Tuesday, January 30, 2018

Life as a Missionary PT Part 3: Clinic Visit and Diagnostic Testing

This is part 3 of a series of posts about what my ministry is like.

Remember, I'm just sharing my personal experience with this particular hospital in this particular country. Other missionaries at this same center will have different viewpoints, as will missionary PTs serving in other places.

When I get to the center on Tuesday mornings, I change into scrubs (us women can only wear scrubs during Tuesday clinic and while in the operating theater. The rest of the time we wear long-ish skirts as is culturally appropriate) and make sure there are enough copies of all the forms we'll need in clinic.

I love sitting in on clinic because 1) I can dialog with the physicians about which patients might need therapy, and 2) by filling out forms and scheduling patients in the surgical schedule, I can keep clinic moving faster.

As we're getting set up, one of the aides will bring in water to fill our instrument sterilization containers. While there is an autoclave and sterile instrument packing protocol for instruments used in the operating theater, we use a system of bleach water and soapy water with timed immersions to sterilize our instruments used in clinic.

This is what our clinic room looks like. It's not big at all, but it works for us. I love the fact that the VVF center is built up about 8 feet above ground so that we can keep the windows open for natural light (and to help us get a better view of the fistula), but no one can see in. We do have one tiny ceiling bulb and a ceiling fan we can use when the electricity or the hospital generator are on, but it doesn't do much good.

I sit in the corner (back left in this photo) so I'm out of the way and can fill paperwork.

Later, one, two, or all three of our fistula surgeons will trickle in, as well as one of our nurses who serves as an assistant during examinations. Ladi will poke her head in the room and hand me the patient's brown card as well as the intake questionnaire form she's filled out. I get started filling out their examination finding form, we'll call in the first patient who's sitting out in the hall and clinic begins.

Fistula is an abnormal opening between the bladder and the vagina through which the woman leaks urine uncontrollably (because there's no sphincter to stop the urine as there is in the urethra), but that fistula can occur in many different locations. The most common cause of fistula is prolonged, obstructed childbirth where the baby's head presses on the mother's internal tissues for a long period of time, cutting off blood supply, and resulting in that tissue dying off--causing the hole.

In order to get a good idea what the surgeon will encounter during the operation, and to decide whether the surgery can be done through the vagina or must be done via a more complex abdominal surgery, we have to actually see where the fistula is. To do that, we insert a catheter into the bladder and then fill the bladder with purple dye. Usually, it's pretty easy to see where the dye is leaking out. 

Then we drain the rest of the dye out and the exam is done. As she's getting re-dressed, we'll discuss when to book her surgery, I'll fill out the scheduling book and her reminder slip, and one of the physicians will fill out the exam findings form. We hand the reminder slip to the nurse who either explains to the patient in Hausa or if she speaks a tribal language, we call in the family member to translate for her. Often, the exam is done in less than five minutes and the whole visit is less than ten minutes. 

If the fistula isn't immediately visible with the dye test, we may ask her drink water and come back in an hour. If she's recently delivered her baby and the fistula is fresh, we might just leave the catheter for two weeks and hope the bladder can heal on its own. Or if her case has failed all surgical attempts, we may send her the head nurse and to the chaplains to discuss a radical and permanent solution that diverts the urine from the kidneys elsewhere. Thankfully, this center has surgeons who are trained in performing the more complex cases and our team works together both in clinic and while the patient is in surgery to come up with the best solution for our patients.

Sometimes, a woman will come back and say that she's still leaking. We may find another fistula that we missed or, as is often the case with the larger fistulas, has converted to a pinhole fistula. We schedule these women again for repeat repair surgeries.

We also have patients that come for their 3-month or 6-month followup visit that say they're dry! We're always happy to do a quick exam and make sure the surgical site looks good, answer any other health questions they have, and clear them to "meet with their husbands again."

If, during Ladi's interview, the patient is complaining of urine or stool leakage but we can't find a fistula with the dye test, then we start thinking about using medication or sending her to me for pelvic physio. Often those patients leave the clinic room a bit discouraged because they thought they'd get another surgery, but yet we're saying there's no structural reason for the leakage. 

And then there's usually one or two each week who come into the clinic room with a smile on their face and a bulging belly! They've come, just like we told them, to get a referral card to the antenatal (prenatal) clinic and schedule their cesarean delivery--all of which is free of charge to them because of our gracious donors. Often what caused the VVF in the first place was the fact that she had a small pelvis, so we don't want her to try to deliver naturally again. Or if she's had a VVF repair, we want to protect that repair site and not risk it breaking down again during delivery. 

We have all sorts of women come each Tuesday, each with her own history of fistula onset and her own course of treatment. We are also blessed to have a medical team that's highly skilled, collaborative, and that trains the more inexperienced members so we can correctly diagnose and treat these women.

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