This was a rough week. Life here seems to come in waves of good and bad. I just came back from a week of vacation with my sister – an amazing 7 days of rest, food, adventure and sisterly bonding. Going into my 6th month of working at the hospital – it came at a time when I desperately needed a bit of home and a familiar face. I came back ready to get back to work again. Little did I know what was waiting for me this week…
My first day back was a shift in our Emergency Department (casualty). From the first minute, as I was leading rounds, the stress and anxiety hit me again like a slap in the face. We were seeing a patient with hyponatremia (low sodium) of 112 (which is pretty low). The night team had decided to put her on 3% saline, and when I arrived, the patient hadn’t had any sodium levels checked in over 12 hours. To put this in perspective, I’ve used 3% saline once in my life in residency – for a severe hyponatremic patient who was seizing, under the guidance of a nephrologist, and with the ability to check labs every 2 hours. And I remember that I didn’t sleep a wink that night!
I asked the nurse to draw a stat sodium level, and we finished rounds. Then I ran into the little doctor’s office, shut the door, hyperventilated, and quickly looked up the chapter on hyponatremia in my Pocket Emergency Medicine book. The words blurred on the page… sentences about checking urine and plasma osmolality, urine sodium, ACTH stimulation tests, cortisol levels, etc… The only lab we have is a serum sodium level. I threw the book back in my bag. Not helpful. I had never seen central pontine myelinolysis, the dreaded complication of over-correction of severe hyponatremia, and I wondered how it might present.
I peeked out of the room and looked over at the patient in Bed 8. She was awake, lying peacefully in the bed, chatting with her family who surrounded her. She didn’t look like she was in distress. But maybe her brain was shriveling up as I watched! Maybe she was about to crash! Did I remember the doses of medicines needed for a rapid-sequence intubation? Do we even have central lines here? What if…what if…what if…
Walking out of the office, one of our clinical officers came over for a consult. She wanted advice on what to do with a patient who had been sitting in casualty for four days. He was a 70-ish year old man who came in with oxygen saturations in the 60s. They had been suspecting TB (tuberculosis) so he was put in isolation while he was worked up. The work-up, painfully slow here, had taken 3 days. First he needed to be stabilized. He was given antibiotics, steroids and inhalers, and now he was saturating in the 80s-90s on 6L of oxygen and had been moved from isolation back to a regular ER bed. He got a chest X-ray which showed some lacy patterns on his left lung. The patient wasn’t producing enough sputum for the normal TB test, so they had to order a blood test which took a few days. Then he needed to get a CT scan of the lung to better identify what was going on there.
The CT scan result had finally come back so we went over to the computer to look at the images. In my mind, I was again panicking. I hadn’t looked at a CT scan in months! People go to residency for 5 years to learn how to read CT scans! What if I miss something important? Our CT scans are usually read by a radiologist down in Nairobi who then sends them back to us, but the process can take a while. And sometimes he takes a day off, or goes on vacation. I slowly scrolled through the images. Black lung fields came into view, followed by… wait! What is that thing? A big, circular goombah in the left lung. Cancer? Abscess? A big TB pneumonia? Should I put on a mask? The white circle was filled with pockets of black – meaning air. Can cancer cavitate like that? He certainly looked ill – like a cancer patient- and he had smoked for 40 years.
I wasn’t quite sure what to do with all of this, so I walked over to the radiology department to see if a tech was around who might be able to tell me if the radiologist was reading images that day. To my disbelief, a visiting radiologist from California was sitting there looking at my patient’s CT scan. I sat with him and we went over the images in detail for the next 10 minutes. I left with a much better idea of how to treat my patient and a thankful heart for God’s provision.
Back to the ER – in my absence, a young pregnant girl had come in seizing. She had a complicated history of a prior brain bleed and antiphospholipid syndrome. She had lost several prior pregnancies and was especially excited about this one – she was at 22 weeks which was the longest she had ever carried a pregnancy. We stabilized her, and I asked our clinical officer to consult the obstetrics team. A few minutes later – my phone rang. It was my clinical officer, consulting the obstetrics team. After a laugh, I told her that yes, normally I do obstetrics, but today I was in the ER and she needed to call the other Family doctor who was covering OB. The first priority was an obstetric ultrasound to check on the baby (who I suspected had passed away since we couldn’t find fetal heart tones). I ordered the scan, but it took about 6 hours to be done as the patient’s family needed to find the money to cover the cost of the scan (about $12 US dollars).
Eventually, the scan was done which revealed the baby had passed away. The patient and her husband were devastated. The ability to have children is a vital part of the culture here in Kenya. This women had been unable to carry any of her pregnancies to term. I was devastated along with her. Our team prayed with her and comforted her and her family, but my heart still hurt for her.
Near the end of my shift, one of our OB interns called me and asked me to come over to maternity to help with a difficult delivery. I told him I was covering the ER, but our other Family doc was in the operating room doing a c-section and there was no one else around to help. I asked my clinical officer (who was more than capable) to cover the ER and went over to the delivery room. I found the intern and he told me about the patient – a first-time Mom who had been pushing for about 1 hour. I examined her and found her baby to be slightly rotated. With the next few pushes, I was able to turn the head enough so that she made some progress. I told the intern to continue to encourage the mom to push (first time moms can push for 2-3 hours before we call an emergency c-section), and went back to casualty, sure she would deliver any minute. An hour later, I got another call from the same intern, telling me that mom was still not delivered. They had pushed for another 30 minutes, and then gave mom a break for a half hour. I went back down and re-evaluated the patient. We started some oxytocin to get her contractions stronger, and then resumed pushing. By this time, after about 2 hours of pushing, mom was exhausted. Her pushing was not making any progress, so I decided to put a vacuum device on the baby’s head, which would allow me to assist mom’s efforts a bit and pull the baby out. After just two short pulls, the head popped out and mom was able to deliver a healthy baby boy. I congratulated both mom and dad and then headed back to the ER.
My shift ended (the hyponatremic patient did fine!), and I went home to get some rest to gear up for being on OB call the next night after a full day of clinic. My call started that evening with a C-section for a patient who had had three previous C-sections. I was a bit nervous that her abdomen would be a mess, but thankfully she had only some moderate scarring and we delivered a healthy baby. After a sleepless night full of calls from my brand new intern, I woke to a phone call at 5AM. The call was regarding a 34-weeks pregnant mom who had prematurely ruptured her membranes and had been transferred here from an outside hospital. She was in breech position and had a prior c-section and was starting to contract. Thankfully she had received steroids (to help the baby’s lungs develop faster) and antibiotics at the other hospital. I drove up to the hospital in the rain, and did the urgent c-section. Baby was small but cried immediately at birth. Exhausted, I started to write my post-op note.
Halfway through my note, I received a frantic phone call from my intern who was in the emergency department with a 32-weeks pregnant mom who had come in with an eclamptic seizure. I raced to the ER (this is a true obstetric emergency) and found the patient with blood pressures in the 230s/130s. The ER team had already started magnesium sulfate and had administered blood pressure medications to help stabilize her BPs. I grabbed the bedside ultrasound machine (internally thanking the heavens above that I had done that extra elective rotation in obstetric ultrasound), and tried to find a heart beat. I saw the head, the arms and legs, found my landmarks and found the heart. A beautiful, four-chambered view of a still and silent heart.
At that moment, I had another internal panic attack. Was I truly seeing the heart? There was no time for a formal ultrasound, and if there was a slow heartbeat somewhere that I was missing, now was the time for an urgent delivery, possibly a crash c-section to save the baby who likely only had minutes to spare. If I called this, I was announcing to the ER staff – and a terrified father – that there was nothing more to do for this child. Am I qualified for this? With only 4 months of Obstetric training during residency, I definitely have been called on to do many things these past 6 months that I don’t feel entirely qualified or comfortable doing. Most of the time, there is no one around to help me with my decision making processes, and I’ve had a few very tough calls that I’ve had to make. But this one was one of the toughest. I scanned through the anatomy again, rotating the probe this way and that way, desperately trying to find a heart beat. Stillness. The only movement being the mother’s quiet breathing, still unconscious from the seizure.
Taking a deep breath, I looked at the ER team and shook my head. They quietly wheeled the ultrasound machine back to it’s place, and continued to administer the life-saving IV medications for the mother. As I broke the news to the father, I wondered, why is this one so hard? I’ve delivered horrible news to many parents and family members. Why did this feel so much worse? Later, after stabilizing the mom, we got a formal ultrasound that confirmed that the baby had died, possibly a few days prior. Knowing my scan had been correct really didn’t make me feel any better.
I finished up in casualty and walked back to the maternity ward, defeated. I told my interns that we would start rounds an hour late because I needed a minute. I went home, changed, and grabbed some coffee, then headed back to the hospital for another full day, running on 3 hours of sleep.
Later that day, I received news that the baby I had delivered a few days ago when I was working in casualty had died – the pediatrics team was unsure of the cause of death- and so for the third time this week, I found myself giving somewhat empty sounding condolences to yet another heartbroken mom and dad.
So yes. This was a rough week. Too many losses for one week. Too much of the unknown, feeling like I am lacking adequate medical knowledge, and having to make really tough decisions without the comforting presence of an attending behind my back. It’s been a hard 6 months. I’ve been stretched medically and emotionally in ways I didn’t know were possible. I’ve done over a hundred C-sections (in the 3 months I’ve been on the OB service), learned how to operate on ectopic pregnancies, repair 3rd and 4th degree lacerations, do D&Cs, and many other things that I never did in residency. But man has it been challenging.
And it’s going to get harder. For the next 3 months, (June-August), we are extremely short staffed here at Kijabe. We are down to one OB-GYN and the two of us Family doctors for the maternity department. I will continue to be challenged and stretched. I’m learning how to be more confident, how to handle stress and anxiety, and to figure out my boundaries. It’s been a tough 6 months, but also a good 6 months. I’ve learned to rely fully and completely on God, and He has come through for me in ways I never expected. I’ve been doing a Bible study on 1 and 2 Corinthians the past few months, and I feel like Paul has become my bosom buddy. I can empathize as I read his words, “we were under great pressure, far beyond our ability to endure, so that we despaired even of life (2 Cor. 1:8).” Ok, I’ve never feared for my life, but these first 6 months have given me a tiny taste of the stress that Paul must have endured. But then, Paul writes the verse that has given me so much perspective over the last few months: “…But this happened that we might not rely on ourselves but on God, who raises the dead.”
Wow. I don’t pretend to know why one child dies and another one doesn’t. I don’t have any great answers for that giant theological dilemma. But I do know that Paul carried on. He survived great peril, and horrible conditions, and despicable things done to him. Yet he carried on, full of joy and praising God for his trials. So I’m carrying on. And in the midst of carrying on, I am finding that I’m beginning to love this place and love these people and this culture. As crazy as these first 6 months have been, it’s starting to feel like home here…
A few light moments from the past week. This is a few of our interns at work. They work so hard yet they always are down for a laugh!
I had our graduating medical officer interns over for dinner one night. I made them Texas style burritos and they loved it! From L to R: Maureen (going into pediatrics), Charles (going into gen surg), me, Patrick (going into pediatric cardiothoracic surgery), Vallery (going into gen surg) and Winne (going into pediatrics). Love this brilliant crew!
One of my interns, Erick, waiting for a C-section towards the end of a really rough night on call… He always cracks me up.
And enormous 4.6kg baby that we delivered this week! Almost toddler size. 🙂
My sister and I after she got to watch me do a C-section. Having her visit has been one of the highlights of this year!