"some days you just have to hate life"

"pa-ra-check hey!"

that quote was borrowed from my friend, erin stopes, who wrote it in an email from the philippines once. i think it quite adequately describes yesterday. the other two quotes that adequately describe yesterday were uttered by my team-mates... yesterday. one simply stated "this is an awful country". the other, as we crawled into our beds at 3am, said "today was a horrible day". i agree on both counts.
where to start, where to start..... well, the biggest issue is one that, for security reasons, i can't write about, which is far more frustrating for me to write than for you to read, trust me. it's a story that will play itself out however it plays itself out, and we have no choice but to see where the tide takes us. there are a number of ways that it could end, but for now we can only wait and see. when i am home and have access to communication devices that are available only to me, i will tell the story.
and then there are the parts of the day that i can talk about.....
at lunchtime i started to feel queasy and i wondered if milena had given me her sickness from a couple of days ago. by dinner i was lying on the bed in the "livingroom" (we don't have couches here in darfur, so we use bedframes instead) trying not to vomit and wondering how sudan could possibly get any hotter. milena woke me up and asked me if i wanted dinner. i declined, saying that i felt like i was going to be sick. she asked me if i had a fever and i told her that it was quite impossible to tell in this heat...that i have felt like i have a fever for the last month. she felt my face, then went to get a thermometer. when she took the thermometer to check it she was SO excited to discover that i did, indeed, have a fever. instead of the expected compassionate, nurse-like response, she throws her arms up in the air and yells victoriously "revenge!". i guess i should explain.... three days ago, as mentioned, milena was sick. when we took her temperature and found that she was feverish, we told her we were going to do a paracheck, which we were quite excited about because hey, it's something to do. the paracheck is a test for malaria and it sucks. the kit comes complete with the test and the lancet that you use to stab the fingertip hard enough in order to get a full drop of blood. she flat-out refused to let us do it, claiming to suddenly feel quite well. as she lay, sick and miserable, on the bed, gus, monica and i made up a "paracheck dance" that quite closely resembled 'the locomotion', complete with a chant "pa-ra-check hey!". milena's response was to get up and do her own song and dance, borrowed from one of the squirrel-like creatures on the 'madagascar' dvd, proclaiming herself to be "phy-si-cally fit! phy-si-cally fit!". as expected we won, and i had to poke her finger twice as she pulled it away the first time and it didn't go deep enough. she was so irritated and monica got a great picture of her giving us the finger and looking at us like she hoped we would die :) the test was negative and she recovered. now, of course, it was my turn for a paracheck and milena couldn't have been happier. i say, first of all, that no one is doing a paracheck on me until i see the dance. they happily oblige and do the paracheck dance around the room. my second stipulation is that they have to do a venapuncture (take the blood from a vein in my arm with a syringe) as they are NOT taking it from my finger. the last time i had a fingerpoke was in the philippines when grubb peer-pressured me into it because she needed to test the new glucometer. i accidentally called her a 'mofo', which i thought was mine and bones secret swearword. i don't know who was more surprised... grubb that i called her a mofo, or me that she knew to be insulted by it :) monica was totally shocked that i preferred a venapuncture over a fingerpoke and i explain that i have no problem with needles, and i let my students practice everything on me (i.v.'s, injections, venapunctures) except for fingerpokes- fingerpokes hurt like hell. i would rather that they took it from my eyeball than my finger. so milena takes my blood, the test is negative, and i lie back down to just let whatever it is run its course.
the only problem with my being sick was that the timing sucked- i had a patient in labour. right before lunch when i was still at the hospital hawa, one of my nurse assistants, came to find me. lacking the english to properly explain herself, she took me by the elbow and dragged me to the delivery room saying something about "moya" (water) and "bleeding". a woman lay on the delivery table, and joyce (one of my khartoum midwives) explained that she had been in the market and water had started to come out, with blood. i can see that there is enough blood to concern me, so i use a speculum to try to see if her cervix is open enough to see if any placenta is visible. the membranes are coming out of the cervix and joyce is looking over my shoulder and says "that's the placenta!". i say no, it isn't, it's the membranes. she starts pacing around loudly proclaiming "that's the placenta! that's the placenta!". i say no, it isn't, it's the membranes. she's now getting mad that i'm not agreeing with her and i finally say "joyce, you are a midwife and you know what a placenta looks like. this is not the placenta so please chill out". hawa looks over my shoulder and says quietly "this no placenta". i smile at her and nod. ok i say to my staff, her membranes have broken and she needs to deliver this baby so it's time for some labour stim. i tell her she can get up, walk around, eat, drink, shower, etc. as i was talking i stood by the woman and, like a total midwife, put my hand on her belly. that was when i realized that something was definitely wrong. i turn to joyce "didn't you say she was 9 months pregnant?". she says yes, that she's 9 months. i use both of my hands now and i remove her 600 layers of cloth so i can feel her bare stomach, and i wince. i turn to my staff and say "she's not 9 months. she's not even close". we measure her fundal height and it's 24cm (in north america you can usually associate the number of centimetres with the number of weeks pregnant the woman is- therefore a full-term pregnancy would be 40cm for 40 weeks gestation. here we assume smaller babies, but you would still expect a term fundal height to be at least 34 cm). maybe i'm wrong, i hope. maybe it's just so small because the baby is so engaged. i leave my staff to monitor the labour and i go home for a very long afternoon of meetings and being sick.
after the first meeting, when we took a break lest we all kill each other and/or ourselves, i go back to the hospital to check on the patient. the bleeding has stopped and her vitals are good. leimona listens for the baby's heartbeat and she tells me that it's too slow. she beats it out with her finger and i ask if she's sure it was the baby's heartbeat and not the mother's. i take the fetoscope, place it on her belly, and listen. nothing. i move it...nothing. i move it again and again, until there is nowhere left to listen. the mom says the baby is still moving, so i choose to think that it's just my hearing loss that won't allow me to find the heartbeat.
later that evening i hear joyce call me on the radio. i step outside for better reception and tell her to go ahead. "i can't find the fetal heartbeat" she tells me. "i know" i reply "i don't think there's one to find".
i went back to bed and fell into a restless sleep until i heard my radio at 1am. joyce tells me the patient is ready to deliver and i reluctantly pull a shirt over my tanktop, still sweating and feverish, even in the cool night. milena sits up in bed and tells me she's coming with me, which i had so been hoping she would say. i felt like crap and the last thing i wanted to do was a delivery, but the midwife on call was joyce who was, unfortunately, born minus the sensitivity gene. the moment i knew that we were going to deliver a dead baby i decided that i was going to do the delivery and i didn't care if i had ebola and was bleeding from my every orifice. i was not willing to subject a woman who was on the verge of a stillbirth to a birth that was anything other than gentle.

note: the rest of this story may not be something that everyone wants to read....

we arrived and i took joyce's place at the foot of the bed, as the woman had started to deliver there. in the low light it looked like the head was out, but it seemed misshapen. i took my lantern and turned it on, and i heard milena say "what is that?" it didn't look like a head, and with further examination i discovered that the baby was breech and that we were looking at her slightly malformed back/butt. the mom pushed until the body was out and then she gave up. we sat there for awhile, waiting for her to push again, staring at this lifeless body lying half out of her. after awhile i asked joyce to ask her if she wanted to push and joyce said no, she has no more strength to push. i told her that it was almost over, but she needed to push a few more times. no, she was done. it was hard not to understand. what motivation is there to work that hard when you know that your baby is already gone? i tried a few more times and still she shook her head, completely defeated. i finally reached inside and brought out the little arms, then tried to maneuver her head out while inflicting as little damage to it as possible. when she finally arrived we were all as silent as she was. "baby, you came too early" i whispered. i cut the cord and handed the baby to leimona, asking her to clean her so the parents could see her. the mom hemorrhaged and i ended up having to subject her to several injections, an i.v. and countless uterine massages. each time i would say "i'm so sorry", which was true on so many levels. when the mom was stable i got up and went to wash my hands. i asked joyce to bring the baby for the mom to hold, and she told me that they didn't want to see her and, in fact, no one wanted to look at her. she was to be wrapped up and buried without being seen. milena and i looked at her with surprise and walked into the delivery room where the baby lay, wrapped in gauze from head to toe and tied with string. we looked at the shrouded figure, we looked at each other, and finally i said "i think she deserves to be seen". milena agreed and we closed the door and unwrapped her. she was small, but not too small to have survived had she been conceived in a developed country. her head was damaged from the pressure of remaining in the birthcanal for so long, and from my efforts to get her out. her skin was raw and peeling in places. we touched her hands and her feet, so little and perfect yet so cold. she was beautiful. we looked at her, we held her and we acknowledged that she had lived. she left too soon, but she was here.