Sunday, February 20, 2011

#25 Timing

Most nights I sleep through the night with only Lyol waking me up or the occasional knock on the door for Olen (one of his nightly visitors usually--ha ha....something medical in the hospital).  Thursday night was special because I had a laboring OB patient that wasn’t going anywhere fast with her progression towards delivery.  

She came in the afternoon.  I had my suspicions that she wouldn’t deliver vaginally when I looked at her feet, which were short and stubby (OB superstitions).  She was only 16 and on her first baby.  Full term-ish.  It was difficult because she didn’t speak French.  I gave her a LONG try at a vaginal delivery.  I couldn’t start oxytocin on her (medicine to give your stronger contractions) because many of her contractions were lasting 7 minutes as it was!  Somehow, the baby seemed to be tolerating it.  Finally, after a much too long try at a vaginal delivery (cesareans are not so good in Africa if you want to have 10 children, especially on your FIRST delivery), at 2:30 am, I called the OR team to the Bloc (the term we use here for operating room).  Simeon (our anesthesiologist, really a nurse who learned spinals here) was called and came from home.  Ndilbe came from home (nurse in OR).  Abre was already working that night, so he scrubbed with me.  

I felt bad doing a c-section since it was her first baby, but it was necessary since her cervix wasn’t dilated all the way.  There had been a lot of meconium (fetal bowel movements), and since we don’t have NICU here, I deLee suctioned the baby’s nose/mouth just after delivering the head.  Simeon handed me the part for the baby sterilely, and he suctioned with his mouth to provide suction.  

Healthy mom and baby.  For now it seems.  After we brought her back to the ward (no post-op recovery unit here), I milked her breast and colostrum came!  I put the baby on her breast and she started sucking!  Trust me, that is a HUGE step towards surviving the first week here in Tchad.  Eventually I will MAKE the nurse on maternity make sure that the mothers are feeding their children.  For now, when I ask why they haven’t eaten the whole night, it seems like the nurses just laugh or shake their head in disgust!  (It should be part of their job to help the mothers nurse their newborn babies).  However, the night nurse is taking care of maternity (5-7 patients) and all of surgery (about 20) patients.  

Needless to say the next day I was tired.  I got home about 4 a.m. and didn’t go into the hospital until 9am.  

I skipped doing surgery rounds so I could do an inguinal hernia with our Uncle Scott, a general surgeon.  I want to learn different ways to do them, and he does a nice bikini cut that we don’t do here.  During and after the inguinal hernia, I was feeling kind of nauseated and my 2nd day of diarrhea was getting to me.  Don’t worry I’ll spare you the details unlike Olen’s malaria blog!  

I went back to the house for a 15 minute break.  I lay on the bed and decided to only do one more surgery that day.  We had an abdominal hysterectomy lined up to follow.  

Finally, I went back.  Our hysterectomy patient got her spinal and I re-examined her.  I was doing the surgery for pelvic pain.  Her uterus was small and felt quite mobile with anesthesia. 

”I should really be doing this one vaginally.”

“Well, why don’t you?” Scott asked.

I already had the abdominal hysterectomy kit opened, but wasn’t scrubbed yet.  I don’t even have a vaginal hysterectomy kit put together yet.  But minimally invasive is much better than a huge abdominal incision that could easily get infected here. 

I decided we could use the instruments in our abdominal kit and just get a weighted speculum in addition. took a few more minutes to put up the leg stirrups and move the patient to her new position.  

Just then the maternity nurse, Juliette, rushes in to see if I’m available.  

She pulls me into the pre-op area.  There laying on the gurney is a pregnant woman.  Not just any pregnant full term-looking patient.  But this woman has a full term baby’s arm sticking out of her vagina.  

“When did it happen?”  I ask in French.  

“Today.”  (That’s better than 2 days, I think back to the last arm presentation I had in the second week I was here).
I run to the office to get the ultrasound.  It’s small and portable, so I unplug it and bring it into the OR prep room.  

Meanwhile, the vaginal hysterectomy lady has her spinal and is prepped, but not draped.  

I put the ultrasound on and find the baby’s heart.  It’s there!  The baby is alive!

“We have to do a c-section, now!”

Will the team let me switch patient’s, or do I have to do it out here?.  I go and discuss with Simeon, and we decide to switch the patients.  We re-wrap the hysterectomy kit and put it aside for after the c-section.  

We quickly switch patients.  In goes the foley urinary catheter.  Betadine (for cleansing) for the abdomen.  Not enough time for a spinal, so we decide to start with lidocaine (anesthesia similar to what the dentist uses) locally and then ketamine IV after the baby is out.  

Quick prayer.  I inject 10cc of local anesthesia and make the first cut down to the fascia for a low transverse incision.  Her fascia is really tense and she starts to move.  Simeon gives her a little ketamine and she quits moving.  Her muscle is still tense, but we make it in quickly to the uterus.  Bladder flap.  I make the uterine incision and open the uterus. 

“Oh my, now wear is the head?”  I search for the head and finally find it over on the patient’s left side, midway up. I switch hands from my right to my left to get better leverage on the head.  

“This is going to be difficult.”  I grab the scalpel and incise about 3 more inches on the skin and muscle to make more room.  

Finally, we were able to bring the head over to the uterine incision and deliver the head, followed by the baby.  

I handed the baby over to the nurse and Olen.  Olen resuscitated the baby with the Ambu-Bag and squirted dextrose in the baby’s mouth.  After a few short minutes, the baby boy let out a small cry.  

We sutured up the uterus, fascia, and skin.  Mom and baby alive!  Two in one day.  

If we would have started our other case any earlier, we would not have been able to do the c-section, while keeping the other patient’s safety in mind at the same time.  Praise God for another life!  

Scott and I wanted to take a short break to eat.  I was already feeling sick today, but somehow adrenaline was now running through my body.  We move the vaginal hysterectomy patient into the OR after cleaning it, so that she will be ready after lunch.  Simeon convinces us to just start and eat lunch afterwards.  

So....we do.  It was successful and not much blood loss.  Even though I did not have a vaginal hysterectomy kit made up yet.  I made due with MANY missing instruments.  At least I had 2 curved Heaney clamps.  It would have been nice to have some straight ones.  I was happy though since it was my first successful vaginal hysterectomy (2nd attempted, the other turned abdominal--see previous blogs), and it went well.  Poor lighting for a vaginal case, poor tools for a vaginal case, but no complications. 

The day was almost over.  Just a few more ultrasounds and GYN consults in the office (mostly infertility or painful and irregular periods).  I stopped by maternity to put the new baby boy on his mother’s breast (otherwise it won’t get done till the next day!).  He started sucking well!  It was her 2nd baby and he too was alive.  He’s not moving his arm, so I’m pretty sure it’s broken. 

That night I was able to relax in Jamie and Tammy’s house singing songs to bring in the Sabbath.   We sang mostly kids songs until I brought Lyol home to sleep....also an excuse for me to go to sleep early.  Sweet sleep again, until the diarrhea hit again in the morning. 

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