I haven't been sure how much to share with you guys about the kinds of things I'm seeing day to day in the hospital. A lot of the things I've been seeing are really very tragic and I'm not sure how fair it is to expose you all to that. Like most doctors, I've developed quite a thick skin, so unlike when I was in Ghana as a student, now not much will shock me. But I realise many of you are living very different lives and I don't want to upset anyone. Having said that, this is reality; we live in a broken world. Whilst most tragedy back home is hidden behind closed doors, it is happening and maybe it's ok to recognise that?
However, the majority of the broken-ness I'm seeing here involves dead babies (being O&G) and I realise that can be particularly upsetting for some people, so I'll leave it to your discretion whether you want to read any further.
Yesterday I had a particularly interesting case, and whilst it had a partially negative outcome, I think it's an example of different specialities working together really well. I'm trying to promote unity between specialties so think it's worth highlighting!
I was on call for O&G and had a referral for a lady on the medical ward who was very unwell. She was a 15 year old girl with a positive pregnancy test and vaginal bleeding, who had also been vomiting with fevers for a week. On seeing her it was soon clear that she was very unwell. (For the medics...) she was tachycardic ~140 (fast heart rate), febrile 39.3, and very tender on the right side of her abdomen with guarding. Initially we were concerned she might have had an ectopic pregnancy as they normally present in early pregnancy with L or R sided abdo pain and vaginal bleeding. James my reg did a bedside ultrasound scan, and found a pregnancy in the uterus (i.e. not ectopic - pregnancy outside of uterus that can --> death), but he couldn't find a heart beat so I took her to the ultrasound department for a proper scan. Adam, the surgical SHO, came to review her too as we thought it could also be an appendicitis.
She really wasn't at all well, but I managed to get her to the ultrasound department in a wheelchair and up onto the scanning bed. The sonographer started scanning, and there was the baby in the uterus, but again she was unable to get the fetal heart beat. As she was looking the baby moved across the screen. It took me a second to understand what had happened, but then I looked between the girls legs, and there was the baby on it's way out. After delivering the baby I tried to deliver the placenta but because the baby was so premature (probably about 20 weeks) with a bit gentle traction the cord snapped. This left me with a very sick young girl on the ultrasound bed with a retained placenta and literally no equipment, medications or midwives to assist me and 2 perplexed sonographers who really had no idea what on earth was going on.
I quickly wheeled her to labour ward, trying not to alarm the rest of the waiting room on the way out, and gave her some oxytocin (makes the uterus contract) and luckily the placenta passed shortly without too much difficulty. She was still very tachycardic, so I gave her some fluids and had a bit of a think. The whole story didn't really add up. It would have been tempting to be entirely distracted by what had just happened and say having a miscarriage at 20/40 is enough reason to be in a lot of pain and as a result be tachycardic, but the tachycardia persisted and there was the fever to explain. The baby showed no signs of an infected uterus (no pus/smell) and miscarriages at 20 weeks are unusual without an underlying reason.
She was still very tender on her RUQ so I thought perhaps she might have cholecystitis (gallbladder infection) which caused the miscarriage. I called Adam who was on his way to review her again. He agreed that something wasn't right, although it wasn't entirely clear what. We didn't have any blood results back and she hadn't actually had a proper ultrasound scan, as we'd been a little distracted!
Adam thought it was more RIF, fitting with an appendicitis, so spoke to his boss about taking her to theatre. Proff (head of surgery) felt sure it was all gynae related but eventually agreed to do a laparotomy (open her up) anyway. Nothing happens quickly in Zambia, but later that night I got a text from Adam saying he was right, she had a gangrenous appendix and Proff owed him a bottle of wine!
So whilst there was one loss, less unwell patients have died here because things were missed, as could have so easily happened here if we'd been satisfied with "gynae pain" being a generic diagnosis. Nothing's straight forward here because we have such limited investigations and patients present SO much later here than they do back home (no one, even non-pregnant, EVER sits at home for a week with appendicitis in the UK).
We have a weekly morbidity and mortality meeting where each specialty takes turns presenting the deaths from that month. Often it gets really awkward because so many deaths here wouldn't happen back home, for a whole host of reasons, so people from other specialties can often be very critical. I really like this case because instead of a tragic death, every specialty contributed to saving her life: we had a very speedy referral from the medics, lateral thinking from O&G and good operating from general surgery (OK so no paeds...).
However, the majority of the broken-ness I'm seeing here involves dead babies (being O&G) and I realise that can be particularly upsetting for some people, so I'll leave it to your discretion whether you want to read any further.
Yesterday I had a particularly interesting case, and whilst it had a partially negative outcome, I think it's an example of different specialities working together really well. I'm trying to promote unity between specialties so think it's worth highlighting!
I was on call for O&G and had a referral for a lady on the medical ward who was very unwell. She was a 15 year old girl with a positive pregnancy test and vaginal bleeding, who had also been vomiting with fevers for a week. On seeing her it was soon clear that she was very unwell. (For the medics...) she was tachycardic ~140 (fast heart rate), febrile 39.3, and very tender on the right side of her abdomen with guarding. Initially we were concerned she might have had an ectopic pregnancy as they normally present in early pregnancy with L or R sided abdo pain and vaginal bleeding. James my reg did a bedside ultrasound scan, and found a pregnancy in the uterus (i.e. not ectopic - pregnancy outside of uterus that can --> death), but he couldn't find a heart beat so I took her to the ultrasound department for a proper scan. Adam, the surgical SHO, came to review her too as we thought it could also be an appendicitis.
She really wasn't at all well, but I managed to get her to the ultrasound department in a wheelchair and up onto the scanning bed. The sonographer started scanning, and there was the baby in the uterus, but again she was unable to get the fetal heart beat. As she was looking the baby moved across the screen. It took me a second to understand what had happened, but then I looked between the girls legs, and there was the baby on it's way out. After delivering the baby I tried to deliver the placenta but because the baby was so premature (probably about 20 weeks) with a bit gentle traction the cord snapped. This left me with a very sick young girl on the ultrasound bed with a retained placenta and literally no equipment, medications or midwives to assist me and 2 perplexed sonographers who really had no idea what on earth was going on.
I quickly wheeled her to labour ward, trying not to alarm the rest of the waiting room on the way out, and gave her some oxytocin (makes the uterus contract) and luckily the placenta passed shortly without too much difficulty. She was still very tachycardic, so I gave her some fluids and had a bit of a think. The whole story didn't really add up. It would have been tempting to be entirely distracted by what had just happened and say having a miscarriage at 20/40 is enough reason to be in a lot of pain and as a result be tachycardic, but the tachycardia persisted and there was the fever to explain. The baby showed no signs of an infected uterus (no pus/smell) and miscarriages at 20 weeks are unusual without an underlying reason.
She was still very tender on her RUQ so I thought perhaps she might have cholecystitis (gallbladder infection) which caused the miscarriage. I called Adam who was on his way to review her again. He agreed that something wasn't right, although it wasn't entirely clear what. We didn't have any blood results back and she hadn't actually had a proper ultrasound scan, as we'd been a little distracted!
Adam thought it was more RIF, fitting with an appendicitis, so spoke to his boss about taking her to theatre. Proff (head of surgery) felt sure it was all gynae related but eventually agreed to do a laparotomy (open her up) anyway. Nothing happens quickly in Zambia, but later that night I got a text from Adam saying he was right, she had a gangrenous appendix and Proff owed him a bottle of wine!
So whilst there was one loss, less unwell patients have died here because things were missed, as could have so easily happened here if we'd been satisfied with "gynae pain" being a generic diagnosis. Nothing's straight forward here because we have such limited investigations and patients present SO much later here than they do back home (no one, even non-pregnant, EVER sits at home for a week with appendicitis in the UK).
We have a weekly morbidity and mortality meeting where each specialty takes turns presenting the deaths from that month. Often it gets really awkward because so many deaths here wouldn't happen back home, for a whole host of reasons, so people from other specialties can often be very critical. I really like this case because instead of a tragic death, every specialty contributed to saving her life: we had a very speedy referral from the medics, lateral thinking from O&G and good operating from general surgery (OK so no paeds...).
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