Sunday, October 23, 2011

Twin II and the Meaning of Life

The White Board lists our Patients
There’s a light on a stand with wheels in the delivery room that’s supposed to be used to help you see what youre doing if a woman needs some stitches after giving birth. The wheels are so filthy that they don’t turn  but in any case I was told it was broken. In the ward office theres a whiteboard which one of my predecessors procured from God only knows where, but when I got here it hadn’t been used for ages because the whiteboard markers were all dried up – more likely because nobody bothered to put their caps back on after using them – the pens  with their stiff dry felt tips and their caps were amongst the litter in the desk drawer. Someone else arranged a system for sterilizing equipment using a series of large plastic bowls – but they all have dead insects floating around in them. When the cleaners come, they have a small bucket of water and just seem to smear the mud and filth evenly round the room with thier putrid mops rather than actually remove much of the dirt. There are so called "safety boxes" - vital in this HIV contaminated world - into which broken glass phials and used needles are supposed to be placed but they are left scattered all over the place. And yesterday, a woman gave birth to twins  about 6 weeks prematurely and one died after seven hours, and the other, which was still alive when I arrived  in the morning to do a ward round, was having nothing done to help it, neither to feed it or even make sure it was warm. And yet I know the midwives know about basic infant feeding and something called Kangaroo Care where a mother keeps the baby between her breasts, close to her skin so her warm body can act as the incubator to keep the baby warm.

Initially, when the midwife informed me a woman had delivered twins in the night, I was again wonderfully impressed with their practical skills and confidence. Like eclampsia, twin vaginal delivery is a high risk situation – in fact in the west the practical skills of managing the vaginal delivery of twins are being lost, as an increasingly nervous and risk averse obstetric profession delivers more and more babies, not just twins, by Caesarean Section.  So yes, I was impressed! But it was discouraging to find nothing was being done for  the surviving twin, which weighed 1.5kg at birth and still had a chance..

A newborn healthy baby
I worked out the amount of milk the baby was going to need at frequent feeds and the midwives found a feeding tube which they then inserted into its stomach.. We sat the mother up and encouraged her to express milk for the baby and we got 6 mls  and put it down the tube. The mothers – as is usual, - filthy dress was closed across the front so we found an old hospital gown with buttons down the front and she changed into it so that the baby could be nursed on her front, and I found a little cloth bag that we put over the babies head to try and keep it warm….progress ? I left clear notes as to when the next feeds were to be given, and how much, and went to the market with Yemataw the shoe shine boy to get a chook.

Later, when I returned to check on the baby, one midwife said all was fine and the other said it was vomiting so they had stopped feeding it. I went to see what was happening and the mother was asleep with her back to the baby which was on the edge of the bed, and there was some milk in the feeding tube but the milk was obviously dribbling out the opposite nostril from the one the tube went down. Now the thing is I have never had any neonatal paediatric training, and no experience whatsoever of  this sort of thing, but I decided that the tube must not be far enough in, so I peeled off all the tape holding it in place and poked the tube down a few centimeters further. This time the milk stayed down. I rewrapped the baby and gave him to its mother who by this time was awake.

Later, we did an emergency caesarean section for a woman who had been in labour and walking all day to get to hospital. She knew  she would need a caesarean because her first attempt at having a baby resulted in its death and the development of a fistula, which had since been repaired. It was a difficult caesarean and the blood loss was excessive but there was no blood to give her. But when I went to bed, and during the night it wasn’t her that was on my mind, it was the surviving twin , and more particularly what seemed to me the indifference displayed by the midwives and even the mother to its survival. Thinking about the whiteboard – for which I got new markers - and the Light which just needed a new light bulb – which I got for it – all those insects in the sterilizing bowls,  the "cleaners"  the glass and needles, I started to wonder what the hell am I doing here?

I can see that if you work here year after year disappointment and death can become easy to accept and to feel we have so few resources theres no point in trying.  What I would like to enthuse the midwives with is the idea that we  do actually have resources, not many but some and we should do the very best with whatever "stuff" we have, and whatever learning and skill we have. but after that, its up to the Gods..

I expect twin II will have "expired" by the morning, the Gods being what they are.

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