Botswana 2011: Women's Health Week

A big part of the Botswana UPenn Partnership is the work in women's health that has been going on here with cervical cancer prevention. Several of us spent from 2-5 days at the clinic working with VIA (visual inspection with acetic acid) and with LEEP (loop electrical excision procedure) clinic. Since the procedures are very complicated, the nurses and doctors at the clinic preferred that we spend multiple days there in a row so that we could learn at first and then be helpful the rest of the time.

I've spent 5 days this week in the women's health clinic, and I've learned so much there from assisting with procedures and shadowing nurses! Doreen Masire pretty much runs the show there and is clearly the clinical leader. (Bio here: http://www.med.upenn.edu/botswana/LeadershipBios.shtml) We also worked closely with another doctor, Mimi, as well as other nurses and staff there who were all extremely helpful and inspiring.

The clinic focuses on treating pre-cancerous lesions with cauterization and LEEP when women are referred from either the main hospital through abnormal paps or from a community clinic post-VIA. This week, I spent Monday and Wednesday in the community clinic observing and assisting with VIA. VIA is a procedure where acetic acid (vinegar) is placed on the cervix so that any abnormal cells turn a white color (acetowhite lesions). VIA is especially good in low resource settings where labs to process pap smears may not be available. VIA relies on the expertise of the nurse (or other clinician) to determine when a lesion is present and to take action. (The "See and Treat" method.)

At the clinic here, they start by doing the VIA with the naked eye, but they then do "EDI" (enhanced digital imaging). They usually have a big screen so be able to see a truly enhanced view. The screen is currently not working, but they are able to zoom on the camera and make a determination. I'll get to what they do with the images later. But then, for the patient, if they have a lesion that meets certain criteria (i.e. not extending into the os, not covering more than 75%, etc), then they do cryotherapy there on the spot. ("See and Treat") If it does not meet those criteria, then they are referred to the main clinic.

I was at the main clinic Tuesday and Thursday. At the main clinic, there is a colposcope, and the patients get another VIA done, which can be compared with the images from the community clinic's exam. (And they are pulled up right then and compared to see why the patient was referred and what the nurse saw in the previous exam that was concerning.) After the VIA, the doctor does VILI (visual inspection with Lugol's Iodine), which is really interesting to see. It is the same process as with the acetic acid but with a special iodine that turns any abnormal areas a mustard yellow color. Then, from that, they determine whether to do LEEP, cautery, etc.

At the end of the week, every Friday, they do quality assurance with the whole team. They review all the images and determinations to see if there is consistency and accuracy in the decision-making of the examiners. If they see anything that was missed, they recall that patient for follow-up. This step is crucial, since as I said, VIA and the follow-up procedures all rely on the clinical judgment of the nurses or clinicians doing the work.

What I was able to do with them all week:

At the community clinic, I did a lot of close observation, since there are certain clinical skills we can't do here even if we are trained in the US to do them (and the exam is short anyway). However, I was able to assist in actually taking the digital images of the cervix -- trying to avoid the speculum, shadows, get the lighting right, etc. Then, after all the images are done, they choose 3 per patient to pass on to the main clinic. I helped choose the 3 images with the best quality and then helped to renumber all of the images in the folder at the end of the day with patient IDs and what sort of visit they had.
At the main clinic, I was a full assistant in all the procedures, and they taught us how the whole process worked, when to get what ready, etc. We were setting up exams, pouring acetic acid and iodine, providing LEEP equipment, preparing the camera settings for images, and more. Dr. Doreen Masire is also an amazing teacher who expects you to know a lot but also is very encouraging throughout the learning process. She let us look through the colposcope in order to point out certain things, which was really nice as students.

An interesting sidenote as well, as future clinicians ourselves: They use a technique here of putting a condom over the speculum (with the end cut out) to help hold back the vaginal walls that have a tendency to collapse inward and obscure the view. I thought it was a really great idea, especially after I saw some clincians at the clinic where I used to work struggling to visualize the cervix of certain patients. I'll be keeping this trick in mind as I move through my career! Thanks to all the clinicians and support staff there for teaching us so much!

Below are some images of posters from the clinic showing VIA and VILI findings.