Botswana U-penn Partnership Global Health – Alexandra (Jana) Freeman, MD

Written by Alexandra (Jana) Freeman, MD PGY2 at the Kaiser Permanente San Francisco OBGYN Residency Program while on global health rotation with Botswana U-penn Partnership in Gabarone, Botswana in February 2015.

I walk through the open-windowed gynecology ward of Princess Marina Hospital in Gabarone, Botswana on my way home from Tuesday clinic. I see her from across the room. She has a muted white dress on: oversized tulips hug her weak, writhing shoulders as they struggle to keep her body upright. A color of pale paints her face that does not require a laboratory value to diagnose severe anemia. My eyes lock into the rise and fall of her chest: up and down as she labors to take each breath of air. I instinctively walk over to her and drop my clinic bag. I know I am staying.

She is hemorrhaging and in septic shock from a septic abortion. In Botswana abortion is illegal, and daily we received women in the hospital who attempted to intervene with their pregnancies – tree branches, pens, anything they could get their hands on to terminate a pregnancy. This particular patient is one that requires your complete attention. In the United States in our residency training, we have so many ancillary staff support systems: we enjoy the benefits of nurses who start IVs and administer pain medication, phlebotomists who gather blood specimens at routine intervals throughout the day and night, operating room staff who help move patients and run blood transfusion protocols to ensure patient safety. At Princess Marina, you are at the front lines. There is something very satisfying about resuscitating, truly resuscitating, a patient. And a young woman, particularly an otherwise healthy young woman, can be extremely resilient – it is amazing to see how gracefully the human body can recover from insult.

I begin gathering everything we need in the supply room. I start the peripheral IV, hang the fluids, draw her blood, hand-label each blood tube and walk them over to the laboratory for analysis. The other resident writes down her history in our paper charts, gathers the IV antibiotics and begins broad-spectrum coverage. We have no ultrasound on the gynecology ward, which covers more than 60 patients, and I cannot confirm an intrauterine pregnancy. Clinically, we know she has septic abortion, but she is not stable enough to go to radiology for confirmation. With the IV antibiotics and IV fluids running, and two bags of packed red blood cells on their way (hemoglobin level of 4), three of us physicians stood at her bedside and discussed her case, and the next steps. It takes several hours to stabilize her, and the Botswana night resident urges me to go home. “Please,” he says. “I will stay with her until she is ok, it might take another few hours. I will not be able to sleep until then.”

On my walk home in the African heat that had not yet lifted even at dusk, I remember smiling. I felt grateful that in my job, we lose sleep if we do not take the best possible care of our patients. Grateful to stand at a patient’s bedside and actively think and discuss with other physicians. Grateful that I have the honor of being on the front line of fighting maternal-related mortality. Grateful that my residency program supports and encourages us to work with other cultures and countries.

I went to Botswana primarily to work in cervical cancer screening and gain experience in gynecologic oncology care and methods of screening in low-resource settings. I worked in the cervical cancer screening clinic on Tuesday and Thursdays, where the cervical cancer screening method called “See and Treat” with visual inspection of the cervix with acetic acid is employed. The program has launched across the country of Botswana piggy-backed upon HIV women’s clinics (9 in total) with a referral clinic, where I worked, in Gabarone, Botswana. Here, I performed many colposcopies with two very experienced Doctors, more than 60 LEEP procedures, and saw cryotherapy for the first time. I worked closely with a radiation oncologist whose primary interests are in cervical and breast cancer treatment in resource limited settings. The Gardisil HPV vaccine launched for the country of Botswana during my stay.

The remaining time I spent on a gynecology team at Princess Marina Hospital where I participated in general gynecologic care of hospitalized patients, cesarean deliveries, as well as scheduled and emergency gynecologic surgeries. I assisted in an exploratory laparotomy for uterine perforation after D&C procedure and subsequent hemoperitoneum, ruptured ectopic pregnancy, ovarian cyst removal, and abdominal hysterectomy. I worked with the Botswana medical students to organize medical approaches to common chief complaints, including abnormal uterine bleeding, hemorrhage, and abdominal pain. I travelled and watched the nurses sing prayers after morning rounds, discussed ebola, politics and the controversy of medical tourism with fellow residents working abroad; I laughed with elderly women awaiting surgical care in the hospital, and I refined my technical surgical skills in loop electrocautery and colposcopy. Ultimately, I returned to Kaiser Permanente San Francisco with a fresh and rejuvenated mentality, a newfound knowledge about cervical cancer and gynecologic global health, and an overwhelming sense of appreciation for the availability of our cancer screening programs here at Kaiser and the support of my medical education to purse my dreams of becoming an oncologist in our global community.