more bleeding

Yesterday a beautiful, educated 22 year old woman was brought into our emergency room on the edge of passing out.  Her blood pressure was quite low.  We put in two IV's with wide open fluids, did a pregnancy test which was positive, got an ultrasound which showed her abdomen was full of fluid -- blood.  The ambulance came right away and set out with her for the referral hospital -- if she was to live, she needed emergency surgery for hemorrhage -- likely due to ruptured ectopic pregnancy. 

 

Before and after the ambulance left with her, I spent at least an hour on the phone, making at least 10 phone calls to seemingly every part of the referral hospital, trying to find a gynecologist accepting emergencies.  I spent many minutes on hold for various providers who never got to the phone, called again after many busy signals, never found a doctor to tell about this patient headed for their hospital.   I was finally able to give the patient's name and story to gyn secretary at the other hospital, and she said they'd attend to the young woman. 

Sometimes people die tragically.  It is painful to be there when it happens.  She probably died, but I don't know that for sure.  

I have been reflecting on spiritual teachings as I prepare for another work day today, and asking to be filled with lovingkindness, for myself and for others. 

I am laughing now after reading a quote from Woody Allen,

“To love is to suffer. To avoid suffering, one must not love. But then, one suffers from not loving. Therefore, to love is to suffer; not to love is to suffer; to suffer is to suffer. To be happy is to love. To be happy, then, is to suffer, but suffering makes one unhappy. Therefore, to be happy, one must love or love to suffer or suffer from too much happiness.” 

first the basics

My first on-call day and night were busy -- the themes were babies not breathing and bleeding people -- one a pregnant lady, already a mother of four, with a near term pregnancy, who had suddenly started bleeding rapidly from her placenta.  The baby had stopped moving the day before, and we discovered it's heart wasn't beating using the ultrasound.  Thank god I had back-up from my medical manager. We had to get blood going and freeze dried plasma reconstituted and transfusing.   We sent her to the referral hospital (Edendale) for emergency surgery at 4 a.m..  I don't know if she lived, but she had a decent chance.   Another bleeder earlier in the day was a young woodcutter who was using a chainsaw and amputated most of his right hand. I sent him and his amputated fingers on ice off to Edendale during a thunderstorm.  He waited more than five hours until the ambulance showed up.  Before that, a newborn on the pediatric ward stopped breathing, and for awhile I was the only doctor helping with the resuscitation attempt.  The baby died.   In the night, there was a complicated labor with a 15 year old girl whose fetus was in distress,stuck in the birth canal for quite a while.  I did my best encouraging the girl to push, and she worked really hard at it.  The nurses pushed down and out on her belly to try and help push out the baby.  Hadn't seen that technique before. My medical manager ended up using forceps for the delivery. Then the newly born baby wouldn't breathe.  My medical manager resuscitated her to the point of spontaneous breathing and intact reflexes, if not crying.  He resuscitated the tiny infant despite the lack of proper equipment, using a bag valve mask that was adult size.  Finally someone brought the infant bag valve mask from upstairs in maternity.

With all of these unnerving and motivating experiences, reading about what I don't know becomes fascinating and urgent -- about neonatal resuscitation, bleeding during pregnancy, likelihood of success in reattaching amputated fingers, and on and on.

Reading, no reading, patients dying, patients living, back-up or no back-up, my main goal for this year needs to be simply showing up for work every day.  That and staying healthy.  There is enormous need here, and so many things that could be improved.  But first, the basics.

On the subject of staying healthy, Steven and I have been taking regular jogs, mostly early in the morning before work.  Here's a cellphone snapshot from one of the nearby routes.  The rainy season has started, and soon the grasses will be green.

When we go later in the day, we've tend to acquire jogging companions from among the village teenagers. They trot along up the hills with us, often wearing flip-flops. We try out our Zulu words and they their English.  It is a fun way to make friends.

Here are more Drakensburg wildflowers, sprouting in an area where the grass was therapeutically burned.

Happy birthday to my brother Brook, whom I admire, love and respect more with each year that passes.

Nkululeko

It's early on a Tuesday morning.  My internet connection has been off and on, so with luck this posting attempt will work.  We went for a stunning hike on Sunday, encountering a herd of eland that included an enormous male (supposedly they can weigh up to 700 kg) and several babies in groups.  Also came fairly close to a Rinkhals, a poisonous snake.

The hike was to the Pinnacles, pictured above.  It was so quiet there.  I napped in the shade of the tallest rock.

Work has been quite challenging.  This is my second week in the "OPD," which is emergency, urgent care and chronic illness clinic wrapped into one.  Yesterday's two big themes were sick babies and nasty fractures.  There's no X-ray or transportation on the weekend, so every Monday morning there's an accumulation of patients that've gotten sick over the weekend or have waited for X-rays of their fractures.  I admitted five babies to the hospital.  For the fractures, thank goodness for the orthopedists where we refer (Edendale).  I must've called them eight times yesterday for help with fracture management, and they agreed to see everyone that needed it.  The patients seem incredibly stoic -- for example sleeping in a chair for 2-3 nights with a fracture waiting for an X-ray, and living with a great deal of pain. 

The work week started off yesterday with a lady lying on a mat on the floor dying of disseminated Kaposi's sarcoma.  She'd been there overnight because there was no open bed in the hospital.  Her sister was with her, and told me how beautiful and light-complected she had been, pointing to my skin and to her sister's skin. 

Triaging here is different than I could've imagined.  I understood rationally that this a place in crisis with a great deal of physical human suffering, and that is one of the reasons I came here -- because I can help to some degree.  Yet actually being with those who are so ill and in so much pain, and not having time or resources to help them is quite baffling and sad at times. The sickest patients often have disseminated infections.  If we can get an IV in them, we can give fluids and antibiotics, but several are already crossing death's threshold, and how long do you try when 30 other people are waiting for you to see them and the pharmacy closes at 4 p.m.?  So far I haven't found enough human or material resources to do effective advanced life support.   I must realize again and again that I am in the middle of an epidemic that is thousands of times bigger than my reach.  And realize also that there are situations every day where I can make a difference for individual patients.

I've met several men and boys named Nkululeko, which means freedom.  The people I meet have so much more in life than pain and suffering.  Freedom is here too, and love and joy.  We cannot lose sight of how much there is to being alive.