We got an early start today, which meant that we were able to see more patients than yesterday. Tomorrow (and for the next week) we will continue to evaluate women, but we have probably seen close to 100 women in 2 days. Pretty amazing, all things considered. Let me tell you a little more about the process.
When the woman arrives at the hospital, she is interviewed by a Rwandan medical student, who completes a form for our records and for the hospital record. It is not the same medical history that we take in the US, but it’s similar. We just need to know the basics: is she leaking stool or urine, when did the problem start, has anyone tried fixing it before, does she have living children (in women with fistula, many of the babies die during the delivery)? There are also questions we never ask in the US: does she have tapeworms, malaria, or HIV? I would say that about 30% of our patients have tapeworms (they don’t need a test for that…they just know), and we must treat them before we operate.
Then the woman waits for her name to be called (for one to two days) and the exam is done. As I mentioned before, there are a lot of people in the exam room. After the exam, the woman is told that we will discuss her case and will let her know the plan; she must wait for her name to be called again, usually within 1-3 days. We briefly explain that we found the problem and there is surgery available (or medication, less commonly).
We re-use the same exam supplies for each patient, which was pretty shocking the first day. We rinse the instruments in a basin of water, rinse in a germicide (Cidex), then rinse in water. It’s the same speculum, catheter, forceps, etc. We don’t change the rinse water. We use a fabric sheet on the bed, and just move it down the bed as it gets wet. It’s just not feasible to use clean/sterile supplies with each patient.
Women who are not surgical candidates are also told to wait for a plan. Today, we gathered 14 of these women together and one of the MDs spoke to them, through a Rwandan medical student. He explained that their fistula cannot currently be fixed in Rwanda. He tells them that they should not continue to seek care until there is a radio announcement that care for women with inoperable fistulas is available. The reason for this is that we don’t want the to see a less experienced MD who might operate on them, not fix them, and leave them with leakage, scarring, pain, or worse. While treatment (in the US) is available in this situation, the lifetime follow up care required for women with complicated fistulas is not yet available here.
Being present for this talk was one of the saddest moments I have experienced thus far. Many of the women were visibly upset, one cried quietly through the entire talk. We gave them handmade waterproof underwear and cotton padding, made by women here in Rwanda. I spoke to them about caring for their skin, washing and using Vaseline, but I have doubts that they can afford such luxuries. I mentioned cooking oil as an alternative, but most women said they do not have oil. Or water to wash their clothes. Or extra cloth to use inside the new underwear. I asked about sex, but the student explained that these women do not have sex because their husbands have left them.
For women who are operable, their is more hope. We start operating tomorrow, and I look forward to some success stories. Being here is sad, inspiring, humbling, and a good reminder that I have so much to be thankful for; like water and cooking oil.