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!?
I spent the last Saturday morning participating in the exams of our Family Medicine residents. They were given 20 minutes with different patients to demonstrate their ability to interview, examine, and diagnose a patient. Overall they did well. I drove to Nairobi in the afternoon to see Avengers with a bunch of high school boys. Almost two hours in each direction makes for a long day, and the movie had better be worth it.
I walked into the ICU and the nurses came to me to tell me how a patient in the far bed was a walking miracle. It turns out he had hurt his neck two weeks previously, yet had continued to walk around Nairobi for a few weeks before he finally showed up in our emergency department. By the time I met him he was flat in bed with two large screws in the side of his head holding his neck in traction. All he complained of was a little weakness on the right side of his body. He was lucky he wasn’t paralyzed! Everyone was telling him how he was a miracle.
The best part of the job is working with residents, medical officer interns, clinical officer interns and other consultants in the hospital. I am feeling especially pleasant this week because I am working on the internal medicine service. Last week I was in the ICU which is definitely intense. There is a definite lightening of the load when one gets to move away from the care of the deathly ill patients. The worst of last week was a young mother who came in at the young age of 32 years. Four weeks ago she delivered a baby premature. Something happened at her delivery, and she ended up needing four units of blood in transfusion. This happened in a hospital a in a different district. She was discharged and slowly became weaker and weaker with more and more trouble breathing. She presented to our hospital, and she was found to have a very weak heart. This is called peripartum cardiomyopathy. Hers was so bad that she had developed multiple organ failure. Her kidneys, lungs, liver, and heart were all failing. On top of that she had a big blood clot in her heart as well as a problem with the ability to clot her bood. We admitted her and began the fight for her life. Initially she responded to our treatment, and I was hopeful that she would get better. However after 3 days she quit improving. On day 4 she began vomiting blood. I had the sinking feeling during morning rounds that although she had improved and was better than when I first met her, that there was nothing more I could do to improve her more. Unfortunately that afternoon her heart stopped during an investigation to determine why she was vomiting blood, and after about 4 hours of trying to rescue her she passed. It will not be easy to get over. This week my patients are less sick, and I find myself almost skipping through the hospital, enjoying the people I work with and enjoying the patients who are getting better.