A Travellerspoint blog

A hard week

This week has been hard. The following is an excerpt from my journal of our time here from yesterday. It was hard to live and probably hard to read, not to mention sprinkled with medical terminology. This is the reality some weeks, I guess.

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The baby born a few days back with birth asphyxia who I suspected was seizing died overnight. I found the mother and told her "I'm sorry." I cried with her and didn't know what else to do. I'm not sure what went wrong with that baby or what I might have done to help.

Hours later, I answered the Maternity Ward phone and was told about 2 transfers from the smaller hospital down the road: one bleeding placenta previa at 28 wks, and one 34 week breech primigravida with hydrocephalus [big head] dilated to 8 cm. It was hard to decide which to be more worried about. When the ambulance arrived carrying both of them, it was easier to see - the breech primigravida writhed on her stretcher with contractions. Once we wheeled her inside I checked her cervix. Just as I'd worried, she was fully dilated and definitely breech. We drew blood and scrambled to figure out if we had time to take her to the OR for emergent C-section It quickly became clear that we didn't - crossing her legs was little help to resist the primal urge to push. After weighing our options, we told her to push and prayed for the best. The butt came quickly, and then the legs in frank breech position. I twisted the body back and forth and it came easily. The shoulders delivered, and then it was time for the head. I pulled. Nothing happened. Dan coached me to pull straight upward, so I did. Nothing. I pulled harder. He tried pulling. I placed my hand inside and tried to tug the head out. I put a finger in the baby's mouth, and felt the baby sucking my finger. This only made my pulling more urgent. I pulled and regrasped and pulled some more. Finally Dan went to find Mr. Khondowe to attempt decompression of the baby's head. Horrified by this thought, my pulling became more urgent and finally, with a finger in the baby's mouth, the head delivered. The baby was limp and small, and the head did not look so big. I checked the baby - a girl. No breathing, no pulses, no more sucking. I cleared the airway, bagged the baby, did chest compressions, did everything I could think of. There was no pulse, no breathing. Nothing. The baby died. One midwife said, "Too bad."

Yesterday I was asked to help with IV access on a severely dehydrated 10 month old boy in the pediatrics ward. Ray the CRNA said there were no veins, so I placed an IO access in the tibia. It worked fairly well, swelling up the leg but delivering fluids as intended. By afternoon the tenting visible in his skin was improving. The next morning, though - today - the tenting looked worse again. This was perplexing since the IO had done its job and allowed an IV to be placed. I turned up the rate this morning when I visited him and hoped things would start to go the other direction again.

After rounds, a 19 year old primigravida at 40w2d appeared in Maternity complaining that her membranes had ruptured a week ago but she wasn't contracting. The ultrasound looked good, the NST looked good, and she wasn't contracting. I placed 50mcg Cytotec to start the labor, and checked back four hours later. Her cervix had dilated to 6cm and she was contracting hard. A spot check of fetal heart tones (FHTs) showed a good baseline in the 140s. I left her alone and came back shortly thereafter to find her dilated to 8cm. Not even 30 minutes later she couldn't hold back pushing. She was almost completely dilated, just an anterior lip of cervix left, so I decided to let her start. The heart rate was still 140-150 and stayed there throughout her pushing. She pushed and pushed, moving the head very little despite excellent effort. At 45 minutes pushing, Dan appeared and wondered if she would be able to do it. We decided to give her 30 more minutes pushing and if things were still not progressing we would take her to the OR. Shortly after this the FHT baseline climbed to about 170. There were a few decels to 90-100, but most went down to 120 only. We shuddered as we heard the wailing of women outside in the Pediatrics Ward. Someone told us the news: the dehydrated baby, the one I had tried to resuscitate the day before, had died. The wailing continued.

The 30 minutes out mark came, but the OR was full - the eye surgeons were doing a complicated eye case and using the CRNA. As this was being worked out, the pt was moving the head down more and more. FHT stayed the same and recovered well between contractions. Finally when we were going to call in the backup OR team, Dan reassessed and because of how close the head was, decided that we could deliver vaginally with an episiotomy and vacuum. I cut a midline episiotomy and the head advanced even further. Several more pushes and the head still didn't come out all the way, so we applied the vacuum. I pulled once and the head advanced to the eyes. We pulled and she pushed and finally the whole head was out. The anterior shoulder came with difficulty, requiring suprapubic pressure and downward traction that we didn't hardly have room for, as she labored sitting upright in a regular bed. Dan got the anterior shoulder and I took over, delivering the posterior shoulder and then the body with great effort. Finally the baby came out. The little boy was not breathing or moving, but I clamped the cord and handed him off, expecting to hear a cry momentarily. I massaged the uterus and delivered the placenta, but still no cry. I repaired the episiotomy as I saw Dan intubate and bag, and then start chest compressions on the baby. I prayed and sutured. Finally she was repaired and the bleeding slowed. I came over to the warmer and saw the baby there, not breathing, not moving, no pulse. Cool to the touch. I began bagging and doing compressions, but it was already 30 minutes out. Nothing more to do but weigh him, and show the mother. She stared at him with blank eyes, but did not hold him. She covered his face with the towel and I took him away.

I don't know what went wrong.

Posted by vagabundos 11:11 Archived in Zambia Comments (0)

Trading Places

No, not the Eddie Murphy movie.

Ben and I have swapped roles in the hospital - now I am working in maternity while he covers the medical ward. Maternity encompasses several areas: the postpartum ward, which is full of the mothers and babies they just delivered via vaginal delivery or C-section, the antenatal ward, where high-risk pregnant women are housed, and, of course, the delivery room, where women labor. My first weekend on call for maternity was a busy one! We had one C-section, a first-time mom with a breech baby, which made for a very smooth and simple first C-section in Zambia for me (as opposed to Ben's experience last week...). Then there were several vaginal deliveries of many of the women in the antenatal ward, who, as mentioned, are high risk for one reason or another, so this was exciting too.

It's interesting to see how the labor process works in another culture. Obviously, the mechanics are the same, but the reactions to things are not. My arm was nearly squeezed lifeless by a very sweet 43-year-old mother of 7 (now 8) as she labored. The next day, she was bright, happy, and even acted as my interpreter for those who didn't speak any English. A 17-year-old first time mom demanded I walk her to the bathroom while she labored, and I, as anyone ordered around by an angry laboring woman would, complied. Both deliveries turned out great, and the babies are doing very well.

The midwives don't call about all deliveries, though, and on Sunday night they called too late. Apparently a woman who was referred from another smaller health center was sent in for failure to progress and the midwife on duty did not do much to get the labor going. She also unfortunately ignored the ominous fetal heart rate pattern that was tracing, and apparently the delivery was a difficult one, too. Dr. Dan was called only when the baby was not reviving with extensive resuscitation and by that time, there was little more he could do. The baby is alive, but does not have the reflexes he should and we suspect is having seizures. We are not sure if he will make it, and if he does he may have severe cerebral palsy. Keep this baby in your thoughts and prayers.

On a happier note, a big team of ophthalmologists arrived here in Zimba a few days ago and have started seeing lots of patients and doing eye surgeries that are not performed anywhere in Zambia, in addition to much-needed cataract removal. More about them here: http://ivvusa.org/

Technology woes continue. We will try to take some photos of the hospital, wards, etc. to post for you to see... someday. :)

Love,
Mariel & Ben

Posted by vagabundos 11:54 Archived in Zambia Comments (0)

Staying Busy

Hello again,

Sorry for the delay in posting again! Rest assured we are keeping busy. We round most every day, and seem to be called in for this and that (i.e. deliveries and C-sections) whenever, in addition to staying until the work is done, no matter what time that is. All of this means we don't have too much down time... but that's just fine with us!

Ben has done several more C-sections since we last wrote, some of which were quite complicated, and was involved in a uterine artery ligation due to lots of bleeding. I have been helping with infant resuscitation after delivery, and there have been some harrowing experiences in that realm as well. One mother came in bleeding with placenta previa and a sinusoidal fetal heart rate (translation: they were not sure the baby would be alive). Though the baby was born limp and not breathing, with great effort he was revived and is doing fine as far as we know! Suffice to say, NRP is coming in handy and Ben's operative skill is improving.

Tomorrow will be our last day on our respective areas, and then Thursday we will switch, so I will be the one in maternity while Ben is in the medical wards. Time to be disoriented again!

We haven't taken many photos yet, but we'll share the few we have from a bike trip a few days ago. We've been getting out on the bikes quite a bit - it's a great way to see the area and get some exercise. Hopefully we will get some more photos to share soon!

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Love,

Mariel & Ben

Posted by vagabundos 11:29 Archived in Zambia Comments (0)

One week in

Hey everyone! Sorry this update is coming kind of late, we have had a very difficult time getting internet set up. It got so bad that people were starting to request we not come near their electronic devices out of worry that we might curse those, too.

Now that we've been here at Zimba Mission Hospital in southern Zambia for a week, we are getting pretty settled in. We've come for a month to do medicine, OB, surgery, and everything in between. We're primarily working with and under two American doctors, Dan & Joan Jones (another physician couple). More on them and the hospital here: http://zimbamission.org

Ben started on maternity service, and I've been primarily in the adult medicine wards. We also both help out in the outpatient dept. when we are able. Ben has delivered about a dozen babies here and done 2 Cesarean sections with Dan, and has been the one in charge of some pretty sick mamas and babies. I think the deliveries he's done might also count for more than one delivery at home - there have already been some very high stress times for him, but he's gaining experience that you can't get at home and helping women in scary times.

In the wards, I'm caring for patients with everything from severe anemia (Hb 3.4, for those medical people among you) to CHF exacerbations to pulmonary TB to kidney failure to AIDS. The HIV rate here is very high, so I am starting to get good at the complicated medicine that surrounds HIV medicines and the opportunistic diseases that accompany it. The lack of diagnostics here is pretty challenging - Xray is the only imaging on site, and the few labs that are available always seem to be out of reagents. My physical exam is definitely improving as I rely on it more to figure out what's going on with patients. There have been some successes, some procedures (lots of paracenteses!), and sadly, a death. But like Ben, I'm learning a lot and seeing things that I don't at home.

Outside of the hospital, we have done some running (though the humidity and more altitude than we're used to are making it harder) and went on an awesome bike ride on Sunday. We rode over dusty, pothole-ridden gravel roads and saw the beautiful countryside with little villages with mud huts, chicken families, and fields of corn. It's rainy season so there are heavy rains most days, but temperatures are usually in the 80s during the day and 60s at night, so we're not complaining. We're living in a big, shared house on the mission compound and eat mostly American food that is cooked for us, but have gotten to try Zambian food. The conclusion: very similar to Malian, except more sardines.

That's all for now! I promise to take some pictures and try to get them uploaded... although with our luck lately, it could be awhile!

Love you and miss you all!

Mariel & Ben

Posted by vagabundos 11:45 Archived in Zambia Comments (1)

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