Friday, August 3, 2007

First day on call

August 1st

I have learned—over the past three years in this process of medical training—that anticipation of challenging medical situations is worse than actually living through them. For the past three years, fear about being in a situation where I am unsure about what to do at a medical decision tree plagues me. Over the past several months I have sensed a mirage; a chasm between being in the process of being trained and knowing. Each day that I move closer to leaving residency, the hope that I will somehow find my way on the other side of the chasm, that I will know grows more intense.

Literally and figuratively, being in Kijabe this short time has caused the mirage to vanish. Knowing is so far off that I am now convinced that it will never fully come. Knowing more while learning along the way is the constant in medicine; there is no chasm, there is no need to get across. Kijabe is teaching me that being a physician means caring, and doing what you are capable of in the moment.

My first 24 hours of work was full. It is one thing to be in a new hospital. And another to:
work in wards with new names: “casualty” (ED), “OPD” (clinic), the “special ward” (for those who can pay more than the routine cost of being on the men’s or woman’s ward)
work among medical professionals with titles such as “medical officer”, “intern”, “registrar”
care for patients who speak a different language
work with nurses who operate with a different set of cultural norms
identify diseases that I have never seen and prescribe medications that I have never heard of
be called in as a “consultant” for people who are not more than three years my junior and have been trained in this environment… from the ED, clinic and the wards all at once.
I was sweating most of the day, did not have lunch until 9pm and did not urinate the whole day… but felt completely at peace in my soul, knowing that life was so full and experiences so rich.

Just a week earlier, the excellent Dr. Wierusz had admitted and taken care of a young female who had an abdominal mass which was drained in the OR and found to be an abscess; 6L of pus was removed from her abdomen. She improved over the next few days and was nearly discharged--pending “mobilization”. But she was increasingly less willing to move as her left lower extremity grew more edematous with a presumed DVT and her abdominal incision opened with infection. When she started bleeding from her open wound, her hematocrit and platelets dropped. In DIC, we transferred her to the ICU during my day on call. The blood bank had several nearly empty drawers of blood, probably about 7 or 8 units. One unit of O+ was promised to an elderly gentleman in the ICU with a GI bleed who had a better chance of survival. The young woman needed whole blood in lieu of cryo and FFP—which are never available. Both Mike and I would have given her our blood; but the amount that could have saved her at this point was more than either of us could spare. She became hypotenseive, tachycardic, and soaked with her own blood. In the middle of the night, Mike and I watched the haunting progression of tachypnea to agonal breathing. She died peacefully. There was no need for a code because there was nothing to offer on the other side of that code. In the traditional Kenyan way, her nurse watched with quiet distress--another one of her patients was dying. There is no escape from death. After all she is working in the ICU where “advanced medical technology” (cardiopulmonary monitors, one intermittently working ventilator, and more selection of IV medications) is available, where the ratio of nurses to patients allows more personal and attentive care, where more money is spent for presumed aggressive medical care, where patients are saved. But even in the ICU patients are still are malnourished causing diminished immune response, disease burden is advanced because of lack of prevention or early detection, and life saving treatments are in short supply and high demand throughout the nation—even in the ICU.

CHF exacerbation, renal insufficiency and hyperkalemia. Familiar--I could have been on 3SW at Swedish and ordered an EKG, started gentle diuresis, and potassium lowering. Unfamiliar--the EKG machine is not working, elevated potassium is often a lab error and can not be trusted, (there is no kayexylate and certainly no dialysis available anyway), and the patient is becoming unstable with tachycardia and hypotension. Stop diuresis and stare at the cardiac monitor above his bed--ST depression, flipped T waves and Q waves develop. He looks unwell. A cath lab does not even exist in the imagination. We watch this man infarct his myocardium. Antithrombotic therapy? Incidentally, his INR is 2.2--not unlike a surprising number of the patients here—possible vitamin K deficiency, or a whole host of other possibilities except of course previous anticoagulation therapy as this is the first time this gentleman has been to the hospital. His death occurs several hours after his young female roommate.

Two of five ICU patients are taken to the morgue, their bodies are released after their poor families pay for the hospital stay.

Six months post partum, a woman with choriocarcinoma is in neutropenic precautions after her course of chemotherapy and in the ICU after her successful resuscitation by Dr. Tuggy two days previously. She has an iatrogenic pleural effusion which is thought to be the cause of her tachypnea. Her breathing however seems to be mimicking the progression seen several hours ago by the 19 year old. None of us mention agonal breathing because her vitals are otherwise holding stable and there is no good reason that she too should die tonight. She, after all has been identified as a lucky one, saved from death two days ago, undergoing aggressive treatment—she is a hopeful recovery. She is a mother.

I left for two hours that night to sleep in my own bed. And hers had emptied in that amount of time. The small African ICU had lost three. The night nurses went home, still quiet. They seemed to be attempting to walk the line between complacency about frequent death and mourning for the young lives that are ending time and time again.

The ICU had another admission that night. A male 3 hours old, born to a 17 year old G1 at about 33 weeks gestation (based on the post partum glance assessment) by LTCS for footling breech and PPROM. He had been in the nursery with increasing grunting, tachypnea 40-50s and tachycardia. Unlike the other patients, I knew this one from the beginning of his time at Kijabe. Under the dim fluorescent lights of an operating room with red-mud-stained tiled floors, in the late hours of my first call day, I did my first c-section thanks to the play by play direction of a family doctor from Seattle who I admire tremendously. The experience of “first” had begun long before I made the skin incision. We found shoe covers that were made of blood stained cloth and heaped together in a bin. We scrubbed with plain ‘ol soap and water followed by squirting some alcohol on our hands. My gown had a cotton exterior and a plastic interior that demonstrated its sterilization process by clinging to itself like a polypropylene shirt with extreme static cling. The anesthetist administered the spinal within 2 minutes in a manner so graceful one might have thought that she was creating some kind of art on the patient’s back. The patient appeared comfortable and I could not tell that she was nervous until she clung to Mike’s gently offered hand and put her head on his shoulder. Her eyes were shinning, scared and young. Her gravid body was the only thing I knew about her. It seemed that she needed a father at this moment, and Mike was filling that role. I hope to God that she has someone other than Mike to hold her hand as she is raising this child. Her shining eyes were hidden behind the cotton sheet curtain while I trembled with anxiety at several points during this surgery--a dystocia of the head for about 2 minutes and a brisk bleed until we closed the placenta. A one and a half pound crying boy was born and handed to an excellent German pediatrician while we closed. It was only after three hours of life that he had begun to look sick accounting to his transfer to the ICU for c-pap… unfortunately the c-pap machine was discovered to be broken… but that is another story.

This was only part of the ICU story that night. I am skipping the patient who was two days post emergent repair of a AAA (who had presented with an upper GI bleed and thought to have an aorto-duodenal fistula) who was now briskly filling his NG drainage bag with bright red blood. He ended up visiting the OR again in the middle of the night for a pyloroplasty and vagotomy to control bleeding from a duodenal ulcer.
The other patient was an 96 year old man with a GI bleed. He was sleeping.

I interpreted the promise of many “procedures” as a carrot for this experience in Kijabe. I was fortunate to get to do a thorecentesis as part of daily rounds on the wards, an LP in the ED (“casualty”) on a seizing 17 year old, a FNA of a 3cm breast mass with associated lymphadenopathy in a patient who traveled from hours away. Procedures here are more than a chance for this resident to develop her skills. They are a necessary piece of delivering medical care to an overwhelming number of patients who almost all have progressed disease and little ability to “follow up.” One does what is needed--now--because there may never be a later. Skill is something I feel a certain desperation to improve for the purpose of being more efficient with my care of sick patients where ever I am delivering medical care. Perhaps someday I will be able to perform an LP as that anesthetist did in the OR the previous night.

Hoping that tonight we will have warm water, I need to bathe Liam. And then will to try to get some sleep around the reflections the percolate when my head hits the pillow. Tomorrow’s morning report followed by chapel comes quickly.

1 comment:

mary said...

Dear Elizabeth, You write so eloquently--I am thrust back into the Kijabe life, now that seems so far away. May you continue to contribute your fine empathetic skills and grow abundantly while there. I look forward to your next entry...