Warning: This post contains a lot of very frank description of the O&G cases that I saw a couple of weeks ago (wrote this a while back, and never got round to posting it). I've written like this because I know my medical friends will find this interesting, but I suspect the majority of non-medics may find this a bit much, so decide for yourselves if you want to continue reading!
TLDR - basically a very self-indulgent post where I tell you all how I'm such a great doctor until it gets to 23:00 and then #spoileralert I get tired and miss a ruptured ectopic. Luckily she survives...
Just in case anyone's been getting the impression lately that I haven't been doing very much work, and spend most of my time swanning off on safari or the like, I thought I'd do a post walking you through a fairly standard day on call. (May have stolen this idea from Becky!) Our on calls start at 07:30 and run for 24 hours. The number of calls we do varies a lot depending on staffing, but generally they're every 2 to 5 days. The days in between are much less strenuous, just doing the ward work, elective surgery and clinics (although I don't do a lot of clinic!).
So talking you through my day on Monday...
06:20 - Alarm went off. For some reason, I find it much easier to wake up and get up when my alarm goes off here than in the UK. Probably because it's much lighter in the mornings, but it might also be because my neighbours cockerel has started the process of waking me up at 5am... I try to have a quiet time every day, using the Bible in a Year notes by Nicky Gumble, but I'm still on August from last year so you can see that's not going incredibly well! (Although mostly that's because it's quite long so often split it over two days) I had a quick breakfast, then just as I was leaving I suddenly remembered it was washing day, so quickly stripped the bed, took my sheets and towels to the mess who do our washing.
07:33 - Got to labour ward a couple of minutes late and found James reviewing a patient with a retained 2nd twin in breech presentation (i.e. bum first). She'd had 4 children through normal vaginal deliveries before and was contracting well, so it wasn't clear why this baby wasn't coming. First twin delivered at 06:55. You're meant to deliver the second twin within 30 minutes, and since the presenting part of the second twin was still high we decided to take her for section - you can't do any instrumental on a breech baby. The medical licentiate students didn't seem to be around so I performed the section with James assisting me. While it sometimes pains me to do it, I generally try to give them preference on operating because 1) they're Zambian, this is their hospital and I've come here to provide medical care, not to take training opportunities away from local trainees and 2) I'm about to go back to a 7 year training programme in the UK where I will receive excellent supervision and training and will not be expected to work independently for a long time, where as they will be left to operate alone in a few months when they graduate. But they weren't around, so I did it with James supervising. I'd never done a section for a retained second twin before, so I really enjoyed it! I got a bit confused when it came to removing the placenta - normally you just have one cord and pull on it to get the placenta out, but here there were two cords, one placenta, and the first cord was sticking through the vagina with a no-longer-sterile clamp on the end (from the first delivered twin), while the second one was in my surgical field. Nothing James couldn't help me with though!
While I was doing the section the rest of the team had finished the ward round (great timing!). Wednesday is a theatre day (M, W, F) so we continued with the elective list. Normally as well as 3 or 4 minor cases we have 2-3 hysterectomies booked, although typically only end up doing about 50% of them due mostly to a shortage in blood. Unusually there weren't any booked that day, so it wasn't a long list. I did a bilateral tubal ligation (female sterilisation) with James watching unscrubbed, then assisted him with a rescue cervical cerclage. A cervical cerclage, for the uninitiated, is a special kind of stitch you put in the neck of the womb to stop the baby falling out in women with cervical incompetence. This poor lady had had five second trimester miscarriages due to her cervix opening too early. Unfortunately by the time we were able to put in the stitch she was 19 weeks and her cervix was already 3cm dilated. They are much more effective when placed earlier (~14 weeks), before any dilatation has occurred. The procedure seemed to go as well as it could however, so we hoped for the best (i.e. James managed to do it without accidentally rupturing the membranes). Lastly I watched our acting consultant Dr Joop do a transvaginal myomectomy (remove a fibroid through the vagina), which was a very straight forward procedure.
After theatre I went to York (gynae ward) and labour ward. As the doctor on call I'm called to see any emergencies, but sometimes don't get called very prompty, so it's always worth checking the wards in person fairly regularly. Luckily there weren't any gynae admissions to be seen and the only patient on labour ward was a straight forward G4P3 who was progressing well.
I went to Bethlehem (ante-natal/post-natal ward) to see how my section patient was doing. She'd had a bit more vaginal bleeding than I would have liked and since she was at risk of having a post-partum haemorrhage (multiple pregnancy, prolonged labour and multiparous) I gave her a small oxytocin infusion to constrict the uterus.
11:30 - Popped home (I live on site) and updated my logbook and revised breech and breech manoeuvres (this is an excellent presentation), didn't get much done because somebody kept distracting me...
12:30 Had lunch - pasta with avocado, chorizo and parmesan. Avocados are in season so are super cheap and tasty. The chorizo and parmesan are a precious supply I brought from home when I went back for my interview. Jess was being particularly annoying, trying to eat my lunch, so I locked her in the bathroom, forgetting I'd left her litter tray outside in an attempt to teach her to poo outside... Let her out of the bathroom 20 minutes later to find she'd very thoughtfully pood where the litter tray normally sits...
Then got a text from James saying there was a new admission to review shortly after the clinical officer interns have seen her.
13:30 - New admission - 26y/o lady with a 1 day history of vaginal bleeding, G6P4, last menstrual period about 3 months ago with a positive pregnancy test and had an ultrasound scan suggestive of retained products. I did vaginal examination and felt products in the os, so did a speculum thinking I might be able to remove them with sponge forceps, but they were very fragmented so moved on to doing a manual vacuum aspiration (if you don't know what that is, you probably don't want to!) The bleeding stopped, so I left her on the ward for some observation and went to check on my twins section lady. Luckily her bleeding had stopped and the observations were fine - very reassuring!
I then went to the lab to chase the haematology/biochemistry/microbiology results. We don't have computers so have to manually collect the printed slips and put them in the notes. Unfortunately most of the patients whose microbiology results were now ready had gone home already, and there were a couple of positive findings, but with no means of contacting them all that could be done was to leave the slips with ward sister in case they are readmitted.
15:00 - Home again, tried to catch up on admin - who knew there could be so much admin from UK when I live 5000 miles away... Had a couple of hours peace with not much going on.
18:00 - Checked on the MVA patient, she was doing very well, no further bleeding or pain, but she didn't have transport so had to stay the night. While I was there I found there a new gynae admission waiting to be seen - a 17y/o primip who came with spotting and had an USS showing empty gestational sac at 7+1/40. She has a closed cervix, and the USS not entirely conclusive of miscarriage (although strongly suggestive), but as she was entirely well I decided wait for the morning for my seniors to confirm the diagnosis and discuss treatment options - most likely medical or surgical management of miscarriage. Back home I would have spoken to them that evening and sent her home to come back the following day, but patients live SO far away and have very limited transport options, and expect to wait, so virtually everyone stays in rather than going and coming back. It's difficult to explain why not doing anything is an appropriate course of action, but here people really do expect to wait a very long time, so it's expected not to bother seniors about this sort of thing out of hours (i.e. totally well patient).
18:40 - One of the GPs wife's, Threes, is retired and was looking for an occupation, so she's recently opened "Threes' mess" where she cooks for us twice a week at cost price. She's a great cook, so is very popular! Monday is take away night and Thursdays we go to their house to eat. On previous Mondays I've eaten the take away with the Scottish medical students who were here and we've watched a film, but sadly they left on Saturday. Instead I thought I'd take it into York with my laptop to eat it while watching a film with one of my favourite patients who has been with us for nearly 2 months and is super bored of being here. Her English isn't great, so not sure how much she followed it, but it made a change from the normal evening I hope.
Initially nobody told me, because in typical Zambian fashion they didn't want to interrupt the most important event of eating dinner, but turns out there was actually a patient waiting to be seen. I felt a bit bad when I found out she'd been there all the time I was eating! I left my friend watching the film (and half the ward who'd also crowded round) and took the new patient into the examination room. She gave a slightly confusing history of having had severe vaginal bleeding for 6 weeks, with previously normal regular periods and no period of amenorrhoea, with a bit of abdominal pain but no other symptoms. She'd had an ultrasound scan requested by the clinical officer showing a normal uterus and a L cystic mass, and had a positive pregnancy test. She looked fairly well, wasn't pale, and had reasonable observations, so it didn't seem hugely likely she'd been pouring out blood for 6 weeks. On examination she had mild suprapubic tenderness, no guarding and vaginally a closed os with a small amount of blood on the glove. I was a little perplexed, but decided to do a speculum in case she had an ectropian that might explain the prolonged bleeding. She did have an ectropian, but that still didn't explain the positive pregnancy test... I then thought of what, perhaps through the retrospectoscope should have been blindingly obviously, which was the possibility of an ectopic pregnancy. It wasn't an incredibly typical story, with the non-lateralising tenderness and no period of amenorrhoea, but luckily I did a colpocentesis (stuck a needle in the pouch of Douglas) which showed she had bloody fluid in her abdomen, strongly suggestive of a ruptured ectopic. I phoned my 2nd on call, Dr Mwansa, and we took her to theatre.
I've scrubbed for a couple of ruptured ectopics before, but only as an assistant, so I was a little surprised when Mwansa asked me if I wanted to do this one. But now I'm getting more comfortable with c-sections, I figured that lends itself to most pelvic surgery, right?! I needed a lot of help, but was able to do most of it. Although it obviously is not good for the patient, it was quite satisfying to see I'd made the correct diagnosis and that she did have an ectopic pregnancy, which I was then able to remove.
After finishing in theatre I went to check on labour ward, which had been unnaturally quiet all day. There was just one patient there who was a G7P6 who most likely would pop her baby out if she coughed, so wouldn't be likely to need any help (except being higher risk of PPH). On York there was another new admission who I started seeing, but then was informed that ultrasound was ready for her. She didn't look incredibly well, but the obs were reasonable, so I sent her round. One great thing about this hospital is that we get ultrasound scans very quickly with very little hassle, and almost all our patients have them requested by the clinical officers on admission and done before they reach the ward. Just a shame they're not always great quality!
22:30 - I decided to pop home while waiting and asked the nurse to call me when she came back, and to do a urinalysis and pregnancy test. When I got home I suddenly remembered I'd forgotten to collect my washing from the mess and found don't have a full 2nd set of bedding... But managed to make do with some chitenges.
23:00 - Still hadn't been called, but didn't particularly trust the nurse on to do anything hastily, and had an uneasy feeling about the patient, so went back in to investigate. She was back, in the bathroom doing the urine sample.
As is typical here, she gave a fairly poor history. She was complaining of central lower abdominal pain that had started that evening and thought she was pregnant (somewhere between 6 and 10 weeks). No vaginal bleeding or any other symptoms apart from feeling a bit light headed. On examination she was tender suprapubically, no guarding, and had a very very tender cervix, with bilateral adenexal tenderness. The ultrasound scan showed an intra-uterine pregnancy at 5+4/40 and ascites, and as you would expect with such a scan she had a positive pregnancy test. It didn't quite add up - why did she have this fluid in her abdomen? Why was she looking unwell if she had a normal intra-uterine pregnancy? The only thing I could think of to put these things together was that she had a bad case of PID making her a bit septic and giving her free fluid and a tender cervix. I put her on IV antibiotics, gave her lots of fluids and sent off bloods and a vaginal swab. Unfortunately, unlike the previous case, I didn't stick a needle in her pouch of Douglas to investigate the nature of that fluid - something I won't likely forget to do in the future...
00:00 - Went home and collapsed in bed, deciding taking a shower could wait until the morning...
04:30 - Woke up to my phone ringing - calls in the night are always difficult to understand due to a mix of poor reception, a very old hospital mobile used for calling that makes everything really quiet, difficult accents and the fact that I'm half asleep and so spend the first half of the conversation hoping they're somehow going to say "Don't worry, everything's fine, sorry for waking you" which obviously never happens... Unfortunately this makes it difficult to assess the severity of the call, so I always just go straight in to find out what's going on.
I was expecting there to be a problem with one of the patients I'd admitted that day, but instead got asked to review the lady James had put the cervical cerclage in that day. I found her bitterly weeping in bed with her 6th tiny tiny baby sticking out between her legs. Besides the obvious disaster, this really is a disaster because I hadn't been called until she'd already delivered. If the patient is contracting, unfortunately you have to remove the stitch because the stitch won't stop the contractions, it only works in a relaxed uterus. Instead the force of the baby can cause the stitch to amputate the cervix, making the chances of a successful pregnancy in the future even slimmer. The baby was sat in the vaginal, but wouldn't come out very easily and I didn't want to tear her cervix any more so I called Dr Mwansa for assistance. By the time he came the baby came out easily, followed shortly, with a little help, by the placenta. We then examined her cervix and after an unreasonable amount of hassle trying to find suitable equipment I removed the stitch. Luckily her cervix hadn't been amputated, it just had a small tear at about 5-o-clock, which Dr Mwansa repaired.
07:00 - Went home for a quick nap and text James asking him to call me when the morning teaching was over (normally 07.30-08.30).
08:10 - Clinical meeting finished, so went back in for the ward round. Tuesdays and Thursdays are grand rounds, so we review every single patient one at a time. I presented the patients I'd seen the previous day including the lady I diagnosed with PID in early pregnancy. Even as I was presenting I could feel something wasn't right, and James reviewed the ultrasound scan report. The summary concluded intra-uterine pregnancy, but looking more carefully at the main detailed report it actually stated intrauterine gestational sac, and doesn't mention a fetal pole... Which I'd read, but didn't take in the significance. She was a bit hypotensive, although not tachycardic, but James decided we need to take her straight to theatre. After briefly considering staying to watch, I decided to go home. I found out today that she did indeed have a ruptured ectopic, and by the time she was opened had 2L of blood in her abdomen... Luckily for her, me and the sonographer, there was blood available and so she was given 3 units and ought to be fine, but left much longer would have had a very different outcome.
11:00 - Finally finished, went home to have a well earned rest! As we're fairly well staffed at the moment we get the day off after the ward round following our on calls which is splendid, unlike when I first started and we'd continue working the next day, making it a 36 hour shift.
TLDR - basically a very self-indulgent post where I tell you all how I'm such a great doctor until it gets to 23:00 and then #spoileralert I get tired and miss a ruptured ectopic. Luckily she survives...
Just in case anyone's been getting the impression lately that I haven't been doing very much work, and spend most of my time swanning off on safari or the like, I thought I'd do a post walking you through a fairly standard day on call. (May have stolen this idea from Becky!) Our on calls start at 07:30 and run for 24 hours. The number of calls we do varies a lot depending on staffing, but generally they're every 2 to 5 days. The days in between are much less strenuous, just doing the ward work, elective surgery and clinics (although I don't do a lot of clinic!).
So talking you through my day on Monday...
06:20 - Alarm went off. For some reason, I find it much easier to wake up and get up when my alarm goes off here than in the UK. Probably because it's much lighter in the mornings, but it might also be because my neighbours cockerel has started the process of waking me up at 5am... I try to have a quiet time every day, using the Bible in a Year notes by Nicky Gumble, but I'm still on August from last year so you can see that's not going incredibly well! (Although mostly that's because it's quite long so often split it over two days) I had a quick breakfast, then just as I was leaving I suddenly remembered it was washing day, so quickly stripped the bed, took my sheets and towels to the mess who do our washing.
07:33 - Got to labour ward a couple of minutes late and found James reviewing a patient with a retained 2nd twin in breech presentation (i.e. bum first). She'd had 4 children through normal vaginal deliveries before and was contracting well, so it wasn't clear why this baby wasn't coming. First twin delivered at 06:55. You're meant to deliver the second twin within 30 minutes, and since the presenting part of the second twin was still high we decided to take her for section - you can't do any instrumental on a breech baby. The medical licentiate students didn't seem to be around so I performed the section with James assisting me. While it sometimes pains me to do it, I generally try to give them preference on operating because 1) they're Zambian, this is their hospital and I've come here to provide medical care, not to take training opportunities away from local trainees and 2) I'm about to go back to a 7 year training programme in the UK where I will receive excellent supervision and training and will not be expected to work independently for a long time, where as they will be left to operate alone in a few months when they graduate. But they weren't around, so I did it with James supervising. I'd never done a section for a retained second twin before, so I really enjoyed it! I got a bit confused when it came to removing the placenta - normally you just have one cord and pull on it to get the placenta out, but here there were two cords, one placenta, and the first cord was sticking through the vagina with a no-longer-sterile clamp on the end (from the first delivered twin), while the second one was in my surgical field. Nothing James couldn't help me with though!
While I was doing the section the rest of the team had finished the ward round (great timing!). Wednesday is a theatre day (M, W, F) so we continued with the elective list. Normally as well as 3 or 4 minor cases we have 2-3 hysterectomies booked, although typically only end up doing about 50% of them due mostly to a shortage in blood. Unusually there weren't any booked that day, so it wasn't a long list. I did a bilateral tubal ligation (female sterilisation) with James watching unscrubbed, then assisted him with a rescue cervical cerclage. A cervical cerclage, for the uninitiated, is a special kind of stitch you put in the neck of the womb to stop the baby falling out in women with cervical incompetence. This poor lady had had five second trimester miscarriages due to her cervix opening too early. Unfortunately by the time we were able to put in the stitch she was 19 weeks and her cervix was already 3cm dilated. They are much more effective when placed earlier (~14 weeks), before any dilatation has occurred. The procedure seemed to go as well as it could however, so we hoped for the best (i.e. James managed to do it without accidentally rupturing the membranes). Lastly I watched our acting consultant Dr Joop do a transvaginal myomectomy (remove a fibroid through the vagina), which was a very straight forward procedure.
After theatre I went to York (gynae ward) and labour ward. As the doctor on call I'm called to see any emergencies, but sometimes don't get called very prompty, so it's always worth checking the wards in person fairly regularly. Luckily there weren't any gynae admissions to be seen and the only patient on labour ward was a straight forward G4P3 who was progressing well.
I went to Bethlehem (ante-natal/post-natal ward) to see how my section patient was doing. She'd had a bit more vaginal bleeding than I would have liked and since she was at risk of having a post-partum haemorrhage (multiple pregnancy, prolonged labour and multiparous) I gave her a small oxytocin infusion to constrict the uterus.
11:30 - Popped home (I live on site) and updated my logbook and revised breech and breech manoeuvres (this is an excellent presentation), didn't get much done because somebody kept distracting me...
Then got a text from James saying there was a new admission to review shortly after the clinical officer interns have seen her.
13:30 - New admission - 26y/o lady with a 1 day history of vaginal bleeding, G6P4, last menstrual period about 3 months ago with a positive pregnancy test and had an ultrasound scan suggestive of retained products. I did vaginal examination and felt products in the os, so did a speculum thinking I might be able to remove them with sponge forceps, but they were very fragmented so moved on to doing a manual vacuum aspiration (if you don't know what that is, you probably don't want to!) The bleeding stopped, so I left her on the ward for some observation and went to check on my twins section lady. Luckily her bleeding had stopped and the observations were fine - very reassuring!
I then went to the lab to chase the haematology/biochemistry/microbiology results. We don't have computers so have to manually collect the printed slips and put them in the notes. Unfortunately most of the patients whose microbiology results were now ready had gone home already, and there were a couple of positive findings, but with no means of contacting them all that could be done was to leave the slips with ward sister in case they are readmitted.
15:00 - Home again, tried to catch up on admin - who knew there could be so much admin from UK when I live 5000 miles away... Had a couple of hours peace with not much going on.
18:00 - Checked on the MVA patient, she was doing very well, no further bleeding or pain, but she didn't have transport so had to stay the night. While I was there I found there a new gynae admission waiting to be seen - a 17y/o primip who came with spotting and had an USS showing empty gestational sac at 7+1/40. She has a closed cervix, and the USS not entirely conclusive of miscarriage (although strongly suggestive), but as she was entirely well I decided wait for the morning for my seniors to confirm the diagnosis and discuss treatment options - most likely medical or surgical management of miscarriage. Back home I would have spoken to them that evening and sent her home to come back the following day, but patients live SO far away and have very limited transport options, and expect to wait, so virtually everyone stays in rather than going and coming back. It's difficult to explain why not doing anything is an appropriate course of action, but here people really do expect to wait a very long time, so it's expected not to bother seniors about this sort of thing out of hours (i.e. totally well patient).
18:40 - One of the GPs wife's, Threes, is retired and was looking for an occupation, so she's recently opened "Threes' mess" where she cooks for us twice a week at cost price. She's a great cook, so is very popular! Monday is take away night and Thursdays we go to their house to eat. On previous Mondays I've eaten the take away with the Scottish medical students who were here and we've watched a film, but sadly they left on Saturday. Instead I thought I'd take it into York with my laptop to eat it while watching a film with one of my favourite patients who has been with us for nearly 2 months and is super bored of being here. Her English isn't great, so not sure how much she followed it, but it made a change from the normal evening I hope.
Initially nobody told me, because in typical Zambian fashion they didn't want to interrupt the most important event of eating dinner, but turns out there was actually a patient waiting to be seen. I felt a bit bad when I found out she'd been there all the time I was eating! I left my friend watching the film (and half the ward who'd also crowded round) and took the new patient into the examination room. She gave a slightly confusing history of having had severe vaginal bleeding for 6 weeks, with previously normal regular periods and no period of amenorrhoea, with a bit of abdominal pain but no other symptoms. She'd had an ultrasound scan requested by the clinical officer showing a normal uterus and a L cystic mass, and had a positive pregnancy test. She looked fairly well, wasn't pale, and had reasonable observations, so it didn't seem hugely likely she'd been pouring out blood for 6 weeks. On examination she had mild suprapubic tenderness, no guarding and vaginally a closed os with a small amount of blood on the glove. I was a little perplexed, but decided to do a speculum in case she had an ectropian that might explain the prolonged bleeding. She did have an ectropian, but that still didn't explain the positive pregnancy test... I then thought of what, perhaps through the retrospectoscope should have been blindingly obviously, which was the possibility of an ectopic pregnancy. It wasn't an incredibly typical story, with the non-lateralising tenderness and no period of amenorrhoea, but luckily I did a colpocentesis (stuck a needle in the pouch of Douglas) which showed she had bloody fluid in her abdomen, strongly suggestive of a ruptured ectopic. I phoned my 2nd on call, Dr Mwansa, and we took her to theatre.
I've scrubbed for a couple of ruptured ectopics before, but only as an assistant, so I was a little surprised when Mwansa asked me if I wanted to do this one. But now I'm getting more comfortable with c-sections, I figured that lends itself to most pelvic surgery, right?! I needed a lot of help, but was able to do most of it. Although it obviously is not good for the patient, it was quite satisfying to see I'd made the correct diagnosis and that she did have an ectopic pregnancy, which I was then able to remove.
After finishing in theatre I went to check on labour ward, which had been unnaturally quiet all day. There was just one patient there who was a G7P6 who most likely would pop her baby out if she coughed, so wouldn't be likely to need any help (except being higher risk of PPH). On York there was another new admission who I started seeing, but then was informed that ultrasound was ready for her. She didn't look incredibly well, but the obs were reasonable, so I sent her round. One great thing about this hospital is that we get ultrasound scans very quickly with very little hassle, and almost all our patients have them requested by the clinical officers on admission and done before they reach the ward. Just a shame they're not always great quality!
22:30 - I decided to pop home while waiting and asked the nurse to call me when she came back, and to do a urinalysis and pregnancy test. When I got home I suddenly remembered I'd forgotten to collect my washing from the mess and found don't have a full 2nd set of bedding... But managed to make do with some chitenges.
23:00 - Still hadn't been called, but didn't particularly trust the nurse on to do anything hastily, and had an uneasy feeling about the patient, so went back in to investigate. She was back, in the bathroom doing the urine sample.
As is typical here, she gave a fairly poor history. She was complaining of central lower abdominal pain that had started that evening and thought she was pregnant (somewhere between 6 and 10 weeks). No vaginal bleeding or any other symptoms apart from feeling a bit light headed. On examination she was tender suprapubically, no guarding, and had a very very tender cervix, with bilateral adenexal tenderness. The ultrasound scan showed an intra-uterine pregnancy at 5+4/40 and ascites, and as you would expect with such a scan she had a positive pregnancy test. It didn't quite add up - why did she have this fluid in her abdomen? Why was she looking unwell if she had a normal intra-uterine pregnancy? The only thing I could think of to put these things together was that she had a bad case of PID making her a bit septic and giving her free fluid and a tender cervix. I put her on IV antibiotics, gave her lots of fluids and sent off bloods and a vaginal swab. Unfortunately, unlike the previous case, I didn't stick a needle in her pouch of Douglas to investigate the nature of that fluid - something I won't likely forget to do in the future...
00:00 - Went home and collapsed in bed, deciding taking a shower could wait until the morning...
04:30 - Woke up to my phone ringing - calls in the night are always difficult to understand due to a mix of poor reception, a very old hospital mobile used for calling that makes everything really quiet, difficult accents and the fact that I'm half asleep and so spend the first half of the conversation hoping they're somehow going to say "Don't worry, everything's fine, sorry for waking you" which obviously never happens... Unfortunately this makes it difficult to assess the severity of the call, so I always just go straight in to find out what's going on.
I was expecting there to be a problem with one of the patients I'd admitted that day, but instead got asked to review the lady James had put the cervical cerclage in that day. I found her bitterly weeping in bed with her 6th tiny tiny baby sticking out between her legs. Besides the obvious disaster, this really is a disaster because I hadn't been called until she'd already delivered. If the patient is contracting, unfortunately you have to remove the stitch because the stitch won't stop the contractions, it only works in a relaxed uterus. Instead the force of the baby can cause the stitch to amputate the cervix, making the chances of a successful pregnancy in the future even slimmer. The baby was sat in the vaginal, but wouldn't come out very easily and I didn't want to tear her cervix any more so I called Dr Mwansa for assistance. By the time he came the baby came out easily, followed shortly, with a little help, by the placenta. We then examined her cervix and after an unreasonable amount of hassle trying to find suitable equipment I removed the stitch. Luckily her cervix hadn't been amputated, it just had a small tear at about 5-o-clock, which Dr Mwansa repaired.
07:00 - Went home for a quick nap and text James asking him to call me when the morning teaching was over (normally 07.30-08.30).
08:10 - Clinical meeting finished, so went back in for the ward round. Tuesdays and Thursdays are grand rounds, so we review every single patient one at a time. I presented the patients I'd seen the previous day including the lady I diagnosed with PID in early pregnancy. Even as I was presenting I could feel something wasn't right, and James reviewed the ultrasound scan report. The summary concluded intra-uterine pregnancy, but looking more carefully at the main detailed report it actually stated intrauterine gestational sac, and doesn't mention a fetal pole... Which I'd read, but didn't take in the significance. She was a bit hypotensive, although not tachycardic, but James decided we need to take her straight to theatre. After briefly considering staying to watch, I decided to go home. I found out today that she did indeed have a ruptured ectopic, and by the time she was opened had 2L of blood in her abdomen... Luckily for her, me and the sonographer, there was blood available and so she was given 3 units and ought to be fine, but left much longer would have had a very different outcome.
11:00 - Finally finished, went home to have a well earned rest! As we're fairly well staffed at the moment we get the day off after the ward round following our on calls which is splendid, unlike when I first started and we'd continue working the next day, making it a 36 hour shift.
