Wednesday, May 21, 2014

Worst Call Ever

"It seemed good to me also, having had perfect understanding of all things, to write to you an orderly account, most excellent Theophilus"  Luke 1:3

 I doubt this scripture gets much attention in missionary newsletters and blogs.  However, after the incredible encouragement sent our way in the past couple of days following Esther's Facebook post on Monday, I think an orderly account of the previous day might be helpful.  Forgive some of the medical terminology.

On Sunday I had what entailed my worst call here.  Two babies, one child and three adults died.  I may have made a poor decision on our obstetrics ward which resulted in a baby dying.  I didn't get much rest or sleep and had a few moments in which to eat.

0730 - Called to Pediatric ward, child in respiratory arrest, intubate, instruct nurses to bag child
0800 - Medical ward, start rounds
0900 - Begin rounds in Obstetrics ward
0930 - Back to Pediatric ward to remove breathing tube from neurologically deceased child, comfort family
1000 - Finish Obstetric ward rounds, resuscitate newborn born without pulse and not breathing
1030 - Go to emergency room and see several patients
1100 - Home for a late breakfast
1300 - Back to Obstetric ward, post-op mother apneic, respirate her while giving naloxone, she recovers, another mother with severe pre-eclampsia is now complete, see more patient in ER
1500 - Called back to Obstetric ward, first time mom now pushing for two hours with little progress, internally debate performing a CSection
1600 - Mom doing a little better, head coming down with contractions
1615 - Apply vacuum, not able to doppler fetal heart tones, deliver baby which is not breathing
1620 - Fail intubation attempt for baby, bag-mask and continue resuscitation
1635 - Intubation successful, CPR and medicines to baby by breathing tube
1700 - Baby not responding, now without pulse and not breathing, discontinue efforts
1730 - Inform mother, then sedate her for complicated third degree laceration repair
1800 - Called back to nursery, initially resuscitated newborn now having seizures, give medication
1830 - See several patients in ER
2000 - Home for a late dinner, make a cryptic comment about a terrible day of call on Facebook
2200 - Order stat blood type on mother in Obstetric ward who is pale and tachycardic
0000 - Call from ER, MVA with multiple passengers, seven injured patients in ER
0010 - Arrive in ER, one patient dies, 6 others to see
0020 - Complete ABC (airway-breathing-circulation) assessments of 6 patients, three stable, two with poor respiratory status, one near circulatory collapse and flail chest
0030 - Second load of patients arrive from MVA, 3 died at the scene, now three more arrive injured totaling 9 injured in the ER
0040 - Lab, Xray and Surgery support arrive
0045 - Ultrasound exam unstable patients, two with free fluid in abdomen
0100 - Place chest tube in crashing patient, intubate, perform CPR and resuscitation without success while surgery resident places chest tube in another critically injured patient
0130 - Reduce hip dislocation
0200 - One patient with splenic injury and free fluid in the abdomen transferred to surgery ward, one patient with fracture spine and paralysis below waist transferred to surgery ward, one patient with head injury and hip reduction admitted to my ward, one patient with pneumothorax and head injury transferred to surgery ward, one patient with head injury and fracture left arm admitted to my ward.
0430 - Home to "sleep"
0600 - Notified that initially resuscitated baby is now not breathing on their own
0630 - Baby dies
0700 - Wake up to conclude worst call ever

 Getting tired of these

Amazingly, the following day I expected to feel both tired and emotionally burned.  Perhaps the Lord divinely allowed me to meet a visiting nursing student named Jonathan.  Jonathan served as a combat medic in Afghanistan, and though I still felt our trauma patients made for a difficult night, I thought to myself, "Imagine trying to care for these people while taking enemy fire."  I stifled any complaints while Jonathan and I spent the day together.

"The work of righteousness will be peace, and the effect of righteousness, quietness and assurance forever"  Isaiah 32:17

As I reflected on my day, this verse hit home.  I am amazed as I work and serve in other cultures at the univesality of people's need for these three things: quietness, assurance and peace.

Near the end of my fourth year of medical school I experienced an episode of depression.  Thankfully it hasn't returned.  However, I remember a very poignant message given at my church during that time about God's goodness.  

The Bible talks about God's goodness at length, but I struggle sometimes to accept it.  Yet during the darkest time of my life, I resolved to trust in God's goodness no matter my circumstance.  What follows is a natural progression.  If I know that God is good, I can trust Him, and if I can trust Him, I can have peace in any situation - even if the outcome seems catastrophic.

After my day of call, I'm tempted to question God.  Why do I see all of these people die here?  Why couldn't I do more to save them?   Why should I go back to see more of the same suffering every day?

But I realize that every one of my questions revolves around me.  My skills, my efforts, my intention and my heart are not enough.  But when yielded to the certainty of God's goodness, I know that He will guide the outcomes.  And though the outcomes aren't what I like, His goodness doesn't change.

This gives me peace, assurance and quietness.

Thank you to all those that prayed for and sent encouragement to me, my family, my patients and our enduring work here during this recent difficult time.

Monday, May 12, 2014

Rude awakening

Working at Kudjip has brought several firsts into my practice of medicine.  Before working here I never performed a bone marrow graft into non-union fractures.  I never took care of patients with Typhoid fever or severe malnutrition.  I never before resuscitated a child.  Now I've done each of these, but every day I feel like I'm in un-chartered waters at least once.

A few weeks ago a young child came to our hospital with fevers and a bad cough.  The baby suffered both of these for a week or two before coming to the hospital, but stopped eating and drinking so her mother brought her to us.

In severe cases of pneumonia (chest infections) occasionally fluid collects around the lung, compressing it and restricting its ability to expand.  When germs infect this fluid we call it an empyema.   Young Serah had an empyema, which is rarely seen in developed nations where these kinds of infections are usually treated early in their course.

To treat empyema, a patient needs strong antibiotics given through an intravenous catheter.  But if the infected fluid remains the chances of the infection clearing are not great.  I attempted to remove some of Serah's fluid with a small needle, but the procedure resulted in air also collecting in her chest, called a pneumothorax.  So the fluid and air needs to be drained, which means placing a tube in the chest.  Once during residency I performed this procedure on an adult chest under the close supervision of a surgeon.  During a training conference.  On a cadaver.

But a few weeks ago little Serah needed a chest tube.  Thankfully, I again performed this procedure under the supervision of a surgeon.  But placing a scalpel over the chest of an infant and then pushing a tube into their lung space still made me sweat. 

My first chest tube, on a smaller-than-anticipated chest

It took several days, but eventually Serah started eating again and her fevers resolved.  Initially scared for her daughter's life, her mother soon accepted my prayers gratefully when I rounded on her in the hospital wards.  Before long, Serah's empyema improved.

 Tube out, looking better

Serah was able to go home soon after and came back a week later looking much better.

Serah doing well

Recently I performed another first, but with somewhat less satisfying results.

Jerothy presented to our obstetrics department with edema in her legs.  Dr Erin checked her blood pressure over the course of the afternoon and found it severely elevated.  He reflexes were brisk so she started treatment for pre-eclampsia while preparing for her delivery.  Because her baby was breech (feet first) she needed a Cesarean.  It was my call night so she let me know and I told the operating theater staff to get ready, thinking this would be a straight-forward case since she had no previous surgeries.

As we wheeled Jerothy into the operating room, her HIV test result came back positive, which she previously did not suspect.  I told myself I would give her the bad news after her surgery.

I made an incision along her abdomen, exposed the uterus and then cut through it and delivered her healthy baby.  As I tried to separate the placenta and conclude the surgery, I could tell something wasn't right.  It wouldn't come out.  I took her uterus out of her abdomen and discovered that her placenta had grown through the uterus and was now bleeding into her abdomen, a condition called placenta percreta.

Jerothy's blood pressure got as low as 51/30 and her pulse up to about 130 while the OR team scrambled to get another IV going and start a blood transfusion.  We had to put Jerothy to sleep because of the now complicated surgery.  Dr. Jim arrived promptly and we performed an emergency hysterectomy.  Miraculously, Jerothy survived her operation, though she later had a seizure on the ward from her eclampsia.

I've been to see Jerothy a couple of times since her surgery.  At first, I think she was in shock.  Today I got the impression she was in denial.  

She experienced quite a rude awakening from that surgery.  Not only did she learn that she could have no more children (after this, her first one) but that she contracted HIV as well.  I prayed with Jerothy and our chaplains have seen her a couple times.

What is going through her mind?  Arriving at our hospital, she and her husband happily anticipated the arrival of her first baby.  Now their relationship is fractured by HIV and she can never get pregnant again.  All of this was true before she came to us, and had Jerothy gone anywhere else that night, she would have died from her condition.  But I wonder if our bringing her all of this bad news eclipses the help that we were able to give her.

I hope not.  And I pray that she and her husband would take joy in the new life God's given them.  That they would stay together.  That her baby would not contract HIV.  And that she would live and find purpose in this life despite the circumstances that have fallen to her.