Wednesday, December 12, 2012

24 hours . . .

On Call

0755 I make my way up the long hill that leads from our home to the Hospital Gate. Up along the broken road, red dirt and busted old pavement, motorbikes, overloaded with passengers, children in school uniforms, women in colorful African prints, stray dogs and scattered chickens, the smell of wood smoke and flowers, bright flashes of birds darting among the purple flowers of the Jacaranda trees.

0805 I reach the doctor’s meeting room for morning report. Consultants, residents, interns and students— flurry of white coats—the sound of English softly accented in a lovely Kenyan lilt, mixed with Swahili and Kipsigis. The phone rings—“Good morning Daktari—they need you right now in Maternity.”
Strange. A senior Medical Officer, who is actually an apprenticed (if unofficial) Ob/Gyn, was on call last night. I wonder what could be happening. I soon find out.

0815 Picture to stay with you the rest of your life: A young mom, lying on the delivery table, a 24 week fetus (I guess the age) who was stillborn, lies on the cart beside her, and the mother’s small bowel has eviscerated out from her vagina—it delivered after the fetus instead of the expected placenta. She does not cry. She does not moan. Like a bird caught in a trap, she is utterly still.

0900 In Theatre. We pray with the mother. We open up her belly. There is a 4 cm laceration on the posterior aspect of her uterus. We pull the small bowel back up through the hole. I figure out the best way the deliver the placenta—the surgical resident undermines it from above and I pull it out from below. I give misoprostol. Pitocin is running. I scrub again and fix the uterus, and learn how to do a small bowel reanastomosis. *

1100 Rounds can finally begin. Forty patients, two hours behind in the day.

1105 Chai time.

1120 We begin in the labor ward. Preeclampsia, trials of labor after C-section, twins.

1130 Stat call to the delivery room: the WORST shoulder dystocia I have ever seen: older mama, grand multip, hypertension, intrauterine fetal demise. I finally deliver the baby by grabbing the posterior arm. I do mediolateral episiotomies out here. Dislodging the baby was pretty awful, but the mom was alright, and we avoided a fourth degree laceration. Fleeting thought—if this baby had not already been dead, would it have survived this delivery?

1145 Rounds start again. Labor room. Room 100 where our immediate post op and post op day #1 patients stay. Our one “private” room. Then the back wards—post ops, Gyn patients, and our antepartum patients. The acuity level here never ceases to amaze me.

1300 I am lecturing on (ironically) “Obstetric Emergencies.” The team is running late. Fortunately, time is a little different out here—it is more or less expected that we will not start on the hour.

1400 I run home to eat a late lunch. Lunch out here is the main meal of the day, and I look forward to seeing my family. I sit down and the pager goes off. Bad strip on the labor ward: the young preeclampic G1 has spontaneous late decels. We do not have continuous monitoring out here—I had requested a NST before we started an induction on this young preeclamptic patient at 34 weeks. We prepare for a C-section.

1500 There is no “thirty minute rule” here. Urgent means ASAP—find the OR team, find an anesthetist. Get the patient prepped. It takes “time and patience” as my son says. Try to rush it. Go on—use words like emergent. Get assertive. Move the patient by yourself. Fuss a little. Fuss a lot. And everything slows down a little more. And you regret not playing by these unspoken rules. Time and patience.

1600 The baby is covered in thick mec—but cries and pinks up.

1700 Finishing the day at MCH (“Maternal Child Health”). Our interns have already handled most of the issues—so perhaps and I can get home. [MCH is an ongoing, M-F, 9-5 walk-in maternity clinic. Run by nursing and a regular clinical officer (equivalent to a physician’s assistant), we help staff it with our clinical officer and medical officer interns. And I serve as the consultant.  I am impressed at how knowledgeable our junior staff is—truthfully, these interns work harder than I have seen interns work in a long time. They see huge volumes of patients, handle tough cases, teach students, study and attend lectures—on call every other to every fourth night working 36 hours straight (oops—you cannot go home post call). And they become really good really fast.  Go figure.]

1800 There are two women with previous scars (this is how we describe previous C-sections) who may be laboring. One has had successful vaginal births before, but she has polyhydramnios and the baby is literally floating. Her random blood sugar was normal but I still suspect she is diabetic. The other has a history of 2 previous sections and was admitted late from MCH.

1830 Up at Theatre. There are three cases from general surgery waiting to go—numbered 1-2-3 on the board. Below, like an unnumbered footnote, are our two patients. Umm. . . I speak with anesthesia—there is only one anesthetist on—we can only run one room right now. OK—but we cannot be fifth as the mom with 2 previous sections is laboring and the baby, and her uterus, will not wait. General surgery weighs in and says we can have the next room.

2100 Home at last after another section. A lot of adhesions—again—but mom and baby are ok. The other lady is not laboring right now. We can wait and do an elective case in the morning.

12 MN Pager goes off. Drat. My clinical officer explains: G7P6 patient with remote history of a C-section followed by successful vaginal deliveries, came in spontaneously laboring at term—heart tones lost, station lost, fetal parts palpated in abdomen, mom tachy.

0030 In theatre, massive hemoperitoneum, beautiful still baby up around liver, uterus ruptured with huge arterial bleeders. Get fluids, get blood. BP dropping. Hands work faster. A lot of prayer. She has six young kids at home. Hands work faster. A lot of prayer.

0200 Patient is stable and going to our recovery room. Adrenaline surge is wearing off—boy I am really tired.

0230 “Daktari, there is that patient with previous scar and polyhydramnios—she is in a lot of pain . . .”
0500 Back home after another C-section. Baby was huge, by the way.

0755 I make my way up the long hill that leads from our home to the Hospital Gate. Up along the broken road . . .

*This lady ultimately did well physically—but her heart was broken.  Abortion is actually illegal here, but  patients obtain them anyway from people in the community who get misoprostol or various herbs for the early pregnancies, and attempt instrumentation in advanced pregnancies. Many come in with hemorrhage that can be fixed with a D&C and blood products. But one presented with renal failure—we think from some herb—and we transferred her for dialysis—but we fear she ultimately died. She was 16. Another had uterine and large bowel perforation—she will live with a colostomy for the rest of her life. She is 17. Family Planning is not readily available to unmarried girls and women in rural areas, and married women cannot use birth control without their husband’s permission. Sadly, whether single, married, or widowed, females in this part of the world do not have a lot of control over when or with whom they have sex, when they marry, who they marry, or what choices their husband makes on their behalf after they marry.

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