Local

We aren’t very frequent blog writers anymore.  Sorry for that.  I guess it’s because after a while everything ends up being same old, same old.  

But believe me, there is still lots going on.  Lots of surgeries still, even though it’s slow season.  Problems with administration.  The accountant who “lost” a ton of money under our old administrator, who admittedly stole money, is refusing to sign his resignation.  So now Olen has to take him to the justice.  Seriously dude, we’re letting you get away with just saying you’re incompetent, not even that you stole money.  Because clearly you are incompetent.  So just accept it!  

Problems with nursing staff.  Yesterday I had my 5^th maternal mortality of the year (I had 3 in January so was off to a bad start).  She shouldn’t have died.  A lovely postpartum Fulani mother with a living baby girl.  I’m sure she died of hypoglycemia.  She was completely fine that morning, just a little anemic and not eating much.  She was hospitalized on oral quinine for several days already.  I went to do rounds this morning and was told that she died.  No one came to say, ”Doctor, she’s getting worse.”  “Doctor, please come help.”  Nothing.  Just…”She died at 20:00.” 

“From what?” I asked during rounds this morning.

“I don’t know, it was the night staff, it just says here that she died.”  

Frustrating when you live 50 feet from the hospital and are always available to help if needed.  

So tonight I went in to see my complicated pregnant patient when the nurse came to tell me she was worse.  

G10P9 admitted in a coma yesterday at unknown gestation.  She had been sick for 5 days, but in a coma for a day-ish.  She had a raging fever and was jaundice.  Her BP was a little elevated, but then the next few were normal.  I did an ultrasound that put her at 26+6 weeks (just under 1 kg).  I put her on quinine for cerebral malaria, gave ceftriaxone, and started steroids for the baby just in case my dates were off in case I needed to deliver the baby (babies don’t live under 1.5kg here usually).  She got a foley.  She got blood for her anemia of 6.  I asked for BP’s every 6 hours so I could have more information whether it was eclampsia or not.  

This morning on rounds.  Oh, come on guys, why hasn’t she gotten ANY BP’s during the night?  (We only usually ask for one set of vitals every day because more than that just doesn’t get done.  This takes place at 5 or 6 am usually.) 

Okay, well, she’s still comatose.  Her eyes are yellow.  Her pee is really concentrated in the foley bag.  The BP at 5am was 150/90.  I retake it during rounds.  It’s 120/70.  Hmm...did someone take it right this morning, or is she really elevated?  I ask for more BP’s to be taken.  The patient responds a little to sternal rub and and during the day opens her eyes but is not really with it.  We continue the quinine drip for cerebral malaria.  I explain to the family (about 15-20 people crowded in when they are not all supposed to be in our tiny room) that we are doing what’s best.  I’m paying for the patient now, so don’t even think about taking her home!  Nice long conversation with the family, including the husband.  It takes several days to recover, and they had her at home for 5-6 days before coming here.  One doesn’t recover quickly from something like this.  I told them she had a 50% chance of living, but in reality it’s less than that.

Several hours later.  Husband demands to take her home.  He sees no change in her state after less than 1 day in our hospital, so he wants to go home.  

Seriously!?  We went over this already!  The family convinces him to listen to me.  

Tonight the nurse comes to get me that she’s doing worse.  

I go to look at her.  She’s not really doing worse, (it’s hard to do worse than coma) but now has a BP of 160/90.  I retake her BP.  The first automatic BP cuff doesn’t work.  The second automatic BP cuff doesn’t work.  Was it really elevated or the machine just didn’t work?  I ask for a manual cuff and miraculously after 5 minutes one appears.  

I take the BP myself and get 160/90 again.  

I decide that it is probably eclampsia with malaria and to operate to increase her chances of living.  It’s a risk.  Her jaundice means that her liver is sick and she has a higher chance of bleeding when I cut her.  (Her jaundice is either from malaria or eclampsia).  I don’t have working exams to test her liver function.  It wouldn’t change anything anyways.  You just learn to do without here.  The only tests she has gotten are hemoglobin, blood type, and malaria smear.  

So, back to the operation.  We carry her to a stretcher because the stretcher won’t fit in the room she’s in.  We push the stretcher to the operating room.  

Ndilbe and I discuss anesthesia.  I pinch her legs, she doesn’t move.  Ketamine not possible with her BP.  Spinal is risky if she has an increased chance for bleeding (sick liver) and, plus, she’s really sick.  We decide on local.  This was actually my first time to use ONLY local for a c-section that I can remember.  I’ve started them and then done ketamine once the baby is close, but haven’t done one exactly like this before.  

Alexis and I prep the patient and scrub.  I inject 10cc of lidocaine just under her skin along the incision area.  She doesn’t budge.  My blade doesn’t have the right knife handle so I just pick up the blade with no handle and cut down to the fascia.  Her fascia is yellow.  Normally it’s white.

I cut down to the uterus and take the baby out.  There is a lot of meconium like the baby was already in distress.  The baby dies a few minutes after delivery.  It weighed about 1 kg.  

I suture the uterus.  It’s extremely atonic (not contracted).  The oxytocin is going in intravenously.  I ask Ndilbe to inject oxytocin directly into her uterus.  It firms up some, but not completely.  I ask for my suture to manually contract the uterus like I seem to do 50% of the time I do a c-section here.  I place sutures through the uterus and cinch down the uterus so it can’t fill with blood once she goes to the floor if the nurses forget about her and she gets worse uterine atony.  

I do a tubal ligation without asking.  Something I would have never done when I first got here.  I’ll tell them if she lives.

I close fascia, then skin.  

All of this with no anesthesia.  Okay, I mean all of this with ONLY LOCAL anesthesia.  

She didn’t budge from pain.  

For those of you that don’t know, the treatment for eclampsia is delivery of the baby.  So at least that part is done now.

She’s really sick.  She probably has eclampsia with cerebral malaria also.  Either way, she needs your prayers.  I restarted the quinine when I got to the floor.  The maternity nurse was in with a delivery.  There was a nursing student helping her.  She doesn’t have a clue.  

I told her to watch the drip and make sure it doesn’t go in faster than 4 hours.  She started translating all of this to the family.  

I said, “No, you are the nurse.  You need to watch it and make sure it doesn’t go in too fast or too slow.”  

I told her to press on the fundus of the uterus and if she bleeds too much, look for the other nurse.  It’s like telling at kid to watch this patient and make sure she doesn’t die.  

That’s what it’s like here.  And I’m sure if I hadn’t been here for 3 years already, there would be a million other details that you would never believe of the things that go on here every day that would never happen in a first world country.  

Please pray for her.  Her name is Berthe (probably Bertha in English).

Danae