Sunday, February 18, 2007

LBJ Tropical Medical Center

Now that I’ve been in American Samoa for a couple of weeks I have an idea of how things are here at the hospital. Many of you reading aren’t health care providers but for those of you that are I just have to include all those details that make practicing here so very different. Hopefully this won’t bore the others of you out there to tears.

The facility itself is very old. It is your typical 1960s cinderblock tropical facility. It’s not what you would think of as looking like your typical “hospital”. The building really needs to be taken down and rebuilt. Apparently during one hurricane there was two feet of standing water through out the wards. Though the buildings are ancient and over used, the equipment is good.

There is a big brand new ultrasound in the clinic, some of the beds in clinic are hydraulic (and there is also one that has rusted so bad the stirrups won’t come out), and there is electronic fetal monitoring. One of the best things about the hospital, unbelievably, is the cafeteria! I never thought I’d say that I look forward everyday to eating in the cafeteria. Ribs, Cornish game hens, fresh salad, stuffed chicken, plantains . . . .thank god Samoans know how to cook!

The outpatient clinics are on the same property as the hospital. Clinic is a rotating schedule (Wed-Postpartum, Thurs-New Patients, Fridays-Return patients). Patients don’t have appointments but come in first thing in the morning and wait: first come, first served. This can be a problem if doctors have to cancel clinic, because there’s no way to know who is coming in and notify them.

On New Patient day the women are all undressed in the hall wrapped in lava-lavas (bath sheets wrapped around them sarong style). Privacy seems to be of little concern here the exam rooms have curtains instead of doors. Labs are minimal, really, minimal. All patients though get a level two ultrasound. Pregnancy dating is really important here because patients usually come into care ½ through their pregnancy around 20 weeks and few remember exactly when their last period was. (One of my first deliveries I thought the patient was 32 weeks by dating and measurement-thank god it came out looking 36 weeks). Apparently postdates issues are huge so induction at term if favorable is strongly recommended.

Diabetes is also a big problem here and all patients get an early glucose screen. (One uncontrolled diabetic came in with a capillary blood sugar of over 314!) There are four OB docs in the call rotation. There will be another CNM here in June. She has worked for years in Samoa and had taken some time off and is now returning. There is a also a licensed midwife, Sati, who is great. She is a Samoan and was trained in Fiji as a midwife.

The labor and delivery staff is skeletal in my opinion. Just like everywhere there is a nursing shortage. There are 4 RNs, 2 LPNs, and 4 CNAs. These women work long 12 hour shifts and keep in mind there are on average 140 births a month! The patient rooms are shared with only curtains for privacy.

Patients go to the delivery room to deliver—no delivering in the room here. However, since there is no privacy and the beds don’t break apart and with the very real threat of shoulder dystocia with these big babies, I can see the rationale for that. Most patients are grandmultips (more than five deliveries) so hemorrhage is a huge fear here so active management of third stage (something I didn’t do before) is now my practice. Vaginal birth after cesarean is standard practice here and isn’t given a second thought as an option. I haven’t heard of one case of uterine rupture or fetal demise from a VBAC delivery. Though there have been demises due to postdates and shoulder dystocia.

There are no epidurals for pain management. IV pain meds are the only option, however I have yet to have a patient ask for anything. Actually, most patients want to go home if they are in early labor (sometimes even if they are in active labor and have to be convinced to stay). Patients beg to walk the halls so intermittent monitoring is standard.

I love the patients and their approach to birth and pregnancy. There is very little complaining of common discomforts of pregnancy and are open to suggestions and very gracious in their attitudes towards care providers. I do wish that the patients had more interest in prenatal care in general. The government has worked to encourage early prenatal care by offering free care if patients start visits by 12 weeks of pregnancy.

There are many non-Resident patients here from Western Samoa (i.e. Independent Samoa). Though many patients speak and understand English, Samoan is the language of choice (especially of Western Samoans) and I will definitely need to learn Samoan. My first words have been pepe-baby, su-su-breastfeeding, ‘oono-push.

The overall mood is relaxed and I love only working a 40 hour work week. When I leave the hospital I can leave my worrying there and enjoy the day. I work clinics Wed-Friday and 12am-8am Saturday and Sunday night. It’s a great schedule. I have most of the day off on the weekend and Sundays here most everything is closed (including most restaurants) so I’m not missing out on much if I have to sleep. I think I will be very happy in this position and have already adapted to the have-nots (though I miss my rapide suture and unexpired 6 ½ gloves).

Next week: A new home for Markus and Me (and Einstein, of course)!!!!!

Saturday, February 10, 2007

First Week in American Samoa

As expected things here are so different. I can't wait to share everything with all of you out there. I’ll be posting something new every week until I start repeating myself (at which point someone should mail me a plane ticket home).

There are so few non-Samoans here. I find this really refreshing. American Samoa receives a lot of U.S. assistance (take me for example) but most probably because non-residents can’t purchase land this small little island remains the sole property of the Samoans. Where else can we say that natives in the U.S. still own their own land? Sure I stand out---a white, young(ish), female, so of course, everyone stares and at first this intimidated the heck out of me!

Living in Portland so long one becomes used to blending into the background, people don’t look at you directly unless they want something or you make an effort to get their attention. It’s not considered rude. I think it’s a way of maintaining privacy in a city. In Portland people even wear clothing that camouflages them: dull black, green, and brown that blends nicely into the landscape and cityscape. In Southern Oregon it was somewhat different a mixture of small town, “hey we know you” with still the ability to maintain some anonymity.

Here it is really the small town feel. Having grown up in Mt. Shasta, I know what it’s like and how things work in a small town. I’m not sure if everyone really knows everyone else here, but there is definitely that sense. Walking the streets when I first got here before the hospital rented me a car, I got more male attention than I was comfortable with. I’ve never been any place where that’s happened to such an extent. It’s not something I’ve had to consider so thoroughly. I don’t think I would ever be in true danger and no one makes lewd remarks or approaches me, but it’s overwhelming, unwelcome attention. And of course, I don't want to avoid interacting with people in public because that makes me feel unwelcome. I find if I don’t make eye contact and ignore the younger males (which seems rude to me, but I think is the proper way to interact) and only smile and greet women and older adults I feel much more welcome and get a warm response.

There is A LOT of gossip. Those of you that work in the health care field know about gossip, well it is 100 fold here. I am a stranger and already I know more about people than I am comfortable with. Word travels fast on what is called the Coconut Telegraph. I’m going to do my best to stay out of the main headlines on this particular version of Samoa CNN.

Ana in Human Resources, a gracious hostess and superb representative of the hospital, let me in on my new title here on the island over a meal at a local Chinese Restaurant. She insisted I order and not knowing what she would enjoy and too fatigued after my second day in Samoa to think to hard about food, I simply chose the dinner for two that all Chinese places have. What followed was sooooooo much food a family of six could have eaten well and come away satisfied. I was embarrassed by the volume and sent Ana home with the majority. I quickly learned to assume that all food orders would come “Samoan”-meaning large, large, large! But I digress.

My new title was palangi. As she described it, when Caucasians first showed up, the Samoans thought they came from Heaven and the name palangi meant, “fell from Heaven.” When she first told me this I couldn’t help but guffaw. “Yeah, right,” I said. “I am sure Samoans today really think we are heaven-sent.”

Later reading Paul Theroux’s novel that Polynesian’s love to hate, The Happy Isles of Oceania: Paddling the Pacific (I think I’ll post my own review once I’ve finished reading it), I enjoyed his explanation of the concept of the palangi:
“It meant ‘sky-burster.’ In the seventeenth century, Tongans and Samoans believed that their islands lay in a great and uncrossable ocean. The story of a long overseas migratory journey was conjectural in Tonga and absent in Samoa, where the local creation myth described how they had risen from a knot of twitching worms in the soil of their islands. So when the first Europeans appeared in this part of western Polynesia . . . the only possible way for them to have arrived was from the sky, exploding from the heavens.”

In truth, I do feel as if I have exploded out of the sky and landed in this beautiful and unknown place. And so, my blog from American Samoa will be entitled Palangi Post, where I get to tell all of you what it’s like living here from my palangi point of view. Hopefully, this will help me to connect to all my loved ones so very far away as I get to know new friends here in American Samoa.

Next Week: LBJ Tropical Medical Center (ladies in the hall in lava-lavas (sarongs-instead of hospital gowns), roosters in the courtyard (or being carried away by boys for dinner), expired gloves in the drawers (only size 8s seem fresh), but where at least 5 lovely Samoan babies are born a day . . . ).