Liberia#9
Sitting in morning worship, they just had begun, when we found out that a lady in labor had a baby that the heart rate was low for that past 2 hours. The nurse reported that she had contacted the doctor, which wasn’t true. The baby was still alive but with a heart rate about 80, normal is about double that. The anesthetist is only here Tuesdays and Thursdays. So this being a Thursday, they would be here sometime after 9AM. It was too long to wait, so Gillian asked me to do anesthesia for her. I prefer to do the operating, but doing anesthesia sure beats doing rounds on all the medical patients (which I did later), or going to clinic to see the outpatients! So was happy to do it. A nurse got a functional IV canula in and then I started pouring in the fluids. The delivery room is a room with one bed in the center, and another against the wall, if there are two women delivering at the same time, or not enough time to clean the central one before another baby is born. Since being here, there always seem to be 2 or 3 women in labor that are waiting around for the delivery. Though come to think of it, I haven’t yet heard screaming coming form there, maybe a few moans. Most seem to be silent. And of course after the delivery, they clean themselves with the nurse’s help and walk back to their room.
So I took the patient to the operating room. Drew up my medicines. After enough fluid had gone in, I cleaned her back with iodine, and placed spinal anesthesia. Her pressure dropped a little, as expected, but was never low. Dr. Gillian prepped her. We gave her a little nausea medicine, and then the operation began. The mother did great. After entering the abdomen, the anesthetist came. So I left the operation and went to do floor rounds.
Many of the same people were there as I described yesterday. I did see some new ones. A very thin lady lay on her cot next to the wall. Her breaths were rapid and shallow. Hollow eyes looked at me. She complained of being to weak to eat, and not feeling like she was getting better. I looked at her lab results, and she was malaria and HIV positive. Black dots and patches marked her already black skin. I found a stethoscope and bathed it in the chlorine solution. Then went back to the room and listened to her. It sounded like water bubbling inside at every breath. I though of a lung infection common to HIV people, so I started her on high dose septra and steroids. She was already on treatment for malaria. So many things here are treated on suspicion alone; I hope my suspicion for her was right, as it may then help her.
I later heard that the baby that Gillian delivered did survive, it had been to long. I found the lady I admitted yesterday laying on her bed mostly exposed. It apparently hurt too much to touch the cloth at the burn areas, which was most of her lower body and left arm. The family had gone out to get honey as requested yesterday. So I had to wait to do her dressing later (done at 7PM when I got my first break in more urgent things). Gillian saw a patient in the “ER” (a room downstairs with a bed and a nurse, without any other equipment) that had an axillary (arm pit) abscess. So she took that patient to the OR while I continued rounds. I was called out to see a sick person in a car.
In the entry to the hospital I put on the gown and gloves and walked out with the guard to the car. He took the temperature with the infrared thermometer, and then I examined the woman. She had generalized body aches and nothing else. I did the few labs that were remotely possible, that I could check. Malaria, typhoid, syphilis. She had just finished treatment for typhoid, but I understand that there is a bit of medicine resistance here, because it’s treated so often. Later on, when I had finished with some operations, I was asked to see her again. All the tests were negative. So I didn’t have much to offer her. I gave her ibuprofen and multivitamin. It seems like most people here (as in Cameroon) feel that a multivitamin will give them strength and a better appetite. They seemed content and drove off in their car that resembled a Nissan Altima. I stripped off my protective cloths, dumping them in a trashcan, bathed my hands and arms in chlorine from the bucket with a spicket, and dripped my way inside.
Next were two people who wanted ultrasounds. One thought she had been pregnant for 8-9 months, and was told the baby was only 5 months at some clinic. She felt the baby moving too. I did an ultrasound, and she was NOT pregnant. All looked normal, but for a small uterine fibroma. She seemed content with my explanation and left. Next another gaunt woman with a large belly. Said it had been that way a long time. And she could eat hardly anything, because if made her belly feel very bloated. I looked and couldn’t easily find intestines, just a lot of fluid. Finally after some time of looking, I discovered it was a huge cyst, going from the pelvic bone all the way up to the sternal bone. The intestines, liver, spleen, everything was up above it in a little tiny space. I suspect an ovary as the origin. I’ve scheduled her for removal next week. Her labs looked OK (Hemoglobin, malaria, and HIV). So much fewer that we evaluate in the US where we have much more possibilities!
Gillian found me and asked if Id do the next two surgeries. OF COURSE! The first was a young woman who had had a C-section about three weeks ago, got an incision infection, and came in today with a gaping wound with intestines visible (wound dehiscence). The second was a woman who has been her a couple days, and it turns out has been leaking amniotic fluid at term, and was not progressing at all, or not even in labor that she could tell.
While I was waiting another person was downstairs that needed to be seen. This time I saw a 3-week-old baby who was breathing fast with a distended belly with a temperature of 104.9 F. People don’t live long with a temperature like that. Grandma denied that the baby had any vomiting, nor diarrhea. The eyes were normal, and he hadn’t eating since yesterday. I admitted him and asked them to start a quinine drip for malaria, while I did the habitual few tests that are available.
The anesthetist student put in the spinal with much difficulty and then the anesthetist offered to put in the Foley (urine) catheter so I could wash my hands and get my sterile gown over my other protective gown. I walked back in as he put on his sterile gloves, then proceeded to unwrap the Foley catheter, open the legs, grab the betadine bottle, open the container with the gauze then grab the Foley to put it in. I said WAIT!!! YOU’RE NOT STERILE!!!!! “Oh, you want it in sterilely?” (The answer to that question would ALWAYS be YES, so no one has every asked that of me before!) YES!! STERILE!!!!!! So he put on a new set of gloves and placed a Foley. My confidence plummeted! He works here and at the ministry of health so I wouldn’t have anticipated that. (I sure hope not in infection control!) I decided then, that I would put all my own Foley catheters in from now on in the operating room. I prepped the abdomen with betadine and sucked residual puss from around the exposed intestines. They had already stuck together in such a way that it was difficult to see lines between them. Some seemed like one big surface, though that wasn’t possible. I decided, if there were that much infection on the outside, there would be some deeper inside too. So I opened the incision up passed the umbilicus. Next I slowly separated each stuck piece of intestine. As I did this, more and large quantities of pus flowed out as I would enter pus pocket after another. Eventually all the loops were free. I was grateful that I did not make a hole in any piece of intestine. We washed and washed till all fluid coming out was clear, then I closed the fascia (deep layer), leaving the skin open and packing it with a dressing.
I wrote a short operation note, then back to the floor to see patients with problems. And another new one.
The c-section went well, pulling out a screaming baby. (music to my ears!). Then off to the wards to see more patients and do more burn dressings. Now I’m tired, and you are to, of reading a long Liberia note. Thanks for your prayers on my behalf and the workers of Cooper Hospital.