Sunday, October 9, 2011

First Day at Work

The Maternity Ward Office and (only) Desk
Fritz and his wife left after he handed over the keys to the Ultrasound machine and an envelope of cash from the Barbara May Foundation which was mine to use to assist patients in dire need of expensive things they couldn’t afford, such as urgent transfer to Addis Ababa. Fritz said that in his now completed 5 week stint he had not been called out at night once, and so I was hoping the quiet times would continue as  I went to Maternity to see our one patient : she had been in hospital for several days with very high blood pressure – she had severe pre-eclampsia, a nasty unpredictable disease of pregnancy that in third world countries accounts for many thousands of maternal deaths every year. The only effective treatment is delivery of the baby but the baby wasn’t due for another 6 weeks as best as we could tell. Much of the testing for pre-eclampsia that is routine where I usually work was unavailable, but the plan formulated  when she first arrived was to stabilize her  condition and then induce labour.  She was stable so I ordered the two tests the lab can do and asked  for her urine to be retested. An empty Blood Pressure tablet pack was on the floor – was she still taking her medicine I asked – and after discussion in Amharic it transpired she had used them all up over the weekend. The family had to go and buy more. Basic nursing practice such as taking and recording observations and noting which medications were given and when is obviously not done well here, and is something that will improve, but for the time being I have decided to simply observe what is done and make subtle suggestions. Later we will have formal update sessions on record  keeping. For now I just want to learn everyones name !

I went back to my flat and began the move next door to Fritz’s one – it was identical in size but had a DVD player and  TV connected to a huge rusty satellite dish just outside in the long grass , as well as a small fridge. I  have yet to switch the TV on but I was told there are 20 or so channels including BBC world. It dominated the tiny desk so I decided to swap the desk for the bigger one from the midwives room which was going to be vacant for the next month or more, and shoved the damn TV into the corner. As I frequently do when moving into new accommodation I rearranged the furniture and cleared all the accumulated clutter from shelves drawers and cupboards. The place started to become mine.

 In the afternoon I was informed a woman was in labour but making no progress. No other details were mentioned except for the fact that she had previously given birth twice uneventfully. The midwifes descriptions of what was happening were a little vague so I decided to examine her myself. The room she was labouring in had two almost completely wrecked metal bedsteads against the wall on each side and a fifth one against the wall opposite the door. The linen was ragged and barely covered quite filthy plastic wrapped thin sponge mattresses. There were no curtains. The floor was filthy with mud and dirt , discarded wrappers from examination gloves and other rubbish. I did the examination and we decided to start a drip, because if her labour still didn’t progress she would need a caesarean. . Before long she was in strong labour and becoming awfully restless and distressed with the pain – but there were no drugs available for pain relief, no “Gas” to breathe, no shower to stand under, just this one room and potentially other women and their families to share her ordeal with. Eventually she gave birth to a healthy baby and her smiles were radiant. It was then I was informed she was HIV Positive.

Meanwhile another woman turned up in labour and was found to be almost ready to give birth. She was assisted by her family into the “Delivery” room where she was heaved up onto an ancient and again, rusty, filthy and almost completely wrecked birthing table.

Delivery Room : the Photo makes it look good
I found a fetal heart monitor and checked the babys heart beat – the baby was distressed so immediately the midwife, Semagnew, reached for a “Kiwi Cup”. A Kiwi Cup is a brand of suction device used to extract a baby – they are single use devices but these ones in Motta are used and reused until they fall to bits, as this one was about to, but still   Semagnew managed to get that baby out pretty smartly. The baby boy emerged with a huge flood of blood clots and fresh blood and he looked dead. He was floppy and didn’t breathe or move – I grabbed him and looked around for the Resuscitaire or anything similar on which neonates are usually placed for resuscitation – it’s a special little table usually with towels to dry and rub the baby, oxygen, a warming lamp, drugs and various other items that might be needed in just such an emergency as this –but there was absolutely nothing, no table no oxygen no towels, nothing. I put the baby down on a bench on some old clothes or drapes or curtains – I didn’t care – and started to rub him, give him CPR and called for some extra help. Semenya had delivered the placenta and controlled the bleeding and came across with a little rubber sucker device to clear his airway – almost useless- and a mask that we used to  deliver some fresh air to the baby whose only sign of life for the first five minutes was a weekly beating heart.. Semagnew roughly and vigorously rubbed the babies back, flicked its feet, gave it all kinds of tactile stimuli that would have horrified just about anyone in such a situation in Australia or NZ but then what else did he have to call upon? At 6 minutes the heart beat suddenly picked up and a few minutes later the baby started to breathe. We wrapped him up as warmly as we could in threadbare cotton sheet that looked like old bed sheets torn up for the purpose and gave him to the mother. The next day they went home. I could see that the practical skills of the midwives were amazing, and obviously of much more use than good note keeping!.

I was too worn out to cook  dinner  when I got back home so just ate some biscuits It had been a busy and dramatic first day,  but worse was to come as the run of undisturbed nights for the Obstetrician was about to end.

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