I decided to quit today.
After weeks of not enough sleep, patients dying, equipment breaking, staff complaints and co-workers being less than supportive, I couldn't take it anymore. The decision came quietly, like a small sigh of defeat and I just decided I would finish the case I was doing and just leave. I didn't yell, didn't share my thoughts with anyone, just kept working but felt very good about my plan.
But when I finished, I realized I was supposed to do a lunch lecture for the interns. That seemed easy enough, so I went. While I was there, the two who were covering the OB floor had arranged some cases and they needed me to supervise. They were really on top of it and I hated to screw up their day. So I staffed the more difficult case.
While I supervised, the anesthetist kept telling me jokes making fun of general surgeons. I laughed and felt better. Then I told him some jokes, too.
Then I was ready to leave. But first one of the staff took me aside. She handed me a bag and said it was a gift. Inside was a pineapple. She said that she brought it because she knew I was having a very hard month.
And so...let me tell you something. Someone close to you may have decided to quit today. You can give them the strength to hold on by doing your job well, making them smile or giving a gift of appreciation. I am learning that it is the small things in life that make or break the day.
I have to get ready for tomorrow. I am working....
"Like a bridge over troubled water......I will ease your mind."
--Bridge Over Troubled Water
Friday, January 20, 2012
Monday, January 9, 2012
Sufficient
My stats:
9 days in the new year
3 ruptured uteruses
4 caesaren hysterectomies
1 ruptured ectopic in cardiac arrest
2 maternal deaths
4 nights of 7 spent at the hospital
Her stats:
6 pregnancies
1 postpartum hemorrhage
12 hours of uncontrolled bleeding
14 units of blood
1 uterus removed
24 hours later out of the ICU and into the general ward
In OB, I have often heard attendings and colleagues say, "Better lucky than good." This refers to the many variables and nuances of medicine that can often be missed, but the patient doesn't suffer. Or more often, physicians do the right thing without understanding why they are driven to do that particular thing. It's instinct. A sixth sense. That little voice inside our head. Luck.
Thus far, 2012 has been a year of exhaustion for me. The holiday season has left us with an onslaught of difficult transports and very sick patients. Volunteers are in especially short demand as well. I am more tired than I have ever been and thoughts of "I don't know how much longer I can do this," are overwhelming. And as I struggle with my own fatigue and doubt, I seek to encourage my team in a time when they are tired themselves and saddened by maternal deaths.
But I am happy to write that even in this most challenging of days, we are.....? Lucky? No. Humbled. Challenged. And above all, blessed. Maybe we are improving, but still not exceptional, but we are blessed.
I received a call around 11 pm Saturday about Jane, a patient who had come into the Labor Ward at term with a footling breech. She had been taken to C section without problem but since the surgery she had had copious vaginal bleeding. I was asked to come and evaluate.
On her exam, she was already showing signs of shock: low blood pressure, altered mental status, no urine output. There was a large amount of vaginal bleeding that was not responding to any medicines (pitocin, etc..). I proceeded to re-open her C section incision. Inside I found that one uterine artery had began to bleed into the abdomen. I ligated both arteries that fed blood to the uterus, stopping the bleeding in the abdomen but the uterus remained very large and bulky. So we proceeded to do a hysterectomy. She was receiving blood by now, but her blood pressure was still very low and overall she was not very stable.
Once out of the OR, we began to fervently search for blood donors. Unfortunately, before long she began bleeding again - this time from the abdominal incision and vagina. Oftentimes, this is a sign of DIC - a condition caused by major hemorrhage, where the blood does not clot normally. I estimated that she had lost 4000mL by this point.
Amazingly enough, people working in the hospital that night - and Jane's family- began to pour in to donate blood. They donated, drank some juice and went back to work. Others came by to pray by her bedside in ICU. Meanwhile, I sat in the ICU, feeling very helpless, wanting to sleep, but just feeling like that had to be something MORE I could do. That this patient was different. And if I stayed - that the answer would come.
At 730 am, the answer did come. After 5 units of fresh blood, the bleeding had not stopped. I knew that it was not just DIC. So I called OtherDoc and asked him to help me take her back to the OR, hoping that he would see something that I hadn't. We found some additional bleeding, including a large hematoma that had formed since her last time in the OR. Almost immediately, her vital signs stablized.
Now, as I reflect back, I try to find out what I did right and wrong. But the thing is - she was completely hemostatic at the end of my hysterectomy. And the labs do support that she was in DIC. Did I miss something? Did the DIC allow her to form the hematoma? I don't know. I only know that if it hadn't been for the people who answered the call to give blood and the OR staff/OtherDoc's willingness to help me take a DIC patient to the OR....she would have died. But today she was in the ward - breastfeeding her baby after a total 14 units of blood - basically a total volume transfusion!
And thus I am deciding it is better to be blessed than good. Obediant to that inner voice, that sixth sense. Humbly reminded that even in the mire: "My grace is sufficient for you, for My strength is made perfect in weakness.” Therefore most gladly I will rather boast in my infirmities, that the power of Christ may rest upon me." (2 Corinthians 12:9)
9 days in the new year
3 ruptured uteruses
4 caesaren hysterectomies
1 ruptured ectopic in cardiac arrest
2 maternal deaths
4 nights of 7 spent at the hospital
Her stats:
6 pregnancies
1 postpartum hemorrhage
12 hours of uncontrolled bleeding
14 units of blood
1 uterus removed
24 hours later out of the ICU and into the general ward
In OB, I have often heard attendings and colleagues say, "Better lucky than good." This refers to the many variables and nuances of medicine that can often be missed, but the patient doesn't suffer. Or more often, physicians do the right thing without understanding why they are driven to do that particular thing. It's instinct. A sixth sense. That little voice inside our head. Luck.
Thus far, 2012 has been a year of exhaustion for me. The holiday season has left us with an onslaught of difficult transports and very sick patients. Volunteers are in especially short demand as well. I am more tired than I have ever been and thoughts of "I don't know how much longer I can do this," are overwhelming. And as I struggle with my own fatigue and doubt, I seek to encourage my team in a time when they are tired themselves and saddened by maternal deaths.
But I am happy to write that even in this most challenging of days, we are.....? Lucky? No. Humbled. Challenged. And above all, blessed. Maybe we are improving, but still not exceptional, but we are blessed.
I received a call around 11 pm Saturday about Jane, a patient who had come into the Labor Ward at term with a footling breech. She had been taken to C section without problem but since the surgery she had had copious vaginal bleeding. I was asked to come and evaluate.
On her exam, she was already showing signs of shock: low blood pressure, altered mental status, no urine output. There was a large amount of vaginal bleeding that was not responding to any medicines (pitocin, etc..). I proceeded to re-open her C section incision. Inside I found that one uterine artery had began to bleed into the abdomen. I ligated both arteries that fed blood to the uterus, stopping the bleeding in the abdomen but the uterus remained very large and bulky. So we proceeded to do a hysterectomy. She was receiving blood by now, but her blood pressure was still very low and overall she was not very stable.
Once out of the OR, we began to fervently search for blood donors. Unfortunately, before long she began bleeding again - this time from the abdominal incision and vagina. Oftentimes, this is a sign of DIC - a condition caused by major hemorrhage, where the blood does not clot normally. I estimated that she had lost 4000mL by this point.
Amazingly enough, people working in the hospital that night - and Jane's family- began to pour in to donate blood. They donated, drank some juice and went back to work. Others came by to pray by her bedside in ICU. Meanwhile, I sat in the ICU, feeling very helpless, wanting to sleep, but just feeling like that had to be something MORE I could do. That this patient was different. And if I stayed - that the answer would come.
At 730 am, the answer did come. After 5 units of fresh blood, the bleeding had not stopped. I knew that it was not just DIC. So I called OtherDoc and asked him to help me take her back to the OR, hoping that he would see something that I hadn't. We found some additional bleeding, including a large hematoma that had formed since her last time in the OR. Almost immediately, her vital signs stablized.
Now, as I reflect back, I try to find out what I did right and wrong. But the thing is - she was completely hemostatic at the end of my hysterectomy. And the labs do support that she was in DIC. Did I miss something? Did the DIC allow her to form the hematoma? I don't know. I only know that if it hadn't been for the people who answered the call to give blood and the OR staff/OtherDoc's willingness to help me take a DIC patient to the OR....she would have died. But today she was in the ward - breastfeeding her baby after a total 14 units of blood - basically a total volume transfusion!
And thus I am deciding it is better to be blessed than good. Obediant to that inner voice, that sixth sense. Humbly reminded that even in the mire: "My grace is sufficient for you, for My strength is made perfect in weakness.” Therefore most gladly I will rather boast in my infirmities, that the power of Christ may rest upon me." (2 Corinthians 12:9)
Monday, January 2, 2012
Driving Pain
A few months ago, I wrote about how driving in Nairobi is an extreme sport/near death experience:
En Route. Apparently, there is now a survey to back it up!
Daily Nation, one of Nairobi's newspapers, published an article on traffic problems in the city this past week. In it they included the following graphic from the IBM 2011 Commuter Pain Survey. This survery ranks the "emotional and economic toll of commuting in 20 international cities."
No big surprise - Nairobi is number 4!
En Route. Apparently, there is now a survey to back it up!
Daily Nation, one of Nairobi's newspapers, published an article on traffic problems in the city this past week. In it they included the following graphic from the IBM 2011 Commuter Pain Survey. This survery ranks the "emotional and economic toll of commuting in 20 international cities."
No big surprise - Nairobi is number 4!
Saturday, December 31, 2011
Christmas in Kenya 2011
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| My first year making homemade Christmas cookies! |
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| My cooking partner.... |
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| My new breakfast creation: Apple Spice Pancakes with Powdered Sugar on top! Yum! |
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| The Snowman Cake I made to go along with the Christmas cookies for my Intern Christmas Party... He has Mentos buttons, a candy bar smile, M&M eyes, a carrot nose and dum dum arms. |
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| Presents under the tree. They were only there for 8 hours - they were otherwise hidden from Teddy in the spare bedroom. The presents were warm fleece scarves and candy for the interns. We also played games and had "prizes" for the winners. |
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| A Kenyan fried fish dish that one of the interns brought to the Christmas party I hosted.....one of my favorite Kenyan dishes so far! |
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| Teddy taking a long winter's nap during the Christmas party.... |
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| All my interns gathered for the "Christmas Bash." |
Saturday, December 24, 2011
Top Ten Ways You Know You Are Celebrating Christmas In Kenya
10. Your holiday plans were cancelled due to a matatu strike.
9. You are instructed to bring your own plate and silverware to the neighborhood holiday party.
8. All the cars on the road have a live chicken on top.
7. There are cows in your front yard and they are NOT part of your Nativity scene.
6. Its 70 degrees and raining.
5. You bought your kid's new puppy from a guy selling them at a traffic stop.
4. You bought a new skirt for your daughter the same time you bought the puppy! (different vendor, of course.)
3. In the Kenyan version of the Savior’s Birth, the 3 Wise Men came from “Not Far.”
2. Your kids put out ugali and sukuma for Santa
Merry Christmas!
9. You are instructed to bring your own plate and silverware to the neighborhood holiday party.
8. All the cars on the road have a live chicken on top.
7. There are cows in your front yard and they are NOT part of your Nativity scene.
6. Its 70 degrees and raining.
5. You bought your kid's new puppy from a guy selling them at a traffic stop.
4. You bought a new skirt for your daughter the same time you bought the puppy! (different vendor, of course.)
3. In the Kenyan version of the Savior’s Birth, the 3 Wise Men came from “Not Far.”
2. Your kids put out ugali and sukuma for Santa
And the #1 Way You Know You Are Celebrating Christmas in Kenya…..
1. You wake up to the sound of your neighbor killing a goat.Merry Christmas!
Sunday, December 18, 2011
Annual Report
As I am celebrating the end of my first year on the field, I am excited to say that I feel like it has been a productive one. The learning curve has been incredibly steep, but the OB team has grown and improved in many ways.
I am so thankful for the way that I have been embraced and welcomed into the OB department. I am much indebted to the many people who have helped make this year possible: nurses, visiting doctors and students, donors, prayer partners - so many that I cannot even name you all, but your assistance and support has meant more than I can ever say.
Resources
Finding and keeping resources is a challenge at any mission hospital. One of our challenges this past year has been supplies: vacuums, protective eyewear and masks, nitrazine paper, a fetal heart doppler and other useful tools that tend to "walk" off.
Thanks to our nursing supervisor, we were able to secure a locker outside the OB theatre and stock it with supplies brought by our very generous visitors. Now, we are better able to alocate and locate our supplies. The interns share a doppler and have been very responsible with its upkeep (of course, I did threaten to disembowel them if it got lost!). They also now have access to protective eyewear for surgery (very important in our high HIV population).
For those of you who have generously donated to my Project Fund - I have used some of those funds to restock equipment for the nurses and interns: new blood pressure cuffs, stethoscopes and batteries for equipment, cytotec for inductions of labor, personal hand sanitizers (great when doing wound dressing changes as soap is not always readily available).
Protocol
When I first arrived at Tenwek, I was often told to refer to the "OB Protocol" Book. It took me a few weeks to find this epic book and when I did find it, I was vastly underwhelmed. It was a softback book, bound in old newspaper, with mainly information, but few actual guidelines inside. In order to standardize care, and decrease maternal morbidity and mortality, a effort was begun to update - and create - hospital protocols.
We now have standard protocols for: Preterm Labor, Rh isoimmunization, Pre- and Post-Op Antibiotics, Miscarriages, Vaginal Delivery after C Section and Operative Delivery. The protocols were a joint effort between OB doctors and OB nurses. Several more are currently under way, but this endeavor has greatly improved communication among caregivers and has hopefully helped to decrease our wound infection rates.
Our OB clinic - MCH - has also asked for practice guidelines regarding common occurences just to ensure that practice is consistent among all the providers/interns.
Education
Education has become a huge part of my ministry here at Tenwek. In August, I purchased pocket textbooks for the interns; the books became so popular several interns have asked to buy their own copy.
In addition to teaching/group rounds, I have tried to implement quizzes during the OB rotation. Each rotation also now holds the tradition of having a "suture party," where interns - past and present, gather at my house for a tutorial on proper knot tying technique and instrument handling. Afterwards, we have dessert and tea!
A few fond memories from the past year:
I am so thankful for the way that I have been embraced and welcomed into the OB department. I am much indebted to the many people who have helped make this year possible: nurses, visiting doctors and students, donors, prayer partners - so many that I cannot even name you all, but your assistance and support has meant more than I can ever say.
Resources
Finding and keeping resources is a challenge at any mission hospital. One of our challenges this past year has been supplies: vacuums, protective eyewear and masks, nitrazine paper, a fetal heart doppler and other useful tools that tend to "walk" off.
Thanks to our nursing supervisor, we were able to secure a locker outside the OB theatre and stock it with supplies brought by our very generous visitors. Now, we are better able to alocate and locate our supplies. The interns share a doppler and have been very responsible with its upkeep (of course, I did threaten to disembowel them if it got lost!). They also now have access to protective eyewear for surgery (very important in our high HIV population).
For those of you who have generously donated to my Project Fund - I have used some of those funds to restock equipment for the nurses and interns: new blood pressure cuffs, stethoscopes and batteries for equipment, cytotec for inductions of labor, personal hand sanitizers (great when doing wound dressing changes as soap is not always readily available).
Protocol
When I first arrived at Tenwek, I was often told to refer to the "OB Protocol" Book. It took me a few weeks to find this epic book and when I did find it, I was vastly underwhelmed. It was a softback book, bound in old newspaper, with mainly information, but few actual guidelines inside. In order to standardize care, and decrease maternal morbidity and mortality, a effort was begun to update - and create - hospital protocols.
We now have standard protocols for: Preterm Labor, Rh isoimmunization, Pre- and Post-Op Antibiotics, Miscarriages, Vaginal Delivery after C Section and Operative Delivery. The protocols were a joint effort between OB doctors and OB nurses. Several more are currently under way, but this endeavor has greatly improved communication among caregivers and has hopefully helped to decrease our wound infection rates.
Our OB clinic - MCH - has also asked for practice guidelines regarding common occurences just to ensure that practice is consistent among all the providers/interns.
Education
Education has become a huge part of my ministry here at Tenwek. In August, I purchased pocket textbooks for the interns; the books became so popular several interns have asked to buy their own copy.
In addition to teaching/group rounds, I have tried to implement quizzes during the OB rotation. Each rotation also now holds the tradition of having a "suture party," where interns - past and present, gather at my house for a tutorial on proper knot tying technique and instrument handling. Afterwards, we have dessert and tea!
A few fond memories from the past year:
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| We miss you, Dr A! |
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| Teaching rounds with interns, visiting PA students and OB nurse. |
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| After rounds, chai time. (Thanks for the photo, Dr P!) |
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| Thanks to all visitors and patient-family members who have given blood for my patients! |
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| Merry Christmas to those who "graduated" from Tenwek... (Study hard!) |
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| On the way to L&D..... If you would like to financially support my ministry at Tenwek Hospital: Please send your gift to: World Medical Mission PO Box 3000 Boone, NC 28607 Please specify Acct #003897 |
Tuesday, December 13, 2011
The Twelve Days of A Tenwek Christmas
The last few weeks have been super busy, so I thought I would condense all the news into a festive, but compact blog:
Twelve Months in Kenya: Happy One-Year anniversary to me!
Eleven episodes of The Glades: I like this show. The medical side is weak, but the sarcasm is strong.
Ten Pints Transfusing: I've blogged many times about the ongoing blood shortage in Kenya. At first, I tried to solve the problem myself:
Then I learned the blood types of others and stalked them shamelessly:
Now, I have taken on a new and bold strategy: I am requiring all elective hysterectemies to bring 3 family members in to donate one pint of blood each before being admited for surgery. And finally, it works! One week, we took in so much blood, we were able to give 3 units to a needy surgery patient. Let's hope my blood nazi system continues to work!
Nine Days on Strike: Since December 5, all government-paid physicians in Kenya have been on strike, protesting for better medical benefits (definitely needed), better medical supplies to district hospitals (definitely) and more pay (join the club). Since that time, all patients have been re-rounted to private ($$$) or mission (that's me!) facilities. We are seeing a lot more transports, and have decreased our elective surgeries in response.
Eight Crying Babies: (Okay, just an excuse to put in a cute baby picture here!)
Seven Attempts to Get this Picture:
Six Bad Placentas: Over the past 3 months, I've had 1 velamentous cord insertion, 1 choriocarcinoma, 1 acreta, 2 incretas and 1 percreta!
Five Inches of RAAAIIIINNN! Sorry - I got nothing else. Theme blogs are hard. I don't see me doing this again.
Four Hours Decorating:
Two Docs Operating: My Co-Post-resident has decided to join me for a few weeks here at Tenwek. Though she is a general surgeon, I managed to steal her away for a few cases.....
And me with a Christmas Tree:
Twelve Months in Kenya: Happy One-Year anniversary to me!
 |
| Sorry, I just really like this picture of me and the worm. |
Eleven episodes of The Glades: I like this show. The medical side is weak, but the sarcasm is strong.
Ten Pints Transfusing: I've blogged many times about the ongoing blood shortage in Kenya. At first, I tried to solve the problem myself:
Then I learned the blood types of others and stalked them shamelessly:
Now, I have taken on a new and bold strategy: I am requiring all elective hysterectemies to bring 3 family members in to donate one pint of blood each before being admited for surgery. And finally, it works! One week, we took in so much blood, we were able to give 3 units to a needy surgery patient. Let's hope my blood nazi system continues to work!
Nine Days on Strike: Since December 5, all government-paid physicians in Kenya have been on strike, protesting for better medical benefits (definitely needed), better medical supplies to district hospitals (definitely) and more pay (join the club). Since that time, all patients have been re-rounted to private ($$$) or mission (that's me!) facilities. We are seeing a lot more transports, and have decreased our elective surgeries in response.
Eight Crying Babies: (Okay, just an excuse to put in a cute baby picture here!)
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| Triplets that I had to deliver vaginally: 2 breech and one cephalic. All 3 feeding and growing well in the NICU! |
Seven Attempts to Get this Picture:
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| Merry Christmas from Teddy! |
Six Bad Placentas: Over the past 3 months, I've had 1 velamentous cord insertion, 1 choriocarcinoma, 1 acreta, 2 incretas and 1 percreta!
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| Placental Increta |
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| Velametous cord insertion from triplet delivery |
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| Placental Percreta |
Five Inches of RAAAIIIINNN! Sorry - I got nothing else. Theme blogs are hard. I don't see me doing this again.
Four Hours Decorating:
Three days in Nairobi: A few weeks ago, I travelled to attend the annual Christmas fair in Nairobi. It is basically a huge, Christmas flea-market. Unfortunately, this year it was preceeded by a LOT of rain, so this was the sight that greeted us! I spent the day shopping in the mud and muck - but found some good deals nevertheless and had an other wise relaxing weekend!
Three days in Nairobi: A few weeks ago, I travelled to attend the annual Christmas fair in Nairobi. It is basically a huge, Christmas flea-market. Unfortunately, this year it was preceeded by a LOT of rain, so this was the sight that greeted us! I spent the day shopping in the mud and muck - but found some good deals nevertheless and had an other wise relaxing weekend!
Two Docs Operating: My Co-Post-resident has decided to join me for a few weeks here at Tenwek. Though she is a general surgeon, I managed to steal her away for a few cases.....
And me with a Christmas Tree:
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