I'm going to be living with another nurse practitioner/nurse midwife so that'll be fun!
I arrived at the hospital at about 3pm and wasn't really sure where to go. After checking in with Ali and finding that he was doing great and was really excited to go home, I set off to find Dr. "B". I found him in the clinic and was directed to the guest house. My friend and I (the experienced navigator...he was very shocked at my unfortunate direction sense....or lack thereof) settled in and hung around for awhile. At about 6 I went to find Dr. "B" again but couldn't find him. I tried calling, but no answer. At about 8pm I decided to hit the showers and then head to bed. Just as I was climbing into bed I got a call from Dr. "B". He invited me over to have a chat with him...and I was confronted with the difficulties of practicing medicine here.
It turns out that I came on one of the worst days. Now I'm going to get a little "medical" here so if you're not interested go ahead and skip to the end or to part 2 coming tomorrow. :)
Dr. "B" had a pregnant woman who had been in the hospital for about half a day. He was called to the OB ward because his patient just "didn't look right." After doing some tests, he thought that she might becoming ecclamptic....but it wasn't a sure thing either way. So the dilema. The only way to cure ecclampsia (really high blood pressure in pregnancy) is to deliver the baby. But her blood pressure was only boarderline. She had some protein in her urine and some slight swelling, but nothing that said...we need to deliver right now! Nobody here knows how far along they were but the midwives were estimating about 35-36 weeks. Baby's heart tones were strong and about 150 bpm. They could go in and take the baby via c-section but here's the dilemna. Mom is only about 18 or 19 and the don't do VBAC's (vaginal birth after c-section) here because they are too risky. They will also usually only do 3 C-sections because then they become too risky as well. So does he take an 18 girl to the OR and limit the number of children she'll be able to have (when having a lot of children is EXTREMELY important in this culture....and you usually have at least one die) if he's not sure that she needs it? But on the other hand, it would be worse to have to take her to the OR and have a C-section for a baby that has already died. Since baby was still looking fine and there were no clear signs that mom needed to be taken to the OR, he decided to wait and re-evaluate later. So he came back a little bit later and heard some crackles in the bases of her lungs and a slight heart murmur that he hadn't heard before. Also, baby's heart rate had dropped to 120bpm. That was enough to convince him and off to the OR they went. They did the c-section and baby came out floppy and not breathing well on its own. They also suctioned out a lot of meconium. They don't have oxygen tanks here but they have an oxygen concentrator so they hooked baby up to that and started bagging. After about 5 minutes, he started coming around....started looking like a normal newborn. He had lung sounds all throughout and was breathing well on his own. The OR was getting really hot because of all the windows so they decided to move baby to the OB ward. They unhooked him from the O2 and went to the ward. In the few minutes it took to get there, baby completely decompensated and stopped breathing on his own again. here The generator had been turned off so they were yelling to start it again right now! How much gas is there? We need more gas...where can we get more gas? This down doesn't have any gas. Oh, yes they do have gas but it's going to be twice what you normally pay...... In the end, they tried to get him back again, but he never recovered. I was sitting with Ali and his dad when I heard people start crying/wailing and they told me that someone had died. I learned later that it was this baby.
Unfortunately, that's not the end of the story. During dinner, Dr. "B" was called down to the hosptial again. This time it was for this deceased baby's mother. According to the nurse, at 7:00pm she had been sitting up, asking her husband for a glass of water. All of the sudden she started becoming restless and short of breath. When they tried to get a blood pressure they found it to be 60/palp (very very low). They started another IV, had fluids racing in, put the O2 concentrator on (her sats were in the low 80's....very low) but within about 20 minutes of her first showing any signs that something was wrong...she was gone. That fast. With no clear explanation as to why. That was what was so frustrating for Dr. "B." It sounded like it had to have been a pulmonary embolus but how do you keep that from happening again? He could have given an anit-coagulant but that wouldn't be good for every patient, plus you don't have the resources to do that even if it was the right thing. And we'll never know what it was that actually killed her. It was a hard day. For the man who lost both his wife and his child, and the man who was unable to save them.
I was talking to the Sierra Leonean who came with me and said, "Yeah, it's frustrating because we don't know why she died." He gave a small chuckle and said, "Well yeah, only God knows." Because of where I grew up, I usually have an answer for the pathophysiology of why people die. But I do often struggle with why God allowed them to die. For this man, they were not different questions. I don't have a poetic way to end this post. That time just made me think about things...medicine....God....
More about my trip tomorrow. And a happier post!