Monday, May 28, 2012

Fellowship of the suffeRing

I started call on Friday. I had been enjoying two weeks of not being on call. Whatever did I do with my time? I rested as much as possible, in preparation for call. So far, this week of call has been one of the worst ever. 
It started with doing two wound debridements on Friday afternoon. One was for a 20 year old with a chronic wound on his leg that we grafted last November, and now almost done of that graft is left. I saw It back in January and prescribed some antibiotics as I think it is a tropical ulcer, and sometimes they respond to bactrim and ethambutol. He never got the ethambutol. I don’t know why. I continued to see him from time to time, but didn’t realize he was still getting dressings, and that his wound continued to get worse. Neither did the guy doing wound care have me see him or his wound, to give direction on what to do. I’m working on seeing wounds on a more regular basis, as I’ve found some people keep getting dressings even when their wound isn’t getting any better, and never see a doctor until it’s really late. Anyway, I had to do this massive debridement on him, and it stunk. I hope and pray his leg will heal, but there wasn’t alot of bleeding with the debridement, which isn’t a good sign. Neither does he really have much skin to be able to do another skin graft if his wound gets clean enough to do another, because he has already had two. Next I did a debridement on a lady with some form of chronic ulcer-I suspect she had an infection, but not sure how it all started. It stunk too. Then I got to go home for a little bit, saw the missionary kids art show, and returned home in time to eat a little something before being called back into the hospital.
Around 8pm, I was called to come in to assist with a vaginal breech delivery-there was one food in the vagina. It takes at least 1 hour to get a patient to the OR from the time a decision is made to do a surgery, if it’s not during normal weekday hours. Sometimes it’s difficult to get ahold of people, and you have to go find them, or send someone to go find them. So, when I found the patient just had one foot in the vagina, I decided to see if I could get the other one to come down. I did. The woman was able to push the baby out the rest of the way, but as is the risk with breech deliveries, the head got stuck on the cervix because it wasn’t quite dilated enough. By this time, there was impingement of the cord (it was compressed) and so the baby wasn’t getting much blood flow. I tried all I could to get the baby out-hyperextension of the neck, episiotomy to make more room for me to get my hands in, and attempted to cut the cervix as a last resort, but found it difficult to reach with the short scissors I had. We struggled and struggled. Her aunt yelled at her that she wasn’t doing enough and tried pushing on the fundus to help get the baby out. I yelled at her to stop. End of story, the baby died in the course of giving birth. Drenched in sweat, I went home, showered, and went to bed.
The next day, I was awoken by a phone call that there was a lady who was 4 months pregnant with placenta previa who was bleeding significantly. I rushed into the hospital but by the time I arrived, she had delivered a stillborn, still in the sac. According to the nurse it appeared the baby had been dead for a few days. I started rounding, and discovered the patient admitted by a colleague the day before for post-abortive endometritis had retained products of conception, which were now infected. She also complained of a lot of pain in her right buttock, where she received an injection at a different hospital a few days ago. I took her to the OR to perform a D&C, and ended up also doing an incision and drainage on a large abscess in her buttock (which smelled HORRIBLE, and the OR still smelled the next day. Not a lot of air circulation in there). 
I continued rounding and was asked to come evaluate a woman with abdominal pain. She’s in her sixty’s, I’d guess, and has a distended abdomen. It’s been that way for several months, getting worse. She’s losing weight, and has blood in her urine. On physical exam, her liver tip comes down to the level of her belly button, and her spleen does too. I did an ultrasound of her belly-large liver, spleen, and lots of masses in her abdomen-likely metastatic cancer. Oh fun, I love giving news like this to families. I explain to the family what I saw, what the likely diagnosis is, and that I had no way of treating it. It’s already very advanced, and I don’t know what the primary source is. And then they say ‘but what are you going to do to treat her?’. This invariably happens just after I’ve explained what I’m going to do for the patient, especially if there isn’t much I can do. It’s like they don’t accept that the white doctors don’t have any medicine to treat it. Or perhaps denial of the illness itself. I don’t know, but it’s tiring. So I explain again. And again. Finally, I think it starts to sink in.
  Once finished rounding, I then was presented with a patient who complained of right thigh swelling for one year, then for the last three months, pus has been coming out a site in his thigh where someone from a clinic lanced it. Now, for at least the last month, when he’s walked on his leg, he says it feels like his femur is broken. Noting how his upper thigh is rotated differently than his distal thigh, kneed, and foot, I believe him. So I took him to the OR to drain the pus out of his thigh, but got interrupted before I could start (but after the nurse had given ketamine, unfortunately).
Before I had started, the OB nurse called to say a woman 30 weeks pregnant came in for evaluation. Her water broke yesterday at home and she’s now having contractions. And there’s a foot in the vagina. Nice.  So I debate between trying for a c/s and letting her deliver vaginally (though there is higher risks, but the baby is small, so might be ok). I call in the team to do a cesarian, but can’t get ahold of people. I end up sending someone to find them. In the meantime, I planned to drain the pus out of the guy’s thigh, but was interrupted by the OB nurse calling to say the patient wanted to push. So I take off to maternity, get there in time to help deliver the infant. This time, the right foot came out first, but the left food stayed up by her head as she delivered. I was able to sweep it down. I was trying to sweep the arms down (Williams Obstetrics and all other books make it sound so easy. Liars.), and was successful with the first one, but as I was ‘sweeping’ the other one down, I felt a snap. I broke the humerus. Great. Thank the Lord, the head didn’t get stuck this time. I took the baby to the warmer and started rescusitation. She still had a heart beat when she delivered, and it was a relatively short time for the delivery itself. She wasn’t breathing at first, and so I used the ambu-bag to give her some air and oxygen. (I will say I’m proud the nurses got the right things out ahead of time for the delivery, except for connecting the ambu bag to the oxygen concentrator. But still, the fact that they had it out is a good thing. And both the incubator  and the warmer turned on.) She started breathing, but required oxygen, and was still mildly hypoxic. I used an adult cannula to create a little more pressure for her (they tend to fill the nose, creating a sort of CPAP). She stabilized, I started antibiotics, I swathed her arm across her chest to stabilize the fracture, and put her in the incubator. 
I then returned to the OR, drained the pus that was there, and am sure he has a fracture by the way his leg bends abnormally in the middle of his thigh. The question is if he has osteomyelitis or a sequestrium that needs to be drained. Will have to get an xray on Tuesday. For now, he’s getting antibiotics. 
Sunday morning, I am awakened by a phone call from the OB nurse that the preemie’s oxygen saturation is low-30%. I’m trying to verify that the concentrator is working and all tubing connected properly (as that is a common cause of hypoxia while ‘on oxygen’ at our hospital) when she tells me ‘now there is no heartbeat’. Perhaps there was no heartbeat for a minute or two, and that’s why the kid was hypoxic. Not sure exactly what happened-if there was an apneic spell, or bradycardia due to prematurity, or something else. I gave the baby caffeine (in the form of instant coffee) the night before to decrease risk of such spells, but it doesn’t eliminate them completely.  So we lost another preemie.
I arrive to do rounds this (Sunday) morning. The lady I worked on the day before is now afebrile, awake, and talking a little. Looking a little better. Praise the Lord. But now there’s a 13 year old with right lower quadrant pain. She is moody and doesn’t respond to questions, but sometimes flops around like a fish on the bed. So I suspect her pain may be more ‘supratentorial’ than in her abdomen. I do an ultrasound and don’t see the appendix, or any mass in her pelvis. So she’s on antibiotics and treatment for malaria, as she had a test done elsewhere that was positive. While evaluating her, a 20 year old girl is brought in from a town about 45 minutes away. She drank caustic soda (lye) in an effort to commit suicide. Sounds like she drank a significant amount. She started vomiting blood, and her lungs are all junky sounding from a pneumonitis. She became hypoxic so we had to start oxygen. She has a high risk of death. 
I leave the ‘ER’ area and sit down outside the church and cry. Angry about the two babies deaths. Angry over this girl drinking caustic soda because of something her dad said to her, who now might die a painful, horrible death. Tired, and hurting because of the suffering of these four women I’ve cared for in the last few days. 
A colleague of mine sat down next to me and was praying for me. As he stood up to leave, he said the Lord told him I’m ‘enjoying the fellowship of the suffering’. I’ll tell you what, it’s not so enjoyable. But it makes me more empathetic, and it brings me closer to God. So I guess it’s not so bad. 

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