Friday, January 28, 2011

#20 Merci Baystate

I am very grateful to all of the experiences I had at Baystate.  I could never thank everyone, all of the patients, co-residents, nurses, attendings, and staff.  Everyday brings new and interesting cases here, and these are just a few reflections.  I think of my friends back at Baystate often.
Thank you Dr. Bailey-Sarnelli for helping me with my one and only hymenotomy during residency.  Today I was able to perform the same surgery.  
This beautiful Arab 14-year-old girl had abdominal pain for 20 days.  She had never had a period (menstruation). My hypothesis of imperforate hymen was confirmed with an ultrasound and external vaginal exam.  Her vagina was closed off and there was no way for the menses (blood during your period) to exit.  Of course in the states you would do extensive imaging to prepare for surgery (like maybe an MRI to see if there is another kind of malformation that is more difficult to repair).  But this young girl is not in the states, she is in Tchad.
Samedi gave an injection of ketamine intramuscularly.  I made a small cruciate incision in the bulging vagina, which immediately freed the dark blood behind the wall that had caused her so much pain.  We evacuated 800 ml of dark blood from her vagina.  She is recovering well.  Tonight the family sent over a piece of fig bread/cake as a thank you gift.  I wish I could share it with you.
Thank you Dr. Burkman for allowing me to discuss “what would I do in Africa....without certain things” during morning rounds.  I remember him discussing giving magnesium IM for preeclampsia with large syringes if you didn’t have a IV pump.  Let me see...yep, we DEFINITELY don’t have an IV pump here to measure the exact amount of medication running each minute.  
Thank you also MFM attendings (Dr. Bsat, Dr. Markenson, Dr. Healy, and Dr. Plevyak) for allowing us to take care of quite complicated preeclampsia/eclampsia patients.  I am greatful for the experience, though I have never had a patient quite as complicated as the one last week.  
Olen told me one evening, “This patient’s for you Dear!”  “She’s 9 months pregnant and breathing really fast, like 40 breaths/minute.”  
I think in my head on the way over to the hospital, what could it be?  Asthma, Pulmonary edema, Heart failure.......???
I don’t remember now how long she had been in labor (most of the time it’s not a good history anyways by the time you go through all the translations), but she was in labor, semi-conscious, and breathing 50 breaths/minute.  
Oh, no...this will be my first maternal death. I think a little negatively I guess.  But death is definitely a reality here, and she did not look good.  There was a maternal death my first week here, but it was my first morning rounding, and she had just died (of hepatic origin).  
Her lungs are wet.  Her blood pressure is high (but not extremely high), 150/90.  I check her vagina.  The head is at +2 station, and the baby has a lot of edema on the head.  (I hoped the baby was still alive).  Sometimes it’s hard for me to tell here how “with it” a person is in labor because often they have been laboring for days and are just tired or ignoring me.  Plus, I don’t speak their local languages, so it’s hard for me to communicate.  No magnesium for her because of wet lungs.  I need to deliver the baby though.  
I ran over to the office to open the locked door and bring the portable ultrasound.  No heartbeat on the baby.  The baby had already died.  The baby has to be delivered, but this patient would not wake up to push.  I tell the family to have her push, but no movement on the baby’s head.  The family “helps” me by plugging the patients nose and mouth so she will have to push.  I say no, and tell them to just explain that it is absolutely necessary.  No luck.  I started my barbaric oxytocin drip.  
I run back to the office to look for one of the few remaining kiwis (disposable vacuums we use to pull babies out).  I WISH I had some obstetrical forceps.  To make a long story short, I cut an episiotomy, and after 10 pop-offs with the kiwi (also not good to do), eventually delivered the term dead baby.  (This patient was not one who would have done well with surgery).  
I started her on IV lasix.  That night she had 2 big seizures.  We gave diazepam.  I told the night nurse to PLEASE check her BP at least 2 times that night (hey, you gotta ask for what’s feasible).  
The next afternoon her breathing sounded much better and slower, but she was still unconscious with wet lungs (though improved).  Oh yeah, did I mention there is no oxygen here?  Continue the lasix and antibiotics.  
The next day Dr. James (who has spent the last 7 years here) arrived.  I told him about her and asked if he had any suggestions.  Maybe it’s cerebral malaria he says.  So we started her on IV quinine.  The next day she’s awake!  She was discharged home a few days later.  
Thank you Labor and Delivery nurses and lactation services for your dedication to helping mothers with breast feeding.  I WISH you were here to help all hours of the night and day.  Yesterday evening I delivered a 2nd twin.  The first one had delivered at home the night before.  It was small and appeared to be less than 2 KG.  I was quite focused on the remaining twin to be honest.  I confirmed that twin #2 was still alive, cephalic (head first, though here it doesn’t matter), and was not having contractions.  She was only 8cm and the head was quite high.  I started her on oxytocin (I think I have mentioned that this in itself is NOT easy here).  I usually aim for 7 drops/minute, but sometimes it’s hard.  
Anyways....while waiting for the contractions, I ask how baby #1 is doing.  Has it eaten?
I’m unfortunately NOT shocked by the response.  This baby is 1 day old already and hasn’t had any hydration or nutrition.  So I try to milk the mom’s breast, but no colostrum yet.  One of the two family members is breast feeding her own child.  I ask permission, then put the tiny little baby on her breast instead.  The baby can suck!  Praise God.  It’s hard to get anyone to give milk through an NG tube to the baby (even the nurses), so this baby at least has a chance.  
The second baby delivers and is a little bigger and vigorous.  Two premature baby girls alive!  If only I could ensure they stay alive.  
The next morning on rounds I spend quite a while putting the babies on their mom’s breasts to feed and make sure both can suck.  I am definitely paying more attention to the babies now after many died in the first few 2 weeks.  I am doing what I can, but I would sure love to have my old L&D nurses here to help keep these babies alive.
Thank you Dr. Case for not being afraid of breech babies.  I had twins come in last week.  The first was breech.  In the states it would be automatic c-section. was her 13th pregnancy.  (yes, that’s common here!).  Anyways.....I ended up breaking her water with a large needle.  Eventually, the babies bottom came down lower.  Two of our visiting volunteers were with me.  Luckily one person (Dr. Doug from CA) had gloves on to catch the first baby that shot out like a bullet.  Jessica from Oregon caught the second one (which was head first).  The volunteers and the living baby twins have all since gone home healthy and happy.  The mother of the twins also received my first tubal sterilization (of which I am promoting here; still no takers on the vasectomy).  
Yesterday I gave oxytocin to a breech singleton.  She also had had more than 10 babies.  She was “8 months” and had broken her water 5 days before.  She was 4cm and had thick particulate meconium (amniotic fluid with baby poop).  While I was in doing a c-section, the nurse delivered the breech baby.  It died shortly after delivery when the resuscitative measures did not work.  
Thank you Dr. Harmanli, Dr. Jones, Dr. Haddad, and Dr. Metz for all of the teaching you gave me in vaginal surgery.  I attempted my first vaginal hysterectomy on my birthday, 2 days ago.  It would have been the perfect case.  She had prolapse and a cystocele.  The problem was that she had had previous surgery, but didn’t know what kind to help with her bladder.  
Four hours later we were done with my first attempted vaginal hysterectomy here.  The problem was that someone had done previous surgery to attach her uterus to her sacrum (I have no records, and the exam did not allude to this). Dad and I (yes, very thankful he is here), did most of a vaginal hysterectomy, then switched to an abdominal hysterectomy, then attached her closed vagina (without the uterus) back to her sacrum, and ended with a vaginal repair of her bulging bladder.  She had the right surgery in the end, was a very exhausting birthday for me.  
I have many more thank you’s to write to everyone at Baystate, but this blog is already way too long.  
So last but not least....
Thank you Springfield weatherman for waiting until after we left to predict the coldest winter in history in Massachusetts.  “Cold season” if you can even call it that, is just ending here.  Things are starting to heat up on this side of the world.  
You might be in Tchad ask for a single use foley catheter to see if the laboring patient’s bladder can be emptied for the baby’s head to come down.  There are none in maternity.  There is one in the trash that the nurse just attempted to use.  You say no, but then realize it is better than nothing, so just pour betadine all over it before using it again on the same patient.  
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