Retrospect: On Call

Home:
I change into dry clothes and get back into bed.  The phone rings.  It is my intern.
Joyce has been taken back to ICU - she has right sided body weakness and aphasia.  A re-bleed.
I sigh and I sleep.


3pm:
The rain is harder than I thought.  And loud.  I cannot hear my footsteps as I quickly walk down the sidewalk from the hospital to my house.  Within a minute, the front of my white coat is soaked, my scrub top, too.  I never carry my bag on the weekends - that's where my umbrella is.  But I couldn't stand to stay at the hospital to wait out the rain....

It runs down my forehead, into my eyes...cooling me....washing away the frustration.  I smell wet earth - clean and fresh.  The grass - lovely and green, the color of spring back home.  The smell of the bovie, the infection, the color of blood are all driven from my mind as I am baptized in nature. 

The turmoil calms.  The images flash slower through my mind....Sara...Angela....I see the house up ahead...my skin is wet and cold now.....I am so very tired.


240 pm:
I push Angela back to Labor Ward.  Her husband meets us on the way.  She is still sedated from the exam.  Her chart drops off her lap and papers fly onto the sidewalk.  It is beginning to rain.  I gather up the chart and her husband assists me with the door.  He laughs softly and says, "She is okay now, yes?"

I think of her blood count, her cancer staging, her children.....the need for blood.  I just smile and push past him with the wheelchair.  No more talking now.


130pm:
I am finaly wheeling Sara to the theatre for her exam under anesthesia.  I push her to there myself; everyone is busy on Labor Ward.  Her hair is short and a little nappy.  There are small pieces of lint in it.  I suddenly feel very sad.  The urge to start picking out all the little white pieces nearly overwhelmes me.

I push her into the operating room and make a plan with the anesthetist - just a little sedation to enable me to do an exam and place a packing to stop the bleeding.   On the exam, I realize that her cancer is definitely encompassing the tissues around the cervix...and the cervix itself is friable and bleeding.  The cancer is a mass measuring 6 x 4cm.  I place surgicel and monsol's solution and pack with two gauzes.  Hopefully, this will stop the bleeding for long enough to stablilize her.

While waiting for her to recover a bit, the anesthetist helps me with more history.  She is married to a farmer with 4 children, a history of only 2 sexual partners.  Yet she has stage III cervical cancer at age 37 and is not HIV positive.  This seems to challenge the old sterotypes we had of women in Africa with cervical cancer - all being HIV positive or prostitutes.  The anesthetist looks at me and says,"Why doesn't someone do something about all these women dying with cervical cancer?"

130pm:
"You need to talk to the husband.  This is not good," the nurse tells me regarding Angela.  I understand what she is telling me.  Often, I am used as the "regulator."  The one who speaks frankly and honestly with families about a patient's condition and the how they were brought in.  Especially in cases of obstructed labor or if a family won't bring in blood donors.  I think they use my foreign-ness and natural assertness to "shame" families into doing "right" by the patients.  I am the Family Drill Sergeant.

Angela's family - the patient with the uterine rupture - has been brought so I can speak with them.  I speak to the translator privately first:

"We need to tell the husband how serious this situation is.  Angela labored so long - her uterus ruptured and the entire baby came out.  The baby could have died - she could have died.  If it were my choice I would do a tubal, but she has many adhesions and it can't be done.  So she will get pregnant again - next time she needs to come before the labor starts!"

The translator nods.  We go to the waiting room.  Two women sit waiting for us.  The translator talks with them a moment.  "Who are they?" I ask.

"This is the mother and the mother-in-law.  The husband did not come - he is at home."
I shake my head.  "No, this is his wife, his child.  He needs to be here."
---more conversing----
"How long was Angela in labor," I ask.
---conversing-----
"She was not in labor.  She had a little bleeding, so they took her to a health facility and then she was sent here."
I sigh as the translator begins to give them my previously mentioned instructions. 

1155am:
Passing through labor ward, the nurse calls out to me: "Daktari?  can you just check heart tones for us?"  The nurse explains that a patient has just been referred from a health center and the heart tones are not picking up very well with the doppler.  I look at the patient: dull, listless eyes, head slung back, no attempt to move......and I know the look of shock - either hemorrhagic or septic.

I go straight for the ultrasound....fetus with a heart rate of ...guessing low 60s and an empty uterus. 

"She has an empty uterus and the baby's heart tones are low," I say.  The nurses look surprised - as if I am devining a message from "spirits."  "To the OR - now!" I say, beginning to help with preparation.  I look at the clock: noon.  My stomach gurgles- no time for that now.

We rush into the theatre....staff hurridly prepping the room, the peds intern prepping the patient's abdomen, anesthesia preparing for general anesthesia...and I go to scrub.  Inside I am focused - there IS time to save this baby.....it CAN be done.  But I must go quickly.

I am already sweating when I am scrubbed and standing at the table, knife in hand, waiting for the signal from the anesthetist.  He must paralyze the patient and intubate before I can cut.  Then I must cut very quickly before the paralytic over-sedate the baby; in this case, a baby already compromised by its very slow heat beat.

I stare at the knife in hand....waiting....the chaos now quiet, but the chaos inside my mind very loud - I am so hot!  The anesthetist gives me the signal and the blade goes immediately through skin down through the layers to the abdominal muscles....I drop the knife on the surgical table, use my hands to retract the muscles and enter the abdominal cavity.  The baby is waiting there...outside the uterus..still in the amniotic sac...I deliver the little one and while my assistant clamps and cut the cord, I rub the baby's face and chest....until a small cry is heard.  Nods and smiles are seen around the room...murmuring of thanks....and the baby is taken by the peds intern. 

A bead of sweat runs down the side of my face.  My job has actually just started.  I pull the uterus out of the abdominal cavity - it is ruptured all along a previous scar site.  I didn't even take time to get a history.  She was a previous C section.  I repair the uterus and try to explore the abdomen.  The scarring is horrible - I am unable to access anything else in the belly because of the dense scar....so I can't even consider doing a tubal ligation....she will get pregnant again. 

I look at the clock again: 1228. Nice.

1030 am:
During rounds, the intern comes to tell me that Sara's bleeding has worsened.  Sara is a 37 year old with cervical cancer that was admitted a few days ago with an Hb of 4.  On pelvic exam, it was difficult to tell the extent of her disease but I had suspected it was Stage III (inoperable).  Her family had not brought blood donors despite our many requests and thus, she was losing blood more quickly than we could replace it.  I sigh at the news of her bleeding; only yesterday we had coated the cervix with Monsel's solution to stop the bleeding.  I am beginning to wonder if she may not make it to be discharged.......bleeding and renal failure are the two causes of death for cervical cancer patients, with bleeding being a frightening thing for patients and families alike.

I pause, thinking, and then tell my intern.  "Prepare her for theatre.  We will take her there for an exam and try again to pack the vagina with gauze."

0930 am:
"How is Joyce?" I ask during the rounds.

Joyce is patient who presented a week ago at 36 weeks GA with severely elevated blood pressures (170+) and a persistent headache with severe neck pain.  She was unable to move her neck to look laterally at all.  The admitting diagnosis was unfortuately meningitis due to the neck pain, headache and an elevated WBC.  On Monday, when I saw her - I received quite a fright.  "She has a head bleed," I told the team.  We got an emergent CT scan and sure enough - a basilar/occipital bleed.  She was quickly delivered under general anesthesia and sent to the ICU for strict blood pressure monitoring.  The baby did well but had severe IUGR.  All week, I have marvelled at her recovery.

"Doing well, blood pressures within parameters, still some headache," the intern told me.  Amazing...to be able to survive a head bleed!

0800am:
I wake at the sound of my alarm.  It is Saturday and I am on call.  I wish I felt refreshed - but I don't.  A stomach bug has been troubling me for a few days.  I roll over in bed, hesitant to start the day.  Maybe it will be a calm day.