G1 at 31 weeks with HELLP syndrome: Platelets 28,000, ALT 800+, Creatnine elevated 3x the norm. Also, with bloody vomitus.
Pluses: My very capable medical officer could do a C section on this woman; our Peds team is able to resusitate the baby if needed. Anesthesia is available 24/7.
Problems: We don't have platelets here - so many times that forces my hand to deliver people that I might be ball-sy and observe for steroid administration in the US. Babies at 30 weeks or less tend not to do well here, so I try to deliver them via C section, if possible.
So, I recommended that this patient be delivered. She was remote from delivery; so the decision was made to do an emergency C section. Problem: In the 3-4 hours it took to prepare the patient, discuss with anesthesia and actually do the surgery - no one checked fetal heart tones again and my medical officer delivered a still birth by C section. Ugh.....!
In addition, she was anuric for 16 hours before I was consulted again. By that time it was 5 pm on Sunday. Her creatnine had steadily increased, now with increased potassium and she had suffered 2-3 seizures. Eclampsia - my fave.
Pluses: The are two facilities that offer dialysis.
Problems: We are not one of those two facilities; so transport is required. Transport at night is difficult due to poor road conditions and also, the business office is closed. And of course, money is a concern.
So, now it is Monday morning and the patient is still at Tenwek. She has had 50 mL of urine output after both saline hydration and blood replacement. The issue with her discharge? Her family had to pay her bill and they could not locate the funds. So her discharge for transport was being declined.
What?!
A young woman in Acute renal failure - Anuric - needing dialysis - to Live, being declined transport until she pays her hospital bill? Talk about motivation to pay your bills. Here at Tenwek, we pride ourselves on providing care to the poor and suffering - oftentimes at the detriment of the hospital. It is not unusual to see patients hanging around the wards for days, even a week, after their discharge, while their relatives locate funds to pay their bill or petition the compassionate care fund (like a scholarship for very needy patients.)
I have always thought this policy was stellar....unfortunately, the ugly "other" side is that there are exceptions to every rule. I am sure that exceptions have been made in that past that maybe I don't know about, maybe the threat and grandour of the policy is to separate out the truly needy from the unmotivated. I say this because - my patient's family did find the money - and she was out the door by noon - now 48 hours anuric. With her bill paid.
I was happy - mainly because I had envisioned needing to chain myself to the big Tenwek sign, "We treat, Jesus heals," until she was released. I'm glad it didn't come to that.
Problem: We have no working doppler right now on OB. We have one fetoscope. All heart tones must be checked in OB. (Can't be done in OR). But it should have been done. So, I meet with the interns, the nursing supervisor, the in charge of nursing students....
It is again the other side of my job - the challenge not to become so distracted by the complications, the making plans, that the simple things are forgotten.
Yet, among all these issues...there is the one that I am most thankful for: that this is one eclamptic that will survive. In the US, that would never have been enough. But here, despite all my complaints and urgings to be and do better, it is enough.
11And the Lord shall guide you continually and satisfy you in drought and in dry places and make strong your bones. And you shall be like a watered garden and like a spring of water whose waters fail not. Isaiah 58:11
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