Baby Face

Baby face

Awe.  It’s so cute.  That’s what I say most of the time at cute, little babies that have just been born.  But this baby is certainly NOT cute.  She is plain UGLY.  She has an ugly face.  

But it isn’t her fault.  And it won’t stay ugly forever.  I hope.  

The mama came in while the midwife, Sabine, and I were doing maternity rounds.  Fideline called Sabine away from me for an emergency.  I waited for a minute, then Sabine called me for a dead breech baby.  

This lady had nine deliveries, and had been laboring for a long time.  She was at a few different health centers before finally being referred to us.  

I quickly put on a glove to examine her.  She’s about ready to deliver a baby.  About four centimeters of baby is pushing out from her, but it’s not breech.  Breech is a baby being born butt first and folded up, followed by legs and belly and finally head.  This is not that.  It looks like a baby butt.  But it’s not a butt.  It’s a face.  It’s a baby face.  And it clearly looks dead.  The mouth is wide open.  The tongue is stiff and not moving.  The skin is macerated even.  They did not find a heartbeat either on initial exam.  (It takes a while to get the ultrasound, so I didn’t bother).  

This poor lady has been in labor for a long time.  With the difficult position of the baby, coming out face first, the baby just won’t deliver.  The poor baby face has had multiple fingers poking at it, thinking it was a butt, and it was all black and blue.  The baby mouth, fingers poked in it, thinking it was a butthole.  The baby eyes.  Fingers poked in it.  Not sure what people thought the eyes were.  All from people who did not know what they were feeling, so they poked more to try to figure it out.  

I feel bad for her, so I’m going to cut an episiotomy to help her deliver faster.  I explain to the three nursing students about mentum anterior and mentum posterior, which one would deliver vaginally and which one wouldn’t.  If the chin is up, she can deliver vaginally most of the time.  Luckily for her, the chin is up (mentum anterior).  

As Sabine runs off to find another delivery kit that actually had scissors (we had taken the scissors out of this kit to use them to remove stitches on rounds), I stay with the patient and push with her.  She quickly advances the head farther out, and in a few short pushes delivers the head and then body.  

The lifeless baby lay in the amniotic fluid on the table as I clamp the cord and wait for the scissors.

Soon Sabine arrives with another kit that contains scissors for my episiotomy, but realizes I don’t need them.  As I wait (maybe a minute after delivery), the dead baby kicks her leg.  What?  Is this baby actually alive?  How could that be?  She’s got rigor mortis in her face.  Her ugly, ugly face.  Her tongue is stiff.  

I quickly cut the cord and bring her over to the delivery table to listen to her heart.  Somebody gives me a stethoscope.  No heartbeat.  

That was weird.  Why did her leg move?

I clean off the ugly, ugly face attached to an otherwise perfect corpse.  Her arm moves.  

Definitely not breathing and no heartbeat.  But extremity movement???  That’s not right.  

Okay, there’s life in this baby.  

Maybe the stethoscope wasn’t working well.  Hand me the ambubag.  

I started breathing for the baby.  This baby has rigor mortis.  Of her face.  Her tongue is stiff from being dead so long.  

The ambubag wouldn’t bag properly.  I remember our oxygen machine is still broken.  Either it’s broken or the plug is broken.  Not sure which.  The alarm had been going on for many many months now after it had been turned on for just a few moments.  We just figured it was dirty, like everything else gets in dry season.  

Olen’s gonna kill me, but this little kid wants to live.  I left her for dead the first minute of life, and now she wants to live.  

I quickly rub alcohol on the baby’s face and start mouth to mouth.  It’s the only way I can get a good suction over her nose and mouth with it being so stiff from edema.  

I’ll just try a little bit.  There is no way that this kid is going to live.  It’s already been a few minutes and been oxygen deprived.  

I breathe for her.  I get good suction with my mouth and breathe life into her lungs. 

Sabine helps me by doing a little cardiac massage.

I listen again.  She definitely has a heartbeat now.  Though slow.  

More mouth to mouth.  

After a few minutes she starts taking breaths on her own.  

Her face is black.  Not from the melanin her genes put in her skin.  From being prodded so much before she was born.  It’s more like a purple black.  Stiff.  Her mouth still is so swollen.  Her tongue is still stiff and cold.  

I breathe more for her.  We stop CPR since her heart is beating now at a normal rate.

She starts breathing on her own.  

Well, I guess she’s living now.  

Now what?  

Antibiotics and steroids.  Her poor little throat is so swollen.  Everything is swollen in that ugly, ugly face.  

Sabine gets a IV line on her beautiful little wrist and we start antibiotics. 

I don’t know how in the world this child is living.  She’s a fighter.  

I finish maternity rounds.  I finish surgery rounds.  I do 3 surgeries.  Slow season is starting, so there aren’t as many surgeries now.  There are a few hernias that want to be done, but they only paid today, so I make them wait until Monday.  Where in the world can you get drive through surgery, except here?  We often do hernias the same day they pay for them.  But I’m tired.  It’s Friday afternoon, and I make them wait.  I get to hear the complaining of the patients who have to wait.  

I go over to maternity to see if our EMR system is working over there.  I had someone cut down some banana plants today that were blocking the signal, and am pleased that it is now working.

I check out ugly, ugly baby face.  She’s still breathing.  The family had tried to give her something to drink.  Not sure if it was water or milk, but I tell them to not give her anything for a day because they are probably going to pour it down her throat and into her lungs.  I ordered an IV dextrose drip.  She is breathing loudly.  I stimulated her by rubbing her back and she actually cried!  It was a croupy cry, but still a cry.  She was sucking a tiny tiny little bit on my finger, but her mouth is still pretty stiff.  At least her tongue is a bit softer now, but still pretty hard.  

I hope and pray that the swelling goes down, and that she lives.  Cute ugly baby face.  If she lives, God’s got big plans for her!  And her beautiful face.  

Date Night 2

Date night 2

There’s lot’s of dating going around here.  Sarah’s dating Gabriel.  It’s a real life romance.  I’m trying to get her to start a blog.  You would enjoy her dreamy romantic life with her young Brazilian-French man.  

But, since she’s not yet writing a blog, you’re stuck with my romance.  

Date night 2.0

Last time we had to save a kid’s life after he fell on his head out of a mango tree.  This time I needed an assist on a Friday night.  Sarah had malaria and we were making her rest.  So, guess who get’s to hang out again?  Us!  

The kids were already asleep.  We live on a compound.  And have a guard.  Don’t get too judgy.  

There’s a C-section that needs to be done.  I need an assist.  Hmmm… Olen needs practice doing C-sections anyways.  He knows how to do it in theory.  

I ask Philippe if he minds taking 10 extra minutes during the C-section and I motion that Olen’s going to do it.  He laughs and says it’s good.  

Olen is an awesome surgeon with great natural talent.  He just needs more practice.  Now that Dad’s gone, I’ve been in the OR non-stop.  Mom’s gone too.  We tried some people out temporarily, but our kids really need school, discipline, and stability.  So Olen and I decided that one of us needs to stay home.  Since I have more surgical experience, I need to be in the OR.  So Olen has been staying home a lot with the kids.  We didn’t really have this planned out that well since we are supposed to be starting our Appalachian Trail hike in six days.  We would have pushed to have a student volunteer harder if we knew we were going to be here now.  

So, Olen jumps at the opportunity to hang out with his wife.  And, wifey makes him become the student.  

I prep the patient.  I drape the patient.  I hand Olen the knife and tell him to cut.  I hand him the scissors and tell him where to cut.  I hand him all the instruments and tell him what to do.  He already knew it, but I wasn’t waiting around for him to think about it.  It was the middle of the night and I wanted to go to sleep.  Some date night, huh?  

Olen did amazing.  He sutured up the uterus in 2 layers perfectly.  He sutured up the fascia perfectly.  He sutured up the skin perfectly.  

The baby and mother are doing well.  This time 2 lives saved. Going to the movies will never be the same again.  

Although.  That does sound fun to me.  And maybe a nice restaurant and a stroll in the park, hand in hand, with city lights and no malaria.  

Date Night 1

Date night 1

8pm on a Saturday night:

“Dear…would you come up and help me with a kid who has a skull fracture?”  I heard my dear husband ask me.  

“No thanks,” I say, “They never live anyways if they are that bad off.”

The kids weren’t ready for bed.  They were running around the house like crazy hoodlums.  Screaming, yelling…

On second thought, “let’s go!”

After some more hassling from my dear husband, I decide to go assist him with the skull fracture.  

Olen’s dad, Kermit, AKA Gampa, had been here for a few weeks, and it was his last night with the kids.  So, we left him to put the kids to bed.  

Olen and I head out the door in our finest clothes for date night, scrubs.  This is becoming a recurring theme since Mom and Dad left.  Put the kids to bed, head out of the house to the hospital.  

Olen brings the kid he had examined earlier into the OR.  I don’t get too involved.  I’m just there to assist.  I sit against the floor in the OR, waiting for Olen to tell me when he needs me.  

Olen knows me.  In the OR, it’s hard to JUST assist.   It’s hard for me to not get involved with the family.  I wish I could just be a machine sometimes.  Just operate.  Don’t get involved.  

“Dear, this kid is actively dying.”  I say.  “Does the family know how bad he is?”  I don’t want them to think that we are killing him in here.  This 14 year old boy is gasping for air.  I’ve seen it many times just before someone dies.  He has wet lungs and could die at any second.  

I ask a nurse to bring in a family member.  

The boy’s father comes in.  Olen had already met and discussed things with him, but I wanted him to see the boy actively dying so that he wouldn’t say that we were the ones who killed him.  

I explain to him that he might die before we start, during, or after.  He had a high chance of dying.  

It was the look of desperation that I will never forget.  His eyes were pleading that we try something.  He told me that the boy’s mother had died when he was little.  He understood that his child may die, but he wanted us to try something.  It was his only chance.  

I told him okay.  

This 14 year old boy had fallen from a mango tree.

I’ve never made a burr hole before.  I’ve never elevated a depressed skull fracture before.  I know how to stop bleeding on the skin with suturing.  So… we’ll give it a go.  

I slice into his skull where we thought the biggest impact was.  I made a large cruciate incision.  I palpate and find a large skull fracture.  It wasn’t depressed, but it was certainly large.  Next I used a kelly to pry under the skull fracture and chip out 2 places for makeshift “burr” holes, minus the burr.  

Old dark blood began to ooze satisfyingly from compressing this child’s brain.  

After packing him and bandaging up his head, we knew we had done all we could do.  

We head home, thinking it was a lost cause.  

The next day I was surprised to see that this kid was NOT DEAD!  What??? He was so close to death last night.  

Maybe we should be doing more of these skull fractures?

Later in the day the family told me he had actually gotten up to urinate.  What???  He still wasn’t making perfect sense, but he was performing motor skills.  

The next day, he could talk and was acting normal.  It was a MIRACLE.  

After several days of dressing changes, the father brought his kid back into the same OR.  The same OR where I thought for sure our work was a lost cause.  Now we exchanged looks (sometimes that’s all you can do with the language barrier) of happiness.  No more pity look.  No more desperation look.  It was pure joy.  Pure thankfulness for the MIRACLE that God performed. 

This time I wasn’t telling him that his son was likely going to die.  I was suturing up the healing scalp incision to hurry him up on his road to recovery.  

I had written this kid off as dead.  Olen made me go on a date to help save a kid’s life.  Can’t think of many better things to do on a Saturday night!  

We discharged him in perfect health.  

A week later I was able to see the boy and his father in the same place (where I usually am, in the OR).  The teenager was dressed in his finest clothes.  A suit that was clearly too small.  But he was the happiest boy I have seen in a long time.  Grinning from ear to ear.  He was so proud to be coming in in his nice clothes.  

But I have never see a happier person than his father.  Pure happiness was etched on his face.  We understood each other.  We were there together when this child had no idea that we thought he was not going to make it.  Our prayers went up, and God heard our prayer.  And for that, we are thankful.

Interrupted

Interrupted

One of Lyol’s favorite jokes used to be a simple one.  

“Knock, Knock”

“Who’s there?”

“Interrupting cow”

“Interupt…..

“Moooooo.”

Well, we’ll just keep it simple here.  We had big plans to take 8-9 months off this year.  My dad, who’s been the general surgeon most of the time for the past 6 years, retired in early February.  We are missing him badly.  We had a wonderful young buck named Christian who had planned to stay from October to October.  Dr. Sarah, Family practice with a year of OB fellowship also came in January.  We had arranged with the GC to take an unpaid leave, a Sabbatical, to take a breather after being here for 7+ years.  Everything was set.  Sarah and Christian were ready.  We were ready.  We were to be starting our big trek on the Appalachian Trail, start date March 11.  

But our plans were interrupted.  

Moooooo.  

Christian got malaria several times and it was taking a toll on him.  So Sabrina (in charge of our nutrition program) and he wisely left for non-malarial grounds.  

Mooooo.

We decided to stay.  

Mooooo.

We are no longer hiking the Appalachian Trail this year.  

Moooo.  

Interrupted.  

Man makes plans.  God arranges our lives.  

Celebrating Birth

Lyol is nine years old. Almost double-digits. I feel all at once very old, and all at once way behind, as so many of my friends have kids driving vehicles already! (I can’t imagine…)

He thinks he had a great birthday, but his parents might not remember this as the best.

The day started with me keeping my streak of morning worship attendance alive (although I’ve missed the two days since). And I had even showered within the last 24 hours, so I had a lot going for me. After my typical couple hours of menial administrative tasks, I came home to watch the kids so Danae could go up to the hospital. She very badly wanted to finish by 2 or 3pm so we could take Lyol to the river for his birthday.

I cleaned the house cleaner than it had been in ages and I baked two cakes for the birthday boy and iced them. Danae made it home a little late and did what she does most birthdays, she made some absolutely awesome decorations for the cake, including one which was a camping scene in the mountains, with river and tent and bonfire and all the rest. Very impressive!

We hustled out to the river with Grampa and played for a good little bit. Even the Dietrichs came to play! We came back to the house and all the volunteers came over (except for Christian, Sarah and Sonam, who were still working hard with emergency cases over in the hospital). Danae ran up to the hospital to make sure Christian and Sarah had a good plan for a pregnant lady. The lady had a dead fetus in her uterus that had to come out, and the options were either to induce her to deliver vaginally or to do a cesarean. Danae virtually always gets these out vaginally, but I think the lady didn’t want any more babies and wanted a tubal ligation and I’m sure there were some other reasons too, like I think she wasn’t progressing in her labor with misoprostol and oxytocin is pretty dangerous here and people don’t watch it closely and it can rupture the uterus, something which rarely ever happens in America due to people not having as many babies and nursing care being able to be more diligent with less patients per nurse. 

(Danae’s addendum: She had an abruption and had already gotten 4 bags of blood, continued to bleed, and was definitely an indication for a c-section since she wasn’t progressing on oxytocin.  But she was stable and had a hemoglobin of 9 preoperatively).

Anyway, both Christian and Sarah know how to do a cesarean, so they were left to do it while Danae came home for the party. Lyol opened presents, we sang the song, he blew out the candles, we ate cake and frozen fruit salad. Everything was perfect.

Then Sonam called. They were doing CPR in the operating room. Well, that’s not good. But I start speed-walking to the operating room. I’ve learned running is rarely warranted. It just gets everybody excited and then mistakes happen. I’m there soon enough and Christian is pushing on the heart through the diaphragm. The dead baby is out and between the mother’s legs. Philippe is trying to breathe for her and Sonam is drawing up epinephrine, she already gave one. The lady has three IVs running. Sarah is poised to do CPR from on top if necessary.

‘Check a pulse.’

Christian pulls his hand out and feels her femoral artery.

‘Dude, you just had your hand on her heart for CPR. Get your hand back in there and feel if it’s beating on its own now.’

He puts his hand back in. ‘Yeah, it’s beating great!’

‘Philippe, cycle the blood pressure. Sonam, be ready with the epi. Actually, Sonam, dig in that drawer and pull out a Mac 4 and a 7.0 tube with a stylet and a 10cc syringe on it.’ Oh, how I’ve missed having an ER nurse. Sonam is spoiling me and has it ready within seconds. I ease Philippe out of the way and intubate the lady easily.

Blood pressure comes back low. ‘Stick the epi into the ringers and start a drip.’ Sonam is used to being able to control the epinephrine down to the microgram per kilogram per minute, but we can’t do that here. Just turn the spin dial to what you would guess is appropriate and then make minor adjustments as needed.

Danae comes in. Well, I guess we might as well finish. Christian and Sarah do a great job finishing the surgery while Danae and I try to piece together from everybody what happened. High spinal in a cesarean. Happens so often. Philippe is a great nurse and he knows to give a lower dose spinal for cesareans, and he did, but it still went high. It would seem we weren’t sufficiently aggressive when we noticed she started having breathing difficulty as the spinal anesthesia started to go high and weaken her diaphragm. As her breathing decreased and her circulating oxygen decreased, her heart stopped. That’s when I got called. Philippe had insisted to Christian and Sarah that it was imperative to get the baby out quickly. He was probably thinking to get pressure off of her inferior vena cava to reestablish normal venous return, but that wasn’t really her probably. What she needed was to have her airway secured via intubation and just be assisted in breathing for a few hours until the spinal anesthesia went away and she could breathe on her own. However, we’ve never taught Philippe to intubate. He still should have been able to breathe for her with a bag valve mask, but apparently it was too little, too late.

At any rate, I had her intubated now and could breathe for her as I like, she had her epinephrine drip running to keep her blood pressure up. It’s not an ideal situation and I’m hoping to get her off of the epinephrine as soon as I can. By the time they finish the surgery, she’s off the epinephrine and I have her endotracheal tube disconnected and she is breathing through it perfectly fine on her own. So I extubate her.

We put her out in the prep room with Sonam while we do another emergency surgery. I sent Philippe home and do the young girl under ketamine, since the gas is expired and the girl is too fidgety and nervous to really tolerate a spinal. We finish that surgery while Sonam is meticulously attending to the other patient in the prep room.

After the next surgery, we bring our lady back into the operating room to monitor her. She’s still breathing on her own, satting 100% on room air and with a perfectly normal blood pressure. But she’s not waking up. She’s not making urine. She’s not well.

A few hours later, a little after midnight, I head home and leave the patient with Danae and Sonam. Sonam just spent the night before with a post-op patient with a typhoid perforation. The poor patient went septic and died. Sonam also spent years in an ICU and knows what can be done. She knows this patient shouldn’t die. She did her best. And the girl still died. She had a hard time with that. And she’s not going to leave this patient either. Danae is stubborn. She won’t leave. She’s the one who had the conversation with the patient about continued oxytocin versus cesarean. She truly thought cesarean would be best for her. And except for a high spinal, it would have been. But Danae won’t leave her. She has that annoying sense of responsibility. So Danae and Sonam spend the night with the patient, just looking at her. There isn’t anything to do. We did all we can here. She won’t wake up. 

Danae crawls in to bed at 5:30. ‘She died.’

‘I’m sorry, honey.’ And I am. But I can’t really offer more than that.

At 9am, Danae comes out of the bedroom. I’m not really doing a very good job keeping the kids quiet. She puts on a fresh pair of scrubs and goes back up to the hospital for another day.

Househusband

The Best Laid Plans on Mice and Men…

So our plans changed. We had planned a nine-month vacation this year to bond with our kids, away from the hectic 24/7 schedule of a mission hospital that has defined our family schedule, or lack thereof, for over seven years now. Lyol is nine and time flies. We don’t want him growing up and just remembering that his parents worked a lot, ‘Because there’s somebody at the hospital who will die if we don’t go up, buddy. Sorry. We’ll be home soon.’ This vacation was our way to refresh for a final push and try to last another three years here without burning out until new docs show up.

We had planned to hike the Appalachian Trail. We bought all the equipment. We went out on eight-mile hikes with backpacks through the sand with the kids. We had a sponsor supplying all our food. We had spreadsheets of all the mail drops, how far apart they were, how far off the trail they were. We read all the books. We knew how unlikely it was we would finish the whole thing. But we also knew how stubborn we are and there was a chance…

We had a schedule. Speaking engagement in Loma Linda March 3 for alumni weekend Sabbath School. The programs were already printed up and everything. Spend a week in the mountains of Big Bear (we already have a condo rented) hiking around to test out our legs and our equipment. Start the Appalachian Trail in Front Royal, VA heading north on March 11. We had the money saved up. We had the church agree to grant us unpaid leave. Everything was perfect.

Well, then our replacement surgeon, Christian, got malaria. And then got it again. And then again. And then again. Like back to back to back to back. His blood must be like mosquito-Gatorade or something. And his malaria is evidently resistant to all our best treatments. So understandably, he doesn’t really care to stick around and subject himself to that anymore. So he’s headed back home. So we’re headed… nowhere. That’s where we’re headed. Nowhere. We’re not going anywhere. We’re staying here. We’re stuck.

So our plans are off. No Loma Linda. No Big Bear. No Appalachian Trail. Nothing. Poo.

Sarah is a fantastic doctor. But we can’t leave her alone for nine months. A few months of slow season, maybe, and we can get some volunteer doctors to help her out. But not nine months. Too much for one doc.

In addition to our longterm surgeon and my father-in-law, Rollin, leaving a week ago today, he took his wife with him! She was the one raising our kids for the last six years. And our cook quit a few months ago. And the kids’ previous babysitters all moved home or are in school. And we always said we wouldn’t ditch our kids with non-family just so we could work. But that was before we were in the position where, if Danae and I don’t both go to work, that means either one of us works A LOT or patients die.

And now we start to throw ourselves a massive pity party.

We can’t leave our kids of 9, 6, 4 and 2 home alone. They need homeschooling. They need guidance. They need oversight. They need fights settled. They need discipline. They need attention. They need love. They need lunch! They need a parent. And Danae would be awesome at all that. She would be the best.

The problem is the hospital. The hospital needs a surgeon. Sarah isn’t capable yet. Danae is. Danae is an awesome surgeon. Danae is a natural surgeon. I tried. I’m a tenth, no, a hundredth the surgeon she is. And that’s me being generous to myself. I learned the little stuff. But I’m no natural at it. The patients need her. The hospital has a reputation of being THE surgical hospital around. So Danae will work. And she will work like a dog. I know her. She will do her best. And she won’t stop until she’s given all she can give. She’s still my hero every single day. Even when she’s working 14-hour days, just like the last two days, doing ten surgeries each day, because they need to be done. The OB/gyn doing hip disarticulations in a last-ditch effort to save the patient with gas gangrene of his leg clear up to his belly who just arrived, after being hospitalized elsewhere for three weeks. (This is literally an example from just four hours ago.) She’s never done it before. Never seen it done before. But she did it perfectly.

So that leaves me being the stay-at-home parent. And this is a very new identity for me. I’m not really sure how this is gonna go, honestly. I can cook. A bit. I can clean. A bit. I can be a parent. A bit. But this will be a major adjustment. I will no longer be the missionary doctor. I mean, I’ll probably still be in the hospital 7-9 at least each morning doing all the administrative stuff. I’ll take medicine and peds and trauma call 3pm-7am every day. I’ll come up and do consults or ultrasound or anesthesia or whatever when they need me. I’ve been in the hospital 8-10 hours every day this week still. I’m sure I’ll still be putting in my forty hours each week. But my primary responsibility will be childcare and wifecare, because childcare and wifecare allow the wife to save lives every single day I do it.

So I’ve decided I’m going to give it my darnedest. I’m going to be the best househusband I can be. I know how hard my wife will be working in the hospital. I need to try to work every bit as hard at home. It would be disrespectful to her not to. Especially knowing she’d do a better job at it. I’ve got two doctorates (one honorary, so doesn’t count), and I’ll be a househusband. Well, my brother-in-law has a masters and is finishing his doctorate this year, and he’s been a househusband for almost a decade now. And you know what, he seems to be absolutely amazing at it. (No offense to my sister, who is a ridiculously awesome mother.) So if he can do it, I can deep six my identity as a doctor and put my money where my mouth is and actually put into practice what I’ve always said, which is that my job won’t ever define me. My family will.

And I’m sure I’m not the only one. I’m sure there are men and women everywhere putting their careers on hold or even in the coffin, because they also feel their families are worth it, and that’s where the need is. My wife is needed in the hospital. Badly. So that means I’m needed at home. To all the men and women who have walked this road before me, I have huge respect for you and I hope to do you honor following well in your footsteps, but I can’t guarantee I’ll be any good at it.

So here we go… I see lots of unsavory meals, sketchy laundry, mislearnt homeschool lessons, destroyed living rooms and many other misadventures in the future. But I will do my absolute best. And I know Danae will too.