Friday, October 14, 2011

Good things happen too!

All young obstetricians in training these days are given lots of formal instruction in the use of ultrasound , and they all are really good at it but when I was trained there was very little formal training. I had my own machine and taught myself the basics but for important things it was always easy for me to refer the patient to an expert down the road. Not here! There is, remarkably, a rather good little portable ultrasound scanning machine brought here I think by one of the Barbara May Foundation doctors. It is kept in a locked room, and I use it every day for various things, mainly trying to date the pregnancies of women from the antenatal clinic. Unfortunately dating a pregnancy  by ultrasound is quite inaccurate when it is done as late in the pregnancy as these women  mostly are when they turn up for care, if they do at all. One day I was asked to do an ultrasound scan on a 72 year old man – his scrotum was swollen to the size of a football, though I am sure he wouldn’t have liked anyone to kick it! I had never done a scan on a scrotum before but it clearly showed the enlargement was mostly cystic : a huge hydrocoele that could at least be drained to give him some relief.

I decided to scan the lady with pre-eclampsia. Her BP was still under control and now it was time to consider getting the baby out by making the labour start but being six weeks premature I wanted to delay as much as possible. Unfortunately even with my crude scanning abilities, I could see trouble was brewing for the baby as there was hardly any fluid left around it , and the measurement around its abdomen showed it was very skinny – the baby was starving in there and was at risk of dying any time soon. Other tests I would have usually done were unavailable to help but time was running out.. The dilemma was that being born 6 weeks premature, and being undernourished as well placed this baby at serious risk – and we had a total of Zero neonatal expertise or even basic equipment such as a humidicrib or oxygen in Motta. I discussed it with the midwives : they  reckoned the baby had maybe a 50:50 chance of surviving if we delivered it here – back home survival would be exceedingly likely, close to 100%.  Furthermore, I then discovered we had run out of the drug used to start labour, called “Cytotec”. Supplies had been brought in by visiting overseas doctors like myself, - though I hadn’t - and now they were all gone. We explained all this to the patient saying we would need to transfer her to our referral hospital at Bahir Dar, which at that time I understood to have better facilities – subsequent events have led me to suspect otherwise – it is certainly a lot bigger hospital with many more doctors but I am not certain the standard of care is much better – but in the event, that is where she went with a letter from me detailing very simply and clearly what the problems were and what needed to be done. I subsequently heard they also had no Cytotec and the baby was delivered by caesarean section. I have no news as to the fate of the baby.

Lots of babies do well, like this one the student midwife is giving its first bath
This incident  with Cytotec illustrates perfectly the dilemma that is created by welfare handouts. I am all in favour of welfare but what it can sometimes do is undermine the ability or perhaps the motivation of the recipients to develop for themselves a sustainable long term solution to the problem – in this case, the supply of  this particular essential medication.
I therefore went to see the Medical Director and explained the vital importance of this drug in Obstetric care – it is used for starting labour, but much more importantly it can  powerfully treat bleeding after childbirth – the leading cause of maternal death – and thus can be  a truly life-saving treatment. It is also a surprisingly cheap drug so there should be no excuse for local or regional authorities not to ensure the hospital has adequate supplies of it. Till now of course there has been no need for them to act because overseas doctors have always brought it with them. We had a meeting with one of the hospital managers and with his support a process is being started that hopefully will result in Cytotec being supplied locally henceforth. That would be a genuine enhancement to the local service, so I am continuing to harass them with enquiries about progress. I shall report back

1 comment:

  1. David, following your stories! Am a sailor but following you on this stage with interest.