Transport

Transport: (According to Merriam-Webster) 1. v. To carry away or convey from one place to another. 2. n. Goods (or people) in the process of being received.

When I was in residency, I knew this word as the noun.  "We are getting a transport."  Any day teetering on the edge of goodness would be quickly pushed into chaos by this sentence.  It made everyone cranky: nurses, residents, attendings.  Especially if there were three transports.  Or unstable transports.  Or transports that had complications.

When I was working locums in rural Ohio, I learned this word as a verb.  "We need to transport this patient."  Suddenly, I was on the other side of the equation - being the physician who realized that she did not have the facilities to care for whatever condition the patient had.  Crankiness turned to anxiety in these days - getting the patient transported quickly, knowing I was responsible until she reached the next hospital, did I move fast enough? should I have caught it sooner?  did the other hospital hate me?

In Kenya, I am again on the receiving end of transports.  The big difference here is that transports are mostly concerned with the medical aspect and not so much with the legal.  In fact, if you - as the receiving hospital - say - "Sorry, we don't have an open beds in our ICU," you are likely to be told - "Sorry, the transport has already left."  There is also a common belief that once that patient leaves the facility - out of sight, out of mind!  Hence, I have received more than one transport that ends up receiving chest compressions within 5 minutes of them being at Tenwek.

Other popular reasons for transport:
       - no gauze, no IVfluids, no magnesium in stock (preeclampsia), no blood in blood bank
       - patient having difficulty breathing, patient can't be extubated after surgery (needs ICU care)
       - no anesthetist, on call doctor can't be reached, surgeon busy with other cases
      - failed induction of labor, needs C section - have had two of these patients who were actually not pregnant, but just had fibroids

Many of these district hospitals lack the medical training to take care of ob/gyn patients.  In addition, the patients who come to hospitals can often go from alittle complicated to  "needs ICU" in a short time. 

Take this patient:  a 34 year old multiparous patient who underwent a C section 2 weeks ago for cord prolapse at a district hospital.  Then 1 week ago, se developed a wound infection.  She went back to the same district hospital and had an exploratory laporatomy with a wash out.  Then she was hospitalized for daily dressing changes.  This past weekend, the hospital called saying that the family was requesting that the patient be transported to Tenwek for ICU care and dressing changes.  Unfortunately, at the time, we had no beds, so I declined the transport - but in typical Kenyan fashion, the hospital sent her anyway.  But it was a good thing they did....

When the patient arrived, the doctor on call took her immediately for ex lap because there was copious amount of pus draining from the incision site.  He paged me when he found a necrotic uterus and pelvis abscess:

Yucky necrotic uterus: I am pointing at the round ligament.

I began the very difficult task of debriding the necrotic tissues and doing a hysterectomy.  Luckily, I was able to at least "feel" the ureters and stay well out of their way.  Unfortunately, I can not even describe how badly this case smelled.  Then, just after we had close the abdomen, cleaned her up and began to move her to a clean bed....I spotted this.....coming out of her...uh...posterior area....

AAAAGGGGHHHH!  I hate worms!!!

Me and the worm

A bottom (low fundal) view of the necrotic uterus.



In the end, she went to the ICU on broad spectrum antibiotics - and albendazole.  She is still septic and will need lots of prayer, support (and washouts!) to get her through this.  Please keep her and our Gyne team in your prayers as we try to care for her. 

And to all my fellow medical co-workers: I am hoping that tomorrow will be a transport- free (both noun and verb) day for all of us!