Saturday, June 30, 2018

Neonatal resus, or how not to kill a baby



I haven't written here in quite a while. The 3rd year of med school was really hard, and after my last time in Chad, I was not in a good place emotionally, which made it all even more difficult. At the end of the year, we have an exam that is the equivalent of Step 1 in the US, which allows us to pass on to clinical rotations during 4th year. Here med school is 6 years, 3 basic sciences and 3 of rotations.

It was hard, but I passed, bought a house (no joke!) and went on vacation for 5 weeks through Central America (Mexico, Belize, Costa Rica and Panama) which did wonders for my mental health. I came back rested and feeling better than I had in a while. Ready to start rotations.

However, as luck would have it, my 1st rotation was OB/GYN. And I started to have flashbacks from Chad. From hemorrhaging mothers and ruptured uteruses, and dead babies. More than once, I had to force myself to think of something else, look out the window and distract myself, so as to not start crying. Nobody here, the residents, attendings, fellow students, know that I've been to Chad and have seen more tragic outcomes in 6 weeks than they will see in their entire careers. As an inexperienced med student with no way to process any of it, and in a setting so poor in resources, than even if I had known what to do, I wouldn't have had the materials necessary to do it.

But let's skip over my 4 months in OB/GYN and jump forward to today. I have now started a 3-week rotation in Neonatology, before moving onto Pediatrics. And today we had a class and sim-lab for neonatal resus. I held it together by forcing myself to concentrate and actually learn everything I could, practicing manual ventilation and intubation, and learning all PEEP and PIP parameters.

At the end of the class, I walked out quickly, trying to hold back the tears. I couldn't stop thinking of one baby in particular, in Chad, who was born alive but died while I auscultated his diminishing heartbeats. That moment will be etched in my memory forever. The feeling. The shock. The numbness that followed. The only ambu bag we had was pediatric, which the nurse was trying to use but I don't think our efforts at ventilating were at all successful. The OB/GYN was busy trying to save the mother's life. I had no idea what to do, and there was no one else. I *know* that there was nothing else I could have done. But right now, I feel like I killed that baby. I feel like I should've been better prepared. And I'm fairly certain that, had that baby been born in a hospital with a NICU, or at least a neonatologist and better equipment, that baby would not have died.

THE UNFAIRNESS OF THIS WORLD MAKES ME INCREDIBLY ANGRY AND SAD.
(Sorry for yelling, but I can't help it.)

The world in 2018 is a disaster, and instead of improving, everything is going to hell. Instead of having a better division of resources, we're polarizing more and more. The rich are getting richer, and the poor are struggling to stay alive. The feeling of impotence and the anger at the world, at the leaders, at the greed of the richest and the apathy of...pretty much everyone (myself included) is getting to me. We need to do better. *I* need to do better. 

Saturday, April 8, 2017

Puzzle pieces

I've been back home for over a month. The first few days I had moments of crying hysterically for no reason, but then it stopped. As usual, I pushed it all down. Classes were starting, and 3rd year of medical school is no joke. 

So every once in a while, I find myself staring into nothing, feeling numb, wondering why. Then I remember. Chad. Dead babies. Hysterectomies. Faint heartbeats getting slower, then stopping, while I listened, knowing there was nothing I could do. 

These memories haunt me. I'm not thinking about them all the time, but one word, one picture of a healthy baby, and it all comes rushing back.

I'm not planning on going back to Chad, at least for a long while. And if I do, I'll try and steer clear of Ob/gyn. I can't handle it. It's too much for me. And like the advice on airplanes say, you have to put on your own oxygen mask before you can help others. I'm no good for anybody if I'm broken. 

So now I'm slowly putting myself back together. 


Tuesday, February 14, 2017

Maternal/fetal mortality and the wonders of modern medicine

I got called in at 2:56am for another c-section for a dead baby with a ruptured uterus which ended up needing a hysterectomy. I have lost count of how many of those I've assisted on in the 6 weeks I've been here. I bet most OB-GYNs in the developed world have never even seen one. (Feel free to correct me if I'm wrong).

I read somewhere recently that late fetal/newborn death rates were around 40% in the 1800s, and only with the advent of modern medicine, pre-natal care, ultrasound, etc., has it decreased as much as it did (to something like 4% globally-- I can't find the article now). According to Unicef data: "The lifetime risk of maternal death in high-income countries is 1 in 3,300, compared to 1 in 41 in low-income." http://data.unicef.org/topic/maternal-health/maternal-mortality/

Well, you might remember from an earlier post, that I said Chad was stuck in a way of life from 2000 years ago. And that means, maternal/fetal/newborn death is still ridiculously high. Unacceptably high.

Call me a wimp, call me a weakling, call me whatever you want, but it's been really hard for me, dealing with it all. Last week I only went to the OR one day, and dedicated myself to teaching at the nursing school. This is my last week, and honestly, I'm glad it is. 

Since I have been trying to push it all down and not think about it, I guess my brain decided to make me deal with it at night, in my dreams. So I've been having terrible dreams, waking up crying, and sleeping badly. Consequently, I'm tired all the time.

I'm glad and always in awe of people  like Dr. Danae, Dr. Olen (her husband), Dr. Bland (her dad), but I don't have what it takes to be a full-time doctor in a place like Chad. I'd last a month, maybe two, run away screaming and move to an island in the middle of the pacific, preferably populated by only nuns and cats (therefore no ruptured uteruses, dead babies, ectopic pregnancies, etc., etc., etc.).

So for those of you who might be wondering if I intend to be a full-time doctor in Africa someday, the answer is no. I couldn't handle it. I'm not strong enough. And that's ok. 

(That's a ruptured uterus, so badly ruptured that it was impossible to save. I think this is the one we gave 5 bags of blood cuz she just kept bleeding)

Wednesday, February 8, 2017

An Ode to Nurses

An ode to nurses

For the past 2 weeks, I've been giving Anatomy and Physiology classes for the nursing school attached to the hospital. It's just 2hrs a day, before I go to the OR. 

I love it. It has helped take my mind off things for a little while, and preparing the classes has been a great way to review stuff. 

But today, at the end of class, I stopped everything, turned off the powerpoint, and told them to pay very close attention because I was going to tell them the most important thing they need to learn about nursing: 

The doctors see a patient at rounds, for maybe 5 minutes a day. The doctor is the detective, that discovers what is wrong, and decides the treatment. But the nurses are the ones who actually treat the patients. The nurses are the ones who realize if something is wrong, and the patient is getting worse. Or if the treatment is working or not. 

If something goes wrong, the nurse is the first one to notice, and it is their responsibility to tell the doctor. The doctor can't guess or devine what is going on. The nurse is the eyes, the ears and the hands of the doctor. 

Nurses: don't underestimate the importance of your work. The doctors could never treat patients without you. 

Doctors: never forget that. Treat your nurses well, because the quality of patient care depends on your interactions with them.

Thursday, January 26, 2017

Sadness

I'm not sure what to write. I think I'm a bit numb, pushing it all down, so I don't start crying every day. So many dead babies, ruptured uteruses, hysterectomies. Here, the value of a woman is measured in pregnancies. Some will agree to anticonceptives, because they know it's just for a while. Few want to tie their tubes, and that only if they've already had... 7-8 kids. We had an uterine rupture back to back with an ectopic, both women in their 13th pregnancy. One had 7 alive, the other 4. Can you imagine being pregnant 13 times and have only 4 living children? I don't know if they were all to term, some might have been miscarriages. But truth is, a lot of them die in their first week, or before they turn 5. The prevailing culture is that it's good to give water to newborn babies. We hammer into their heads that they cannot, under any circumstance, give them water before 6 months, but it happens. And the babies who are born at home (by far the overwhelming majority) don't have us hammering into their mom's heads not to give them water. 

There is no water/sewage system here. You walk around and see people defecating on the ground. Waterborne diseases are rampant, and we treat ALL our pediatric cases for parasites, regardless of presentation. Imagine what that does to a newborn baby, who should be safe and protected from any food/water borne disease by drinking only breastmilk. But isn't.

Yesterday I was out of commission myself, having eaten something someone kindly made for us, but gave me diarrhea. Today I was better, so I walk into the OR to see Dr. Danae in the middle of a hysterectomy. Ruptured uterus. The patient went to a village health center 40km away on Tuesday evening for prolonged labor and they referred her here. Who knows how long she had been in labor up to that point. Today is Thursday, and that's when they brought her here. The baby was dead, she was hemorrhaging, and a little longer, she would have died too. The baby was long dead, skin peeling off, flacid, like jelly. 4.2kg worth of a baby boy, who would have been big and strong, if only... so many things. 

She asked to see the baby. I wrapped him carefully, trying to cover the worst parts and took him near her face. A tear ran down from the corner of her eye. I almost lost it. 

Being in Chad is always hard. There are always cases that get to you. But the previous two times, I was working at a hospital with no OB-GYN. No ruptured uteruses, no ectopic pregnancies of 10wks with bellies full of blood, no hysterectomies, no dead babies. I've lost count how many we've had, and Saturday will be only 3 weeks since I got here.

There are good cases too, of course. To finish on a ligther note, I'll leave you with a picture of darling twin girls, born by C-section (mom had pre-eclampsia). My first (and so far only) set of twins. 

Saturday, January 21, 2017

Being a doctor (or med student)

Being a doctor (or in my case, a med student) is a privilege and a responsibility beyond what I can actually fathom. I think if I stopped to think about it too much, it would overwhelm me. 

We are allowed access to people's bodies in a way nobody else, ever, is. We stick tubes down body orifices (urinary catheters, nasogastric tubes, ventilators). We insert our fingers and hands in those orifices and others that we make, by cutting them with a scalpel. We stick needles in their arms, back, groin, neck, feet, scalp. 

All of those "assaults" are allowed, because we want to make them better. Cure whatever is ailing them. Help them breathe. Help them eat. Deliver their babies. Fix that strangulated hernia. Remove that ovarian cyst. 

But what happens when medicine is not enough? When there's nothing we can do to help? 

We're there still. We hold a tiny hand wrapped around our fingers, and listen to a newborn's heartbeat slowing down, until it stops. You check your stethoscope. You reposition. You try to stimulate the baby, but you know he's gone. That tiny little life breathed only a few minutes, then stopped. And you were there. 

It is a privilege and an awesome responsibility to be a doctor (or med student). 

Tuesday, January 17, 2017

Babies


The maternity ward here is full to overflowing. There's people sleeping on the floor (they don't mind, sometimes they even prefer it, because that's what they're used to at home. Nobody has beds at home.)

Yesterday I finally had dinner at 9pm, only managed to sneak a couple of bites of chocolate around 4:30pm to avoid a hypoglycemic episode. We were in the OR until 8:30pm, which included a ruptured uterus where the sac was out of the uterus but intact, the placenta was in the uterus, but the baby was dead. We had to do a hysterectomy, the uterus was unsalvageable. 

Then an ectopic pregnancy with removal of fallopian tube. 

Then lots of other things (prostatectomy, giant lipoma, etc., and finished the day with a pre-eclampsia lady with twins at 33wks 4days. My first set of twinsies!! So adorable!! Mom and baby girls doing great this morning! 


But today I'm feeling like Izzie on Grey's Anatomy, when Addison has her taking care of a baby everyone knows is going to die. I'm monitoring this 1wk-old baby who probably has pneumonia, gasping for air and having very low sats even on O2. She's on antibiotics and I'm just sitting here making sure the nasal canulla doesn't fall out. The pulse ox we have is too big for little baby fingers, so it's impossible to keep it on. There's nothing else I can do, except watch her. She'll either get better or die. I can only hope and pray her little body is strong enough to fight whatever infection is ailing her.