My nurse on maternity just came to my door. It’s 1:30 in the morning. Sabbath morning. She’s got lots of experience so I trust her. She just came to tell me that one of our patients had delivered and was quite anemic (hemoglobin 4). The baby died soon after delivery. I gave her the keys to the operating room where we keep the blood bank so she could get another bag of blood to transfuse because the family still wouldn’t give blood. Sad. One of my realities.
The same patient had come in the night before very pale with anemia symptoms and a hemoglobin of 3 and no bleeding. (For reference, any hemoglobin under 7 is typically considered life-threatening and gets transfused in America.) We gave her two bags of blood, about half what she would have received in America. The family wouldn’t give. Our blood bank is limited. Mom said baby was moving less. She had no due date (unsure of her last period, which is typical here) and I have no ultrasound for the moment. I explained that the baby needed the mom’s blood to survive. Still the family wouldn’t give. They fear they may not have the strength to work in their rice fields if they give their blood. They play a dangerous game of chicken to see if we will give from our blood bank. And it’s a game we always lose, drawing blood before every elective surgery, drawing blood from our volunteers, drawing blood from our staff…
Once last year I went without an ultrasound machine for two days. It was a very long two days because I depend on it so heavily. Now I’m at five days and counting with two busted machines. It is a very terrible situation. But what do you do?
Three days ago I opened a young lady with a small Phannensteil incision for possible ectopic pregnancy. Positive pregnancy test. No ultrasound to confirm, but pain. Not too terrible though. Not anemic to speak of. I just couldn’t send her home without knowing. And…..there’s nowhere near that has an ultrasound. Everyone usually comes to us for referrals. Lai, Kelo… even further.
Well, it’s a good thing we opened her, because she had a growing and life-threatening ectopic pregnancy in her right tube and she was actually ruptured with a small amount of blood in her pelvis (500cc).
Oh, and just prior to her case I was told we didn’t have any 10, 12, 14, 16, 18 size foleys (tube to empty urine from bladder). I found a bunch of straight catheters, so taped one of those in place during the case. Again, one of my realities. It’s never a surprise anymore. Just do the best for the patient with what you have.
Today I opened a “three month” pregnant lady with a huge flank/pelvic mass that I shouldn’t have had to. An ultrasound would have clearly told me that I didn’t have to open her. She had such pain and the patient said through translation that it had only been there since the pregnancy started. Differential diagnosis: ectopic (hey, I’ve had a seven-month ectopic pregnancy), torsion with large ovary, huge liver abscess, other abscess, cystic kidney, intestinal tumor (less likely) given no vomiting.
No ultrasound. What to do? Positive pregnancy test. I opened her.
It turned out to be a large retroperitoneal mass (more than 15cm) extending down into pelvis with a normal (or at least intrauterine) pregnancy. So my most likely diagnosis now is a large cystic kidney. Of which an ultrasound would have easily shown. At least it was a small incision. And don’t judge me for opening a normal pregnancy.
I closed her up, not messing with a kidney while pregnant. We’ll bring her back after she delivers to deal with her mass if still necessary at that point. I re-questioned the family when explaining the diagnosis. They said, oh ya, she’s had that mass since she was married (a few years). Awesome… that’s not what you said BEFORE the case!
Invasive testing (a surgery!) when otherwise wouldn’t be necessary. Part of my reality right now.
Back to the repair of our ultrasound machines… We swapped ultrasounds with our sister hospital in Moundou, since their machine was better and we do more ultrasounds. Then Moundou’s ultrasound broke while in our possession. We sent it back to America for repair, which took three months. We then took back our ultrasound machine from Moundou while their machine was getting fixed. We finally got back the good ultrasound machine from America. But then it just broke. And then the old machine broke right away after that!!! I don’t know what we can do with the old machine, but we will send both machines back for repairs with the next volunteer returning to America in a couple weeks. But it will likely not return until January. So odds are good we will be without an ultrasound for the next 4-5 months!!! That’s really going to hurt us financially and with the care we give also. (Ultrasound is about 6-7% of our income and 1% of our cost. That’s good business!!!) We’re hoping to find either a donated machine or the funds to buy a new one. SonoSite sells Adventist Health International a sweet portable machine for $7500 plus $2500 for each probe. We really should have a spare.
This week I got to remember what it’s like to be a single parent to three kids temporarily. Olen’s been in the Ivory Coast for a week and a half for global healthcare conference. Mom usually watches the kids during the day. But… she got malaria this week. Thankfully our new student missionaries have jumped in and helped out so much taking care of the kids when I’m at work.
It’s just me and my dad taking care of things at the hospital. Then Dad also got malaria! So one of those days it was just me. He was in bed for a day, though I did make him come in for five minutes to start a thoracentesis. I just didn’t feel like puncturing a lung since it wasn’t urgent.
Dad’s getting better (he’s 72-years-old) after three days of Malarone and Fansidar. Mom’s (also 72) treatment is finished, but she’s still sick. So continue to pray for her recovery. She may need quinine, but we’ll see how she does overnight. I told my dad that I am stuck with the old (them) and the young this week! He’s not really old, my parents have a strange youth to them! Malaria can knock any young whipper-snapper down on their butt.
On a positive note, I somehow managed to treat a few cases out of my comfort zone while Olen and Mason were away and while Dad was under the weather. A 20-year-old boy with diabetic acidosis (complete with Kussmaul respirations and not quite with it in the head). Fluids, fluids, fluids. Lots of checking to see if nurses were actually giving it. Checking to see if family were paying for the fluids that I prescribed. Night one at 11pm, found nurse sleeping. Didn’t yell (go me!) and instructed to please get a second line like I said to the previous nurse, and pound the fluids (10 more bottles before morning!). Next morning, no more Kussmauls. Yay! Some improvement.
Next day. Patient actually able to communicate and actually with it. Thank you Jesus. I thought for sure I was going to kill him. (Not me, but the sickness of diabetes).
(Editor’s Note: Danae treated this extremely-non-obstetric patient who would have otherwise died as perfectly as any physician could in our circumstances, saving his life. I discharged him the day I got back.)
Next to him was a CHF exacerbation that I somehow managed not to harm, and actually to treat. No ultrasound. And we’ve never had a working x-ray here. Another reality. Just go on exam and symptoms. Labs… what are those? I’m serious. Hope he’s not hypokalemic with the Lasix I’m giving him. If he were, we don’t have any potassium supplementation. Eat lots of green foods!!
(Another Editor’s Note: Danae treated this dying patient perfectly as well. I discharged him too the day I got back on atenolol and minimum-dose furosemide.)
Another 20-year-old kid on surgery that had a couple of leg abscesses walked for the first time in a year and a half with the help of a walker. He is such a bright, happy, smiley kid. He is so happy to be up on his feet.
He thought he was paralyzed. But his legs actually have sensation and can move some. He can’t bend at his hips at ALL. I have no idea what he has! I’m an OB doctor. But because of his sensation and slight movement, I said, why don’t we see if the walker can help him! Up till now his family has been carrying him around everywhere, or he just stays in place.
Today I got to see his smile while he was using the walker for the second day. He was so, so happy. He said he hadn’t been upright like this for a year and a half! Pray for his continued practice with the walker. Hopefully we can give him a little independence with practice!
We were just in America for a month to celebrate my parent’s 50th wedding anniversary! Congrats mom and dad!
It’s not really a shock to go back and forth anymore (between America and Tchad).
However, this time I attended a board review course for my obstetrics/gynecology oral boards. The shock now is in studying! Ha ha, really it is in studying what labs and tests I’m supposed to be ordering on my patients. It makes me chuckle and laugh, and a little sad. These patients don’t even have 1/10th of the care they are supposed to be getting! We don’t have much to offer them. (And now we don’t even have an ultrasound!!!) It’s sad. It’s the reality here. You get used to it. You get used to not having supplies. Accepting less than quality care because to enforce more would literally take up your last amount of energy and you’d never make it long-term. You get used to death. Of cute little babies dying. Of moms, struggling to have a family, dying in childbirth. Of old people who have lived a happy life dying. Fifty is old here, well past the average lifespan. If you live to fifty, you have made it.
I’m so happy that Olen has returned from his galavanting! Mason and Olen returned last night. The conference was wonderful and now they will fix our hospital! Ha, not likely, but hopefully gathered a few more tools to keep us from going insane earlier than expected. (The cultural challenges as they pertain to work, school, church and home are still by far the greatest stressors. Perhaps that will change over the course of generations as the world becomes smaller and globalization advances each year.)
Please continue to keep us in your prayers. It’s easy to get back to America and forget that the daily struggles continue here. And it’s impossible to describe fully the struggles we share with the Tchadians. But, I assure you, they are very real every day here. But so is God, and He keeps us sustained.