I am back on the obstetrics service. Family doctors are good at floating in and out of different areas. Within the last year we have had family doctors working in pediatrics, internal medicine, obstetrics, the outpatient department and emergency room. For most of us it is a pleasure to move around the hospital. It keeps life interesting. The reason I am back on obstetrics is one of the volunteer obstetricians is leaving, and so the consultant staffing is a little bit low. So I am back to fill the needs of the hospital. We are starting this call right with a woman with severe pre-eclampsia, pulmonary embolism, and treatment with warfarin and one previous cesarean section scar needing an emergency surgery. She also has a large anterior uterine fibroid. Without explaining everything, let me say that is a tough case. Below is the team that will take care of it.
All my obstetric calls seem to take me on to places I do not want to go. My last call started with a older woman with severe high blood pressure at about 26 weeks pregnancy. These pressures were so high she was at risk of seizing, and her baby was not getting the blood flow through the placenta that it needed to live. So off to the operating room we went to deliver this too young baby. To complicate the matter there were big benign tumors all over her uterus. God is good and we were able to deliver her baby without too much difficulty. Unfortunately 2 days later her baby passed. 26 weeks is a threshold age for premature babies at our hospital where the chance of survival decreases. This same mother did end up seizing 2 days later from her pre-eclampsia, and is still in the ICU being treated for very high blood pressure. As this was going on we had a call that a patient was coming in with a molar pregnancy, which is a non-viable pregnancy that can transform to a cancer. She had been bleeding, although she was stable on arrival. Then another call came with a possible ectopic pregnancy arriving (an ectopic pregnancy is a non-viable pregnancy outside the uterus which can cause massive bleeding killing the mother). We started evaluating her, and a another call came in letting us know that a woman with a cancer of her hand (she was going for amputation of her entire arm the following day) who happened to be pregnant had unfortunately lost her baby. It is called an IUFD or intrauterine fetal demise. Did we need to induce now or wait until after surgery. We decided to wait and get the arm taken care of first. Another older woman rolled into the casualty (ER) with severe pelvic pain. We admitted her and it turned out that she had bilateral tubo-ovarian abcesses that were causing her to become septic. This are major infections of the female reproductive organs. Somewhere amidst all of this another woman arrived. She was 38 weeks pregnant, and she had a huge vulvar abcess due to an infected Bartholin’s gland. We admitted her to prepare her for surgery the following day. It was a busy night, and not all of it is exactly the bread and butter of family medicine. Oh yeah. I have just been switched off of medicine to do a month of full time obstetrics. The needs of the hospital must be met. 🙂 What have I got myself into?
This is what it looks like in the middle of the night right before doing surgery on a woman with an ectopic pregnancy. This mother of three came to our hospital with severe lower abdominal pain, a very fast heart beat, and low blood pressure. When we examined her abdomen it was very tender in the lower pelvic region. We did a quick ultrasound confirming our suspicion that she had a ruptured ectopic pregnancy. This is a surgical emergency. I walked quickly to the operating rooms and woke up the surgical staff, but I could not find the anesthetist. It turns out he was trying to help revive a 28 week baby who had been born two days earlier. I found him because the pediatrician called as I was sitting the in the OR and asked me how a different, critical patient in the ICU was doing. This other patient was admitted for severe HELLP syndrome. This is basically a multi-organ failure during pregnancy resulting in anemia, liver failure, clotting failure, and in this patient’s case she had developed blood clots in her lungs. I said she was stable, asking why she would want to know. It turned out this unfortunate woman’s baby had died. My on call anesthesia tech had been helping try to resuscitate the baby. Ari (the pediatrician) wanted to assess how the mother was doing in the ICU before she let her know her baby had died. I ran up to ICU to check on her, and I watched as Ari in the most gentle manner shared the bad news of our sick patient’s baby’s death. I walked quickly back to the OR, scrubbed in and opened up the abdomen of our ectopic pregnancy patient. The pelvis overflowed with blood and clots, but with suction the uterus was seen and the large ectopic pregnancy (this is a pregnancy outside of the uterus) was seen in the area where the fallopian tube enters the uterus. We took care of the dead ectopically positioned pregnancy, started a transfusion for the mother, and then closed up. I went home only to be woken to the news that another patient had a severe perineal tear from her early morning delivery. Back to the hospital I rushed to sew up this bleeding tear in the operating room. Today I have a lighter load, doing lectures in the ICU. I am so glad, because it was a tiring night. Oh, and its my birthday! A great start to year number 49. Yes that means I am 48 years old today. I cannot believe it.
Karanja is one of my many excellent medical officer interns. He is a very good doctor,and I would trust him with my family. There are others like him, who have come to Kijabe after finishing medical school to do their first year of post-medical school graduation training which is referred to as an internship. This is a year of practicing medicine under the supervision of consultant / attending physicians. It is a system much like we use in the United States to be sure all of our medical school graduates transition from classwork to the practical work of actually caring for patients. I am privileged to serve as one of the consultant physicians at Kijabe, and truly the pleasure is all mine. It is a great blessing to work with these young doctors. Karanja is a good example, as he strives to become better at each skill placed in front of him. I am humbled by his and the others’ desire for knowledge. God is using Kijabe to train doctors for works of service throughout east Africa, and when I talk to these young men and women I am challenged by their ambition to show God’s love and compassion through their work and lives.
Another night of obstetrics call is in the books. It began with mother who was admitted with a femur fracture from a traffic accident. She was 31 weeks pregnant, and the baby’s heart tones were not completely normal. I watched her overnight as she was readied for surgery the following day. I imagined that her placenta would separate from the wall of her uterus due to the trauma, and I would have to rapidly take her back for a cesarean section; I wondered if I would need to call the orthopedic team to fix her fractured femur at the same time. Next was a severely ill pre-eclampsia (high blood pressure in pregnancy) patient. Her pregnancy already was complicated by severe growth restriction in the baby and loss of fluid around the baby both of which indicate that the placenta is failing. The estimated weight of the baby was about 2 pounds which indicated she was about a month behind where she should be. As I watched the heart tones of the baby they were minimally reactive indicating a unborn baby at the end of its rope. I took her for cesarean section and pulled out such a small little girl. She is doing well as of now on a ventilator, and I hope she makes it. The call ended with a delivery of twins right at midnight. The first came out normal looking for the exit. The second backed its way out in a breech position. The interesting thing is despite being twins, because of the timing of their birth, they have different birthdays. Cool!?