Saturday, July 20, 2013

Night Life

The nights here are dreadful. Usually its so hot in my concrete room that I lie sweating on top of the thin cotton sheet tossing and turning till it becomes a crumpled damp rag that my feet get tangled in and I am left on the mattress. The bed is enclosed in a mosquito net that makes the space seem close and airless. I am always on call so the mobile phone is nearby, but even in the daytime reception is poor and I have great difficulty being understood  and understanding whats being said to me – at night I go outside in the dark and wander about trying to get a better reception but not talk too loud and wake the other ex-pats sleeping nearby. On every second or third night I am First on call so have a small hand-held ICOM  VHF radio/walkie-talkie as well, but it seems to pick up interference from something and intermittently make a noise that wakes me, thinking I am about to receive a call for help from the Hospital, and I lie there waiting for it, and when it doesn’t come I wonder if perhaps its malfunctioning and they are desperately trying to call me and getting no response. I realize now, after a few disturbed nights and phone calls to Maternity to check I was not needed, that it’s a fault with the phone but when youre on call you sleep lightly, and are easily disturbed. On a quiet night at 5 am the call from the Mosque wakes me, but the most horrible thing at night are the packs of marauding dogs. We see them when being driven into the hospital in the dead of night, the only living things on the deserted filthy streets, packs of five to fifteen of them hurrying into the darkness as we approach. At all hours of he night they can be heard, sometimes a long way off and only faintly, but more often closer and sometimes on the street a few meters away barking snarling fighting and howling in number, a dreadful savage and chilling racket that erupts and then ceases after a few minutes with yelping and squealing. We are under curfew so are not allowed out of the compound except in a vehicle after dark, but  that’s not what would stop me wondering the streets – its those  mangy mongrel dogs. So sleep is never good.

A few nights ago, at 2am a call on the ICOM woke me from my usual sweaty and twitchy sleep and suddenly even being awake was a nightmare : “Please come quickly the peritonitis lady is very sick I think she is having a heart attack, I think she is dying”

Oh my God I thought – this was the woman I thought we had rescued from MOH and now she was dying. I dressed feeling sick and hurried to find a driver to take me to the hospital, all the time just feeling sick and overwhelmed and powerless.

On the interminable ride along the potholed mud track that passes for a road I tried to imagine what on earth had happened to her – she had been improving when I last saw her. Actually I already knew what the problem was because I had encountered it already with other patients: we have so few resources here its impossible to provide monitoring and care anywhere near as complete as would happen back home, so effectively we are “flying blind”, just guessing at whats going on inside her abdomen, her chest, her lungs and heart, her blood chemistry. At home such a sick woman would have been in a real Intensive Care, she would have had XRays and serial blood testing and balancing of  a multitude of biochemical and electrolyte markers, continuous heart monitoring, hourly measures of output and input, oxygen saturation, Blood Pressure and kidney function, and of course the input of multiple experts in surgery, intensive care, emergency medicine and nursing – all this and we would have had some idea of what was going right and what was going wrong, what changes  could be needed, what drugs should be changed or added or stopped altogether, how safe it would be to get her to drink or eat, whether or not her apparent improvement was masking sinister new developments. But here we had no idea, we just had to rely on gut feeling, prior experience, guess work, luck…and now it seemed we had guessed wrong.

Earlier that same day,  flying by the seat of our pants we had managed a complicated obstetric patient almost perfectly. She had come in because of vomiting and she was complaining of  pain in the upper abdomen and was discovered to have extremely high blood pressure (240/130 - for anyone not in the know, this is frighteningly high).  She was not in labour and it was her first pregnancy. The baby was alive and she said she was “eight months” Her urine was the colour of blackcurrant fruit juice indicating blood was being destroyed in the circulation (hemolysis,) a very serious complication, but there was very little urine being produced indicating potential kidney failure. A urine test with a dipstick showed abnormally high amounts of protein in it. We guessed she had a serious complication of preeclampsia called HELLP Syndrome but of the countless blood tests we usually would order to confirm this, and repeat every few hours to monitor her progress, and especially to check on her Platelet count, only one was available : Haemoglobin! It was really high indicating her blood was abnormally concentrated. We used all three types of blood pressure drug we have available in Aweil to get her Blood Pressure down to something reasonable and try to prevent a stroke, we gave her specific medication to prevent convulsions which she was at extreme risk of developing, and to keep her kidneys going, some fluid but I had to guess how much to give.

And then I had to decide how much time I had – her condition was going to continue to get worse until the baby was born – so one solution would be to immediately do a caesarean. Her platelet count was unknown but was probably falling, making difficult, even life threatening bleeding from surgery very likely, because Platelets are a vital component of the system which stops bleeding – and we would struggle to get blood to give her. Back home hardly anyone would have hesitated to do the caesarean – the baby was still alive, she had not developed convulsions and her blood pressure was under control – just – and her kidney function and platelet count were only going to get worse – back home we could even give her platelets, but not here - a caesarean could kill her, and the longer we waited the more likely that if we did it, it would. We would be flying blind again.

On the other hand, with her Blood pressure  adequately controlled, and her anticonvulsant medication and some fluids given, there was a small window of opportunity that could allow us to try to get her labour started and the baby delivered normally. Midwives have always believed that women with pre-eclampsia have quick labours and as this baby was small, at eight months, perhaps this young woman would prove the midwives tale true. We decided to try and gave her some medicine to start the labour – and wonderfully, it worked well, her labour established within a couple of hours and a couple of hours after that, to everyones huge relief and delight the baby was born in perfect condition, small but vigorous. From that moment on, the mother started to get better.

For that mum, our luck had held. But for this poor woman at 2 am, it seemed it had run out. I felt cursed, frustrated, angry, embarrassed and stupid : of course she would die, how on earth could such a sick person not die when  all you can do is guess at whats really going on, when youre not an Intensive care Specialist but a gynaecologist, when you have three drugs and two types of fluid and no monitoring other than Blood Pressure and Temperature, when the people trying to look after her have only ever had the most basic and rudimentary training? What was her Potassium level? What was her Sodium level? What was her kidney doing? What would an ECG tell us?  A Chest XRay? What? What? What?…it was all “what?” and the answers were all “I have no bloody idea so what am I doing here?”

The van stopped at the hospital gate and as I headed in, my phone rang again. I just knew he was going to be ringing me back to say “no need to come, shes dead”. And yes, just as I guessed “ theres no need to come” he said – “but I am already here” I replied – and then he said “ Its OK, Shes fine” She had just fainted!

That was a few nights ago and today she walked from the hospital. I hadnt realized until she stood up from her hospital bed what a tall and elegant and most beautiful woman she was, wonderful white teeth shining from her smiling black face, braided hair , long arms and slender hands and fingers that seemed unnaturally long, she walked from the ward hesitantly but proudly tall, and didn’t look back. 

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