Words From a VVF Surgeon

I wanted to share a letter we received from surgeon Jerry Putman.  He and his wife, Marty, left Friday after four weeks onboard.  Dr. Putman is a VVF surgeon.

Dear Crew,
I just wanted to take a moment before Marty and I depart to thank you all for a great 4 weeks of fistula and gynecologic surgery.  As of March 31st we have done 43 surgeries.  The people of Madagascar are gracious and fun-loving, a testimony that poverty alone does not destroy the human spirit.
I want you to know I have witnessed the many hours you all have loved and prayed over these women, counting the endless milliliters and sometimes drops of urine, flushing catheters, giving endless doses of lactulose, and putting up with my wearingly constant reply of please keep the catheters flowing.
It is a privilege we all share that these ladies have invited us as strangers into the most private parts of their lives, allowing us to share their shame, frustrations and embarrassment of a loss of dignity as they have lived lives being soaked in urine and odor.  It is a sacred responsibility God has granted to us to care for the vulnerable and be used as He heals their physical and emotional pain.
I have never worked in a fistula environment with such a competent staff.  So far I think 2 of our ladies will to come back for a 2nd surgery, though there may be more.  That means many will go home happy and dry.  The reason is because of your diligence to not allow catheters to remain blocked and repairs to open up.  Thanks to excellent and safe anesthesia, diligent and professional ward nurses.  What an amazing organization!  Putting the fistulas together is the easy part.  Keeping the catheter flowing requires hard work.
As we leave, you all will be in my prayers as you continue your labor here.  I am deeply indebted to you for your commitment.

Jerry Putman, M.D.

This topic is difficult to talk about simply because my heart breaks for the women who come through our ward.  I was working the first evening when two buses arrived from up country with seventeen women diagnosed with fistulas.  This first group of women were referred to us by another organization within the country.  You can see the hope on their beautiful faces.

I interviewed five ladies, taking a detailed history for the surgeon to review.  Only one of these ladies had family to list as an emergency contact.  The others had been completely abandoned by everyone they loved.  All of these women developed fistulas after giving birth.  Due to the long days in labor, the women were left broken and most of their babies died.
**I am a nurse and am constantly fascinated by how complex the human body is; how completely wondrous God made the many parts to work together…so the following is a bit of an anatomy lesson**
In labor, the uterus contracts, pushing the baby down through the birthing canal.  Obstructive labor occurs when a baby is unable to pass through the pelvis.  Healthcare is expensive, so many women seek help too late or not at all.

Many of the women who experienced obstructive labor are very tiny.  Their bones are small, including the pelvis.  The baby's head is too large to fit through the small opening of the pelvis.

In this picture, one can see where the baby's head pushes against both the bladder and rectum during the labor process.  This particular picture shows the baby's head after it has passed through the pelvic opening.  Note the pubic bone.  If a head is unable to get beyond the bone and the contractions continue to push the baby downwards, the baby's skull will continuously compress the bladder and rectum.  Under so much pressure, the bladder and/or rectum tears.

The vagina shares a wall with the bladder on one side and the rectum on the other side.  It is more common to develop a whole in the bladder or urethra, the tube connecting the bladder to the outside world, than a whole in the rectum.  This photo shows the whole, or opening, between the bladder and the vagina.  Once this whole develops, called a vesicovaginal fistula (VVF), urine constantly leaks from the bladder through the vagina.  A whole in the rectum-bladder wall is called a rectovaginal fistula (RVF).


The repercussions are terrible.  The smell is pungent and constant.  Most women are abandoned by husbands or lovers.  Many are also abandoned by their family.  These women are filled with shame and despair.  Humiliated and disowned, these women feel hopeless.
We give hope.  The wholes are usually repaired vaginally so there is rarely an abdominal incision.  Foley catheters are placed to empty the bladders so that the bladder does not stretch out during the healing process.  It is vital to the healing process that the foley catheters not get blocked.  If the tubing placed within the bladder does get blocked, the bladder slowly stretches as it fills with urine.  The stretching pulls on the stitching and may cause the repair to fail.
We strictly monitor the patient's intake and output to make sure that the foley is functioning properly.  Even after the foley is removed, we continue to strictly monitor the patient's intake and output.  There are blue pads on every bed, which we monitor every few hours for any sign of leaking.  If we can spot leaking early, we may be able to stop the repair from breaking down.
While their bodies heal, God is restoring their spirit.  These ladies arrive onboard and suddenly realize that they are not alone.  Then, with each day they are dry, relief and self-worth start to replace the shame.

On March 27, we had our first Dress Ceremony. This ceremony is to share in the joy of those patient's who are considered healed.  Each lady is given a new dress to symbolize her new beginning.  In most of western Africa, there are dresses specific to each tribe or country.  However, there is no single dress typical to Madagascar, but there are Malagasy hats.  Our hospital chaplaincy team spent eight hours going from shop to shop in Tamatave looking for dresses, accessories, and hats.

We have a few more weeks of surgeries.  A surgeon from west Africa has arrived to continue the good work Dr. Putman started.

A documentary movie was made about a VVF clinic in Ethiopia.  The following is a link to watch the video on You Tube: https://www.youtube.com/watch?v=TPTA4g5rGrs