Since it’s the New Year, I will do a New Year’s Post. While I’m not much for resolutions, I will often apply a theme to the year. Something I can go back to when I’m feeling directionless and/or stressed. This year, the letter B called to me. Be Better, Be Balanced, Be Bold.
Be Better. Part of my purpose in life and one of the purposes of this blog is to live my best life and to help others live theirs. The only way to do that is to constantly try to make myself better. Please don’t get that confused with perfect. Perfection is not a goal of mine. Instead, I try to do the right thing, be nice to people, help out where I can and when I make a mistake, try to do better next time. Having grace for yourself and others will go a long way.
Be Balanced. Work hard, play hard right? Or maybe, work enough, play enough, might be more appropriate. Living on the extremes can sometimes get you in trouble. I don’t believe you should work yourself to exhaustion or party yourself to destruction. It’s always great to be that “good tired’ after a day at work. Or managing to achieve the perfect tipsy with no hangover after a night with friends. Just enough…
Be Bold. To me, being bold means not limiting yourself. Employing the adage “nothing ventured, nothing gained,” I often push my comfort zone. Partly to push myself to grow and partially because I get bored easily… It’s difficult to be great without taking any risks. So this year, I will push my comfort zone some more. Try things I’ve never tried before. Go places I’ve never been before. Of course, in 2017 I decided to live in Kenya for 6 months. Not sure how I will top that in 2018, but I’m up for the challenge.
So with that, I implore you all to find your theme or themes for 2018.
One of my colleagues in Mutomo asked me what I was doing for the holidays. I said, “I’m going home, to see my family.” He responded with a quizzical look, “I thought you didn’t have a family.” Now, I was confused. Did I imply that I was an orphan…? Maybe something got lost in translation between my English and his? He quickly followed with, “You told me that you didn’t have a husband or kids.” Oh…now it was clear, his concept of family only included marriage and procreation. Another physician in the room piped in, “Maybe you need to broaden your definition of family.” Indeed, I would agree.
My biological family is great! And, all four of my parents have been there along my journey, even when they didn’t understand what I was doing or why I was doing it. They trusted me to believe in myself and follow my purpose. My extended family has continued to grow over the years. I posted a few weeks ago about how I love my friends. And truth be told, I consider most of my friends, family as well. I make friends for life so, I make an effort to maintain and strengthen those relationships.
In my professional role, in order to provide good medical care, I need to understand the community in which my patients live and my co-workers work. On the residency interview trail, I asked one of my interviewers where most of the residents lived. She responded, “well you can’t live around here.” My feelings were hurt and I wasn’t even from that city. Needless to say, they slipped to the bottom of my rank list. On one of my other residency interviews, I laughed so much at dinner, I thought, “I feel at home; this feels like family.” And, I knew that was where I was supposed to be. When I moved to Pennsylvania for my first job, I asked for recommendations on where to live. The response, “well if you want, why not live around here?” I moved into an apartment less than 2 miles from the hospital. One of the toughest decisions leaving that job was leaving my Montgomery work family. I still love them dearly and they have continued to be there for me. That’s what family feels like. As I traveled doing locums before venturing to Kenya, I liked to take assignments that lasted long enough for me to a get a sense of the local community. I accepted invitations to dinner and church, to potlucks and to happy hours. I didn’t want to just work there, I wanted to live there.
I have those feelings from time to time, that fleeting, intangible moment that you know you are at the right place at the right time. I have had that feeling in Kenya. One weekend I found myself sharing a meal playing cards with my Mutomo work family, and I knew I’d found my tribe. I don’t know how many of you have had the experience of traveling to a new city, and one of your parents says, “call so-and-so when you get there. She’s your cousin…” A cousin that you’ve never seen before, met before, heard of before. But you call as instructed, and that cousin takes care of you like she’s known you since birth. Similarly, a friend introduced me to a friend of his who’s American but lives in Nairobi. She invited me over for dinner shortly after I arrived a couple months ago, and if you saw us today, you would think we had known each other forever. In the same vain, my CMMB family has been incredible in making my time here as comfortable and rewarding as possible. It was only fitting that I celebrated Christmas with them, before returning to the states for the Holidays.
Family to me, are the people around you who support and encourage you to be your best self. I look forward to spending the holidays with my family, all of them, whether related by blood or by spirit.
Kuzaliwa kumoja, maisha mengi = Swahili Proverb, translated: The same birth, but many lives. Human beings are born in the same way but their lives may be different.
Taken behind my house in Mutomo
A friend and colleague forwarded me a story from NPR this week. You may have seen the article circulating about a mother who recently died soon after childbirth. Maternal mortality is defined as the death of a woman during pregnancy, delivery or shortly thereafter. In the United States, it represents the 6th leading cause of death among reproductive age women from 25-34. Recently, the rate of maternal mortality has been on the rise in the United States, with the rates among black women being 3 times as high as for white women. And, according to JAMA, “Even if you look only at white women in the United States, the rates of mothers who die is greater than those in other developed countries.” In the developing world, the statistics are even more startling. The WHO reports, “The maternal mortality ratio in developing countries in 2015 is 239 per 100 000 live births versus 12 per 100 000 live births in developed countries.” Here, in Kenya the number is 510. Reading this article made me reflect on my evolution as a physician, and how stories like Shalon’s motivate me to continue the work that I do.
Going into medical school my plan was to be a forensic pathologist. I’ve known I wanted to be a doctor since I was seven but this particular aspiration grew from reading novels in high school in which the main character was a forensic pathologist. The field intrigued me for many reasons, one was that it functioned between two worlds, the law and medicine, it allowed me to work with my hands and avoid a traditional clinical practice… I have been described as quiet, shy, reserved, introverted or all of the above at different stages of my life. For this reason, I was nervous about how I would be able to cultivate the doctor-patient relationship. Pathology gave me a way out. Those patients didn’t talk back. You can only imagine how devastated I was first year of medical school, when I discovered, I did not like pathology or histology, or the microscope really. I would fall asleep looking at slides…
As with this lesson, I learned a lot about myself in medical school. I now credit my personality as an asset to my bedside manner, not a hindrance. Thanks to that revelation and to a few other serendipitous events, I found my way to Obstetrics and Gynecology. And without a doubt, it is the field for me. But old dreams sometimes die hard, so my fourth year, before submitting my Ob/Gyn Residency applications, I signed up for a forensic pathology rotation housed at the Metropolitan Government of Nashville and Davidson County Medical Examiner office. And I loved it of course! But it was time to let it go. In order to merge my old interests with my new ones, I presented on Maternal Mortality for my Externship project that month. As I was learning to articulate my interests in public health and health disparities, this subject underscored both and I have carried it with me through the rest of my training and into my career. I encourage you to read Shalon’s heartbreaking story, which tells the story far better than I can.
Throughout my training, I have been drawn to organizations or institutions that have a mission to serve the underserved. To start with… I attended a college that was founded by a Saint! Katherine Drexel, born to a wealthy family, instead of spending her fortune on finite possessions she chose to join the Sisters of the Blessed Sacrament and dedicated her life to improving the lives of black and brown children in the South. The Salt Wagon Story describes an act of kindness, which prompted Samuel Meharry to found the medical college, where I eventually did my residency training. This legacy, started to educate a then disenfranchised Black American population in the South, continues to address health inequities in this country.
While in residency, our hospital served as the city’s safety net hospital. Though we did care for insured patients, we also provided services for those under and uninsured populations of Nashville. Tennessee at the time funded a state system called TennCare which worked to fill the gaps for small business owners or those who were unemployed. However, there were those who still fell through the cracks and they came to us. The hospital population included many Black American Women and Latina women, who bear a higher burden of uterine fibroids. Fibroids are benign tumors of the womb that can cause heavy bleeding, pelvic pain and anemia. Multiple treatment options exist, but the definitive treatment is still a major surgical procedure, a hysterectomy. There were times when uninsured women could not schedule their surgery due to their inability to pay, literally going home with the fear of bleeding to death with their next period. When I was looking for my first employed position, I chose to work for a group in Norristown, Pennsylvania, where one of their offices provided similar services for the women of that community.
Here in Mutomo, some patients have the National Health Insurance. However, many still pay out of pocket for their care. This week I cared for a young woman who had been transferred from another facility due to the infant being in breech presentation (specifically the foot was visible at the opening of the vagina). She was rushed for cesarean section on arrival, she, and the infant recovered well. On the day of discharge (day #4), the infant was noticed to have yellowing of the eyes. We tested for and diagnosed him with neonatal jaundice. A relatively common condition of neonates that is treated with light therapy. This treatment requires further hospitalization and monitoring, and therefore an increase in cost. After two additional days in the hospital, the mother asked me if she could be discharged. I said no, the bilirubin levels were still elevated. She was visibly upset and frustrated with me. I reassured her that it was in their best interest to stay. I tried to explain (with the help of the nurse) that yes, her infant appears fine now. But left untreated, neonatal jaundice can lead to serious complications. She replied, “Daktari, you don’t understand…the bill.”
I get it. I do understand. In that moment I was disheartened that she thought I didn’t understand, but also that I could do nothing to change the dilemma that she faced. Was it possible that she could go home and her newborn son would recover well? Of course. Was it also possible that if left untreated the condition would progress to cause seizures or brain damage? Yes, of course. In either case, why is it fair that a new mother has to weigh the mounting health care costs with the costs to her child’s health?
Many women, many people face these complicated decisions everyday in hospitals and clinics across the world. I hope that this generation continues to move the needle forward toward supporting the basic right of universal health care coverage for all people.
The first time I spent Thanksgiving away from home was my senior year of college. I wanted the opportunity to soak up a few more precious moments with my college friends and to experience the Bayou Classic weekend in New Orleans. Fortunately, a couple of my friends had an off campus apartment and they were willing to host us. We all chipped in and cooked a potluck style dinner, most of us contributing to a Thanksgiving meal for the first time. I remember listening to Maxwell’s new album Now in the days when we still had a CD player. We attended the battle of the bands in the Superdome and probably went to a party or two… nothing fancy, just food, friends and fellowship.
Since that year, I have spent more Thanksgivings away from my family, sometimes because I had to work on the days around Thanksgiving or sometimes actually being on call in the hospital. On those occasions, I would celebrate with the closest friend I had to the area. Most of the time preparing a dish but sometimes showing up empty handed, when time didn’t permit me to cook. They welcomed me graciously either way.
Over the past few years, one of my friends has officially hosted Friendsgiving. Usually the Friday after Thanksgiving, to give those of us away from home the opportunity to enjoy the holiday and for those close to home the benefit of not having to choose to spend the holiday with friends or family. The best of both worlds.
This year, I spent this week in Kenya, and I am missing the turkey, cornbread dressing, collard greens, macaroni and cheese, potato salad and, since I’m dreaming, chess pie! But I wanted to take this moment to say thank you to all my friends, around the globe, that have supported and encouraged me on my journey. I look forward to making many more memories with you!
5 Reasons why I love my friends:
1. They understand my punctuality. I have a strong desire to do everything or conversely the dreaded condition of FOMO (fear of missing out). This condition sometimes causes me to arrive early to the function, so I can leave early or sometimes I’m a little late to the party. But if I say I’m going to be there, I’ll be there. So thank you for not getting annoyed with my fluid interpretation of time.
2. They understand my love of travel. I have friends with whom I have literally traveled around the world. We’ve planned trips together and I’ve also inserted myself into a few already planned trips 🙂 I also appreciate those friends who host me when I show up on the their doorstep, suitcase in tow. To the question, “where are you staying?” My answer, “here…?” is always met with a gracious welcome. And in the same vain, thank you to those who host my belongings in my absence!
3. They understand my need to stay connected. This fact is especially true in Kenya. I was a little nervous about being so far away from family and friends for an extended time. Without skipping a beat, they have been supportive and responsive to my random text messages, facebook messages, whatsapp messages, emails… even when I lose sight of the time difference…
4. They understand my need to be entertained. I love activities and I enjoy new experiences. From house parties to canoeing to kickball games to whitewater rafting to attending the Kentucky Derby to skydiving to tattoos to dinner 1150 feet in the air, to staying up until sunrise (more times than I can count) we’ve done them together!
5. They understand me. They allow me to be unapologetically myself in all my forms. They provide encouragement when support is needed, reassurance when I doubt myself and honest reflection when I need a little, let’s say reality check. They keep me accountable and are instrumental in helping me be my best self.
After being in Kenya for 8 weeks, I thought I’d take the opportunity to share with you 8 of my favorite photos from my time here.
Having fun with my Dad at the Nairobi National Museum.A giraffe at the Nairobi National Park. Because who doesn’t love giraffes!My first day of work picture, because this is what happens when your dad drops you off in Kenya.My new favorite breakfast. Mandazi and Chai.Dinner with the team in Mutomo.The view, at dusk, from my front door.Looking at the Indian Ocean, Diani Beach, Coast of KenyaSimple. Perfect. Words to live by.
Typically, my clinical responsibility ends at birth. When all things go well, after guiding the mother through prenatal care, labor and delivery, I happily hand off the new bundle to the awaiting nursing or pediatric staff. I congratulate the parents and wish the baby “happy birthday”, before exiting the room to complete my notes. Here in Mutomo, my responsibility is not over. Normal newborns with no issues are assessed at birth and then discharged with their mothers to follow up as outpatients. However, we admit those neonates with complications and they become part of the maternity service, i.e. my service. As you can imagine, I had to tune up on my newborn medical knowledge.
My second week on service, as I finished rounds, I was called to evaluate an infant who had been doing poorly for the last few days. He had been diagnosed with meconium aspiration and neonatal sepsis. The treatment regimen included antibiotics and supplemental oxygen. Over the previous few days, he had increasing difficulty breathing and maintaining his oxygen levels. One of the nurses was actively trying to resuscitate the infant when I arrived; I assisted but felt at a loss in offering any additional support. As we watched the oxygen saturation levels drop into the 30’s, the infant was barely responsive to stimuli and losing muscle tone. I asked for one of the other doctors to come to assess the situation, he then relieved me so that I could report to the major theatre (OR) for a case. I learned soon thereafter, he pronounced the infant and consoled the family. A few weeks later, I was walking past the maternity unit on my way to dinner and I heard, “Dr. Mary, can you stop in?” One of our admitted infants, born to a mother the day prior after a difficult vacuum assisted delivery, no longer had a heartbeat, no longer showed any evidence of respiratory effort, no longer… She called me to write the note to certify death. As an Ob/Gyn, we handle difficult situations more often than we would like. I have diagnosed miscarriages and stillbirths however this was the first time I pronounced death after delivery. The discussion of a death of child with a mother, whether at 8 weeks, 36 weeks or 2 days after birth isn’t comfortable. It doesn’t get easier with time. There are no consoling words.
During residency and then as a public health student, I developed an interest in how I could work to reduce infant mortality, both locally and globally. One of the health predictors of a country is linked to how well the newest members of its population fare after birth, more specifically, infant mortality is the number of infant deaths before his or her first birthday. As advanced as health care is in the United States, we still do a subpar job in protecting one of our most vulnerable populations. In 2010, the infant mortality rate in the United States was 6.1 deaths per 1,000 live births. To compare, the rate in Finland was 2.3, France 3.6 and England 4.1. The discrepancy between populations in the United States is even more disheartening. We see a large gap in the rates of infant mortality between white and black women; the most recent data reveals a rate of 11.3 (which translates to a ratio of 2 to 1).
One way to combat this problem for me clinically is by providing comprehensive, appropriate care for women, especially reproductive age women. The best prenatal care starts at pre-conception and continues into the pregnancy. However, we know that adequate medical care is not sufficient and even when controlling for education and income, black women in the US still have increased rates of infant mortality. Studies have confirmed that stress plays a factor in these outcomes, especially the stress due to the consequences of racism in the United States. See the link to the PBS special entitled Unnatural Causes.
In Kenya, the infant mortality rate is 38.3 per 1,000. According to the WHO, “the main causes of newborn deaths are prematurity and low-birth-weight, infections, asphyxia (lack of oxygen at birth) and birth trauma. These causes account for nearly 80% of deaths in this age group.” CMMB through its CHAMPS (Children and Mothers Partnerships) program has collaborated with Mutomo Mission hospital to combat this situation in sub-county of Kutui South. Interventions include promoting antenatal care, training community health volunteers, supporting community health centers, providing equipment and supplies, in addition to enlisting the aid of volunteer doctors and nurses. I can see the results of this program when taking the history of our patients in labor and delivery. Women who have traditionally delivered at home are now seeking care in a skilled facility and pursue referral earlier if complications arise.
The public health community has made great strides to reduce infant mortality and the rates have decreased. But there is still much work to be done at home and abroad. Though I don’t have any biological children, I experienced pregnancy and childbirth alongside two of my closest friends. I am now blessed with two godchildren who are healthy and happy. I hope my work, in some way, allows more women to experience the same blessings.
One of my favorite parts of traveling is sampling the local cuisine and I often collect spices, recipes or cookbooks in order to re-create the meals at home. Over the past year I’ve spent quite a bit of time working in Norway, Maine. Though not what you’d call a food destination, the community there prides itself on supporting local farmers in both in their homes and in the local restaurants. I enjoy shopping at the neighborhood co-op, but even the commercial grocery store displays a wide variety of local items. I was fortunately in town this year for the annual food festival held in August. The festival showcased fresh produce, food trucks with Maine classics and information on food waste as well as how to support the vendors in the future. As a bonus, it was headlined by Carolyn Costanzi and the Cobblestones, (you may remember her from an earlier post, Ob/Gyn by day, Rockstar by night). Because my travel to Kenya would affect my assignment there, she knew I would be spending 6 months in East Africa. She said, “you should meet my neighbor, he’s from Kenya. I’ll have party, invite everyone over.” Who says no to that! True to her word, Carolyn hosted several of us for dinner, complete with Western Maine grown fruits and vegetables, regional sausages and homemade ice cream.
In turn, Dexter and his wife Jenna, invited us over for to try a few traditional Kenyan dishes. Jenna, originally from Massachusetts, was volunteering in Kenya, when the couple met. They relocated to the states where Dexter completed his dentistry training on the east coast and have now settled in Norway with their three children. They each shared their personal experiences, and though they had not been to Mutomo, (or heard of it even) they described generally what my expectations should be of the country. One of the most important of those…food! They prepared a meal of goat, ugali and kachumbari. We also had chai (or tea, made with milk and sugar). I greatly enjoyed the meal and truly appreciated their efforts to help me prepare for a smooth transition.
A frequent question when I first arrived was, “you know ugali?” Thanks to them, I could respond in the affirmative. “Yes, yes I do.” And, Kenyans love their ugali. It’s a staple dish, made from maize meal and often served shaped in a mound or ball, ugali can be served with all meals. Usually the question asked when ordering a meal is, “What would you like with your ugali?” Up for a challenge, I even attempted to make my own ugali last weekend, which requires patience and forearm fortitude. The maize mixture is poured into boiling hot water and stirred frequently with a wooden spoon until you achieve the correct consistency. A restaurant (and I’m sure a home) will be judged by the consistency of your ugali. I would describe it as somewhere between polenta and cornbread. It’s soft, but firm enough to be cut with a fork or knife. Mine is a work in progress, but I think it turned out well for my first try!
In Mutomo, I take most of my meals in the canteen which serves as the hospital cafeteria. Ran by a local restaurateur, Nameless Café II, has a standard Kenyan menu. For breakfast, I have an Andazi and chai. An andazi reminds me of a beignet without the powdered sugar. Only slightly sweet, it less rich than an American doughnut, but sweeter than bread. A typical afternoon or evening meal will consist of nyama choma, cabbage, ugali or chapati. Nyama choma refers to grilled or roasted meat that can be served in sauce. Chapati is a wheat flour flatbread, which I would describe as a cross between naan and a tortilla. Now a favorite side dish of mine is kachumbari. Light and refreshing, it’s a tomato and onion salad, that may include avocado when in season. It’s most similar to pico de gallo and at times includes hot peppers as well.
When I expressed concern about whether I would enjoy the food here, Dexter and Jenna reassured me that Kenyan food is very flavorful and filling. And they are indeed correct!
Andazi and ChaiBeef, cabbage, ugali, chapatiBeef and Chips Marsala, CabbageRoasted Chicken, Ugali, KachumbariUgali a la Mary, with Chicken and Curry Vegetables
Over the past year, one of the first questions I’m often asked after people learn I’m from the States, is about our last presidential election. I traveled with friends to Thailand last fall and while on an excursion, the tour guide referred to us as the Obama group the entire time. Now with Trump in office, people often ask what I think about him. More specifically, “how did you all let that happen?” Abroad people seem more aware of American politics than Americans are of global politics. I have not been here long enough to weigh in with an educated opinion about the upcoming Kenyan re-elections. However, I did want to take the opportunity to share what I have learned thus far in case you would like to follow along.
The Republic of Kenya gained her independence from colonial British rule in 1963. They adopted a democratic system that elects presidents to five-year terms. Evidence of the country’s deep respect of the first president, Jomo Kenyatta, permeates most of the country, gracing street names (Kenyatta Avenue in Downtown Nairobi), university names (Jomo Kenyatta University of Technology and Agriculture), airport names (Jomo Kenyatta International Airport), just to name a few. His vision for Kenya included the east African tradition of Harambee (let’s all pull together).
The current president, Uhuru Kenyatta, is the son of the first president, Jomo Kenyatta and Mama Ngina Kenyatta. He is a member of the Jubilee Party of Kenya. The major opposition party candidate, Raila Odinga, is the son of the first Vice President of Kenya and is endorsed by the National Super Alliance (NASA) coalition for the 2017 election. Both men have been very active in politics throughout their careers and are credited with shaping the current democratic landscape of the country.
As I prepared for this time in Kenya, I was blessed to meet a few people who helped in my preparation and expectation setting for my time here. One of those individuals, a fellow locum physician who I met in Danville, PA, is from Kenya and visits her family here often. She informed me of the upcoming presidential election scheduled for August and passed along local information surrounding the campaigns that did not always make it to the international media outlets. As I was scheduled to start in late September, I anticipated my arrival would be after all campaign fervor. As luck would have it, for the first time in African history, the past presidential election has been overturned by the Supreme Court due to suspicion of voter/ballot tampering. The election will be held again, this week, on October 26th.
On my arrival, I noticed the media coverage focused on the tensions between the two major parties and speculations as to which one will win out the second time. In a recent turn of events, the opposition party has withdrawn from the race. As of now, all candidates have been invited to participate on the next ballot. The Independent Electoral and Boundaries Commission (IEBC) has a challenging, dynamic and contentious responsibility of presiding over a fair and just repeat election. In the past week, one IBEC commissioner has resigned and the CEO has taken leave. Each night the news features video clips of marches and rallies both for the presidential candidates and against the IEBC. The country encourages her citizens to be peaceful regardless of the results, but will prepare for unrest given the precedent set in 2007 when the country suffered from violence between the parties following the highly contested presidential election.
I feel safe in Mutomo. Located in Kitui County, it is sheltered from much of the political turmoil seen in larger cities like Mombasa and Nairobi. Though not likely a site for protest or demonstrations, the people here are engaged in the process and we have discussed the topic often. I encourage you to look it up for yourselves, as the landscape is changing so rapidly, this conversation may be completely different in the days and weeks to come. I hope that whether here in Kenya, or at home in the US, that we can learn to embody the spirit of Harambee and work collectively to improve the human experience for all of the world’s citizens.
My first day of clinical orientation consisted of shadowing one of the other newer doctors on staff around for the day. She has been here three months and has a fondness of the maternity services as well. As with many small community hospitals, the expectation though is to “help out” all around as situations arise. A typical day starts with Morning Prayer and announcements in the atrium, followed by morning report with the clinical staff before we report to our designated areas. The physicians then round on the wards, for me this includes what’s equivalent to labor and delivery, the newborn nursery and postpartum. For those of you in the field, it is truly baby friendly here. The dyad are kept together and cared for together unless more specialized infant care is needed. Even then, as in the case of prematurity, the mother serves as the incubator in what’s called kangaroo care (infants are placed skin to skin on the mother’s chest and kept there for 24 hours a day). I round with the nurses who offer insight into the policies and procedures of the hospital as well as translate for me. Most patients speak Swahili and some, only the local dialect, Kikamba.
After rounds, if there are no scheduled cesarean sections, I can assist in the minor theatre, a well equipped procedure room adjacent to the major theatre, or operating room. Here patients are seen as referrals from the outpatient triage area and inpatient follow-ups. The queue includes women, men and children. These patients may be seen for variety of indications, including simple dressing changes or I&D’s, fractured bones, pre-operative consultations, skin grafts, pelvic pain evaluations or prenatal complications. The attending physicians in the area are well versed in all aspects of medicine, with only the most complicated cases referred out to a larger hospital. The day typically ends around 5 pm when the call person takes over to handle any issues overnight. Like the other physicians and some of the staff, I live on the hospital compound, making this my shortest commute yet!
I must say, I was a bit overwhelmed after that first day. The number of variables presented were steep, a new country, a new hospital, new languages and a new medical culture. Mentally and physically exhausted (as my sleep had not yet regulated) I came home and took a nap. The second day was better; I led ward rounds and assisted a bit in the minor theatre. I even scheduled a case for the major theatre the following week. As with any new experience, each day builds on the day before. I am grateful for the warm reception and the patience the other clinicians and staff have afforded me as I adjust to this new space.
by 
Typically, my clinical responsibility ends at birth. When all things go well, after guiding the mother through prenatal care, labor and delivery, I happily hand off the new bundle to the awaiting nursing or pediatric staff. I congratulate the parents and wish the baby “happy birthday”, before exiting the room to complete my notes. Here in Mutomo, my responsibility is not over. Normal newborns with no issues are assessed at birth and then discharged with their mothers to follow up as outpatients. However, we admit those neonates with complications and they become part of the maternity service, i.e. my service. As you can imagine, I had to tune up on my newborn medical knowledge.
