fun....

Ajiko Sarah

This is a new post about Sara, who is a person I've been paying for trade school training for years because she has a pretty serious physical handicap. (Previous posts about Sarah here and here.) I've actually started this post repeatedly and really don't even know exactly what to write. Sarah has gotten pregnant. I'm trying not to be judgmental or angry..... Yet I find myself listing off in my head all of the reasons this was terrible. 

1.) This could very possibly kill her. If there was a category for higher than a high risk pregnancy she would be in it. She breaks bones regularly so the likelihood that this pregnancy will break her pelvis or back is high. I'm not sure how her bones will tolerate the 30 pounds she will need to gain. 

2.) The baby could possibly have the same terrible disease she does. That is, if the baby even survives until birth. 

3.) She lives 10km from the clinic where she has to go to get prenatal care. She certainly can't get herself there. 

3.) Her family can't feed all the mouths it currently has. Two different NGO's give food, medical supplies or pay school fees for her family. How are they going to care for one more?!

4.) There is no father. Well, there is a father. This wasn't an immaculate conception or anything.  But Sarah had relations with no intention of getting married. He is a 16 year old boy (4 years younger than her) who has not yet completed school.   

5.) The training program she is in is run by catholic nuns so because she isn't married she has been kicked out of the program. They don't keep this rule a secret. Everyone knows it. She won't be allowed to complete and get her certificate. 

But she wanted to get pregnant. So she did. Now she expects me to help her. 

She is 5 months along. So far no complications. I check on her every two weeks and once a month I go out and pick her up and take her to the antenatal clinic. This month I also got her appointments with a neonatalogist and the doctor who will preform the c-section. We had a meeting and decided on the absolute earliest date they could possibly take the baby. 

I really struggled this week with frustration with her as we rode back and forth from appointments and spent hours sitting in waiting rooms. As I was dropping her back off at home I realized that even though we saw three different doctors over the course of the day no one had done FHTs or measured fundal height. (This actually isn't all that surprising and could be the topic of a whole different post.) Because I keep my own chart on her to keep things straight in my head, in the dark little hut she sleeps in we did one last exam for the day. When I said, "that is the baby's heartbeat, strong", she lit up. And I realized that I've been so frustrated and discouraged that I had never really thought of her as a young mother, really excited about having her first baby. I'm trying to be less judgmental and filled with more grace.....