January 25th, 2010 Posted in Uncategorized | No Comments »
there is so much going on and it leaves me exhausted that i eat, drink and then collapse in the bed. i’ll start with today and work backwards.
monday:
today really started with last night. I was in the operating room until 1am doing a c-sxn on a lady who had a previous csxn due to cephalopelvic disproportion and wasn’t progressing with her trial of labor. I then had an eclamptic pt walk in. This means they are pregnant,have htn and are convulsing. I managed to stabilize her. Once she walked in I knew to turn her on her side, give her a loading dose of 20mg of mg sulfate. 10 in each thigh. take her Blood pressure, it was high and gave her 10mg of hydralazine. Found fetal heart tones, non distressed, also confirmed on u/s. Then about 15min later, she started to convulse again. I didn’t know what to do at that point. Was it too soon to give her more mg sulfate? I went to theatre to ask the general surgeon who was operating on a perforated intestine, he had no clue what to do for this seizing pregnant lady. I drove the car to the ob/gyn’s house and he told me to write for valium 10mg every 2 hours PRN. That it is pretty rare they keep convulsing, but she did. Once stabilized, we monitored her because we wanted her to deliver vaginally, which is still better for her than a section. I also had a lady that had given birth via spontaneous vaginal delivery, and then about 10 hours later developed tender abdomen. this is not good. and too early for it to be an obstetric problem. plus we didn’t do a section on her so it was really weird. Everyone was teasing her…”why are you in pain? you just delieverd you shouldn’t be in pain” “you are weak and making a show”. she was refusing to eat and she was tender so that previous afternoon I had put her antibiotics and started IV saline despite the heckling. she was sweating, tender and had a distended abdomen and just didn’t look well to me. I did an u/s and saw no retained product just to make sure.I had one of the er docs take a look at her later that sunday evening/monday morning and he confirmed she had peritonitis. We started her on some flagyl in addition to the amp and gent and bolused some more fluids. That was my sunday night/monday morning. Then I went to sleep. I woke up and rounded at 7:30am. We induced the eclamptic with cytotec. She was still post ictal and pretty much unconscious. She was twisting and wriggling all over the place. we finally had to put her on the floor and had two of her brothers holding her. she still was having ctx which brought the baby down closer. I was on the floor with them managing the delivery. Finally after a lot of work, pressure and movement of the floor, we had a baby girl. The mom had so much valium and mgsulfate througout the night the baby was drowsy so we had to keep stimulating her. Mom did better after we delivered the baby. The treatment for eclampsia is delivery so it is a very fine line you have to follow.
Then I looked at my lady who had the peritonitis and she looked better. I could feel her stomach without her fighting to remove my hand. So I thought maybe she was getting better. Then by the afternoon she she looked worse. I had the GI surgeon look at her and he agreed to take her in for an exploratory lap. we found an internal hernia with dead bowel and a perforation in the cecum. She is stable now.
In clinic, someone tells me a woman went to toliet and now is delivering. I run out to the field and there is a lady with a breech baby, hanging out of her vagina. I get her down on her back and finish delivering the baby. I pass the baby off to jen and she starts rescuitating the baby. i turn back to the mom, waiting to deliver the placenta and the cord breaks. I manage to retrive the placenta. we get mom and baby inside. It turns out she was referred from another hospital for a 26wk pregnancy, a prolapsed cord and no fetal heart tones and didn’t make it inside. The baby is still alive. and mom is well.
….break,,,,,, left for a call and now just returned. i left at 11pm, it is now 4am.
this has been a rough day for me. I am on call tonight. I had a mom that was admitted with congestive heart failure and a 38wk pregnancy. we gave beta blocker, lasix and fluid. we planned to induce her in the morning. she went into labor, delievered the baby, and had a worse time breathing. i gave her fluids, and lasix, put her in trendelenburg. she was still bleeding, I did a uterine massage which stopped the bleeding. later that night she was started bleeding again, we gave her oxytocin. her breathing kept getting worse and i went to the ob/gyn to see if there was anything else i could do. i read to give morphine, oxygen and furosmide. we only had furosmide. the ob/gyn said to give lasix and that she might end up dying anyway because her heart was so bad. her hct is 22% and she is pale. i am going to transfuse her but i can’t find her husband. i send the type and cross and i don’t even know what she was. I would have given my own blood if i had time. (and everyone knows i am never given blood because i am scared of being stuck myself) I keep trying to monitor her. the lights and power kept going off in the hospital as we were trying to give her lasix. i am trying to assess her bleeding and the only light i have is an opthamoscope light. someone in the ward has a flashlight but the battery is dying and keeps flickering. her pulse is getting weaker and her breaths are becoming agonal. one of the nurses tries to do compressions, but he isn’t doing it hard enough and only with one hand. I take over and start chest compressions. i hear the rib break but know that is what needs to happen. by now i am covered with blood. I can’t see anything and I am trying to give compressions. someone has found oxygen but with the power out it is useless. also i am trying to get the bed flat to give better compressions and it is stuck…so much kept going wrong. I tried to slide her down so i could have some flat area. she is heavy and limp. looking back i should have got her to the floor. there was just so much happening. it is pitch black dark, there is blood everywhere, nothing is working. everyone in the ward is just watching, horrified i am sure and clutching their babies. every time the lights flickered on for a second i saw her face. and i have that image. i finally had to call her death. it is so hard for me. there was nothing else i could do. my staff and i were so frusturated. the medicine we need is not there. and i am a 4th year medical student. i wish i knew more. and i feel like it is my fault even though i know it isn’t. her baby girl is still alive. we have a little bit of lactogen now and can’t get more until morning. I go and ask jen if i can give d5 until morning and she helps me figure out what how much i can give baby. there is also a new admit of a lady who has weakness in her legs after she collapsed and the wood she was carrying on her head landed on her. i gave her prednisone now until morning. i am not even tired. i can’t sleep. truth is the tears come now as i am writing this blog. I already consuled my staff and now i have to face myself. death… it never gets any easier. so i know this is a bunch of rambles but i can’t even think straight at the moment. I will have to write about the weekend later. i went to a crocdile pond and to a slave camp and learned alot. but i will have to write about it later.
people have asked me if i have experienced culture shock. what i have experienced is shock. A hispanic doctor from the states is shocked from clinic today. he says it is not this bad even in rural mexico. even there they have oxygen. There is so much and not enough. the people are amazing. I had one twin die over the weekend and i was apologizing. the grandmother said to me…it is God who giveth and God who taketh away. today one of the midwives said to me it is God’s will. It is so true and so hard still.
