Wednesday, March 30, 2011

On call day 2 (yesterday)

Started out innocently enough. Did not receive any phone calls overnight, so I slept well.  Rounds went relatively smoothly, especially after Stephen came to help round since his flight was cancelled again. However, around 11:00 am, I was asked to come to Maternity to evaluate a patient. It was a woman with twins at about 20 weeks, but one of the twins had passed away some time ago. Now she is having bleeding and cramping. I put her on bedrest, which is about all one can do. Then there is a woman in the next bed who is laboring, and the nurse starts to push with her. She asks if I want to assist with the delivery, so I come over to help. That’s when I realize the patient is really only 8 cm, and not ready to start pushing. So I have her stop pushing and let her labor more. I go back to try to finish seeing the other inpatients. Just before we finish, the nurse comes to find me again to see two patients in Maternity. One is unsure of her last period, and could be either 30 weeks (by fundal height) or 42 weeks (by her last period).    The other is laboring and almost ready to deliver. Sounds ok, right?
Here’s the other thing I should tell you: there are only two delivery beds in maternity. One was currently occupied by the woman with the 20 week pregnancy. When the second laboring patient came in, she was ready to push, so the first laboring patient had to get up, so the other woman could use the bed to deliver in. Labor patient #1 walked around, or laid on the floor, sometimes buck-naked. Labor patient #2 then starts pushing, but not really doing a consistently good job. She kept refusing to push. Mind you, she wasn’t flinging herself around, she laid still, but just wouldn’t push. She doesn’t speak any French, so I have to talk through the nurse to tell her anything. The nurse is yelling at her to push, and saying some other things I’m sure weren’t polite. At one point when the patient was refusing to push, the nurse actually slapped the patient across the face! I’ve been told that technique has worked in the past here for difficult patients, but it didn’t work in this case. In the mean time, Labor patient #1 is complete and ready to push. So we have them switch places again. 
You may be wondering “How long does it take to change a bed for the next patient on a maternity ward in Africa?”. I’ll save you the trouble. It takes no time at all, because there was no wiping down the plastic covered mattress between patients. (They don’t keep sheets on them.) Labor patient #2 is now on the floor, sometimes grabbing at our legs. This makes it difficult to focus on patient #1. Labor patient #1 starts to push but is going nowhere fast. Labor patient #2 (on the floor) suddenly starts grabbing at our legs again. I start unleash her hand from my leg, when I notice she’s pushing, and crowning. I have dirty gloves on, as does everyone else. I manage to have one clean glove on to help deliver the infant, and Karen (another physician here) gets her gloves on in time to help out as well. The little boy and his mother are doing well. After taking care of the infant and mother, we had to work around the mess on the floor until it was cleaned up. Labor patient #1 isn’t making much progress with pushing, she complains of being too tired to push, so she just doesn’t at all. I end up taking her back for a cesarean section later because she just didn’t making any progress. Perhaps even with good pushing the infant wouldn’t have delivered vaginally, as the infant had a cord around his neck, and the cord was on the shorter side. Both mother and infant recovered well. 
It doesn’t end there. After the delivery of patient #2 and before the cesarean for patient #1, I evaluated the patient with the unknown due date, was asked to see a newborn with a fever. After getting the infant started on antibiotics, before I can leave the room, I’m asked to see another woman who is 16 weeks pregnant with twins (did I mention there is a high rate of twinning here?), who was in the hospital for bleeding, now has abdominal pain, but no bleeding. I get the ultrasound and take a look. Both infants are alive and moving. Placentas appear to be ok. After watching the patient a few it appears the pain is not constant as she says, but actually worsens for a period of time. (They snap their fingers when in pain here, such as during contractions.) I start an IV and give her some meds to try to stop her from contracting, though I fear they won’t work. I find out after the cesarean that she delivered while I was in surgery. 
There were also outpatients to see, but fortunately Stephen saw most of them for me because by the time I finished with all of the above, it was 5:30 pm. Then the night nurse asked us to come evaluate several patients with him. I finally made it home about 7 pm. 
Yet, it didn’t stop there. There is only a small piece of bread left, not enough for breakfast, so I have to make granola, without an oven. It’s now 10:00 pm, and I’m finally going to hit the hay. Good night world.

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