Sunday, November 29, 2015

Internship snippet: Obs/Gyne

I was just thinking about how I never really managed to put out anything concerning my working experience during my medical internship during the time I was actually doing the internship (timing issues and not wanting to unceremoniously leak any confidential issues). Well, now, the internship is all but over, save for the issue of winding up and getting some signatures. I have to say that transitioning and finishing up for me has always been a bit of a difficulty. Anyway, I was talking to a friend the other day, and she asked me whether I had actually done any Caesarean sections. At the time, I told her that I had probably performed close to 100 as the primary surgeon; well, as per the official count in the OR log, it currently stands at 124 as the primary surgeon (there have been quite a number where I was the assistant, then there were also nights when I was just too tired to log in some entries).

It really has been quite the experience: Kisii Teaching & Referral Hospital, where I served my time is a really busy centre and referral cases come in aplenty. Nowhere does this sentiment ring truer than within the Obstetrics/Gynaeceology (Obs/Gyne) Department. I can remember nights when I’d hear an ambulance pull up to the hospital, say a prayer hoping that they were bringing in a case for the Surgical Department to deal with, and then rush up to the ambulance to confirm for myself. (Of course, I prayed the opposite prayer when I was doing my surgical rotation). :(

I must admit that Obs/Gyne is a hustle to deal with: due to Kenya's fascination with the Millennium Development Goals (MDGs), maternal-child health is a big deal; however, we embraced the ideals and goals, but have not exactly put in a step-by-step program to achieve them. What this did was create an untenable work environment where the onus for maternal death is put on the hospital (particularly the intern), regardless of the pregnant mothers' antenatal care history. On top of that, the work is tedious; I actually lost weight during my Obs/Gyne rotation.

Personally, I love practising surgery, and there’s no better teacher than lots of hands-on work. I still feel as excited stepping into the surgical theater as I did almost 10 years ago when I first volunteered at the Harrisburg Hospital. Performing surgery is art and science melded into one, a beautiful dance where everything enriches the experience: the anaesthetist with his/her real-time command of the patients condition, your assistants both at the operating table and those in circulation, and recovery; even the cleaners keeping the place nice and orderly are a massive help.

Obs/Gyne is not as varied a field as General Surgery, so there were very few procedures you get to perform; king of them all is the Caesarean Section. At this hospital, it's pretty much regarded as an Intern's procedure, unless there is a particularly extreme degree of difficulty inherent to a specific pregnancy. That is quite a lot of pressure to place on an intern; consider that (according to my friend in Australia) post-graduate students in other countries ONLY assist with the C-sections! The quicker you learn to be confident at performing a C/S, the better; my immediate superiors - the medical officers - were none too fond of being woken up in the middle of the night by an intern to come assist with a C-section. Knowing how to handle things at night with a skeleton crew is key.

All risks considered, a C-section is a pretty safe standard procedure; I have only had one mother succumb on the operating table (and that was because she had severe antepartum bleeding). I can't forget the near misses, though: on one occasion, a mother developed hypotension as soon as the spinal anaesthesia was injected and she just flatlined (breathing and heartbeat stopped cold)! Hence, before progressing to anything else, we basically started by resuscitating the patient; once the patients vitals were restored, we performed one of my faster C-sections. There doesn't seem to be anything written in literature sources, but it is a startling experience dealing with someone who has flatlined in the course of being anaesthetized: they pretty much seem out of their mind, overly emotional, unsettled, which in turn makes you question whether some sort of brain damage occurred. Thankfully, daunting as the experience is, the patient is in good condition when we review them the morning after.

I don't see a future for myself in Obs/Gyne, but I am at least thankful for the experience. Many a prayer were silently prayed over my patients as they lay on that table; prayers when I was starting out and the thought of being in-charge of systematically slicing someone open weighed heavily on my nerves; prayers when difficulties were imminent, and especially when complications arose. Thankfully, the Lord was faithful.

One downside to this whole experience is the sheer number of patients that we get to deal with. The intensity of the experience, at least on my part, meant that I formed deep relationships with mothers who I had to reassure and counsel on the best course of action for themselves and their unborn children. This occurred day in and day out; sadly, I can scarcely remember many of those interactions; it's as if they were wiped clean from my mind as soon as they were formed to make space for more equally intense versions of the same experience with other emergency patients. Or perhaps I'm just bad at remembering my own patients beyond a certain space of time. Thankfully, the patients never forget: Kisii is a small town, so its not unusual for me to bump into a lady on the street, for her to hail me as "daktari", and then remind me that it was I who helped her with a difficult delivery. It's things like that which make working in the medical profession a blessing, much more profound than anything money could ever offer.

I don't exactly know whats slated to come in the near future, nor where exactly I'll be headed be it another part of Kenya or Post-grad school - but I'm hopeful God will push me in the right direction (because I plain stink at transitioning).

Have a great week. God Bless.

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