It's already been quite the tumultous start to 2017 down here in Kenya. The doctors' strike drags on for yet another week, and now, in much the same manner, university lecturers are also on strike due to talk of yet another unfulfilled Collective Bargaining Agreement (CBA) from 2013. The writing on the wall is obvious: politicians can't be trusted to fulfil any pledges they make in the wake of an election year. Lord knows what other messes they'll be orchestrating in the remaining 7 months of election campaigning.
I feel like the doctors' strike would have ended earlier if we only had a limited number of people taking part in the negotiations, i.e. the president, his ministers of Health and Labour and the doctors' union. In all honesty, other groups like the SRC (Salary & Remuneration Commission) and the Council of Governors have nothing of importance to add to this issue. Devoid of such organization, we are being treated to trivialities that border on the obscene. Social media was ablaze with #IamNotSewage because the Labour Court judge (Wasilwa) hearing the case openly referred to the collective striking medical body as stinking of sewage. (Apparently judges must be skipping Decorum 101 these days). As if that wasn't enough, just recently a 'nominated' Member of Parliament tried to whittle the strike into an issue of tribalism; this earned the ire of the medical fraternity, and now we have #TribelessDoctor trending.
All the wrong people are doing the talking, which is driving the doctors irate. Has any of these sanctimonious individuals ever set foot inside a public hospital, apart from occasions for photo-ops? Can they really sympathize with a general public with whom they have nothing in common? Do they even understand the situations that medical staff have to contend with, especially those that go above and beyond the call of duty? It is probably for these reasons (and many others) that another topic has been trending - #MyBadDoctorExperience. I hear that initially the topic was created to highlight patients' bad experiences at the hands of incompetent doctors; but as later stories will attest, the doctors are currently using it to highlight the traumatic experiences they've experienced at the hands of the healthcare system. It is only a glimpse of what doctors experience, but it is enlightening nonetheless; and I guess it's time to add my experience to the fray.
*Friendly Advisory: beyond this point, some of this gets a little graphic!
It was about mid-December 2014, and I was knee deep into the 2nd rotation of my internship (Obstetrics & Gynaecology). I believe that at that point, of the 3 interns in the department (Fiona, Lucy and myself), I was 'stationed' in the Labour Ward. I use the word stationed lightly because throughout the course of the day, we all converged at the Labour ward to handle whatever business came up. Considering how overwhelming the work could be for 3 interns, it was very typical for the 2 interns who weren't on duty to end up leaving the hospital after 11.00 pm. Only one of us was ever on night-duty, but we figured that it would be better for us to let the intern-on-duty disappear to freshen up at home; that intern would then report back to the hospital around 7.00 pm, but we'd basically have the intern relax in the call room while we cleared every issue in the wards. Some time before 11pm, we'd join our colleague in the call-room and just debrief each other before we set off. Turns out it was a great way to de-stress and keep ourselves sane.
On this particular day, around 4.00 pm, a patient (about 38 years old) showed up to the Labour Ward; (for my convenience, I'll refer to her as "Edna") by all regards, she was a stable patient, obviously in the 3rd trimester of her pregnancy, and had been admitted because she noted reduced fetal movements in the course of that day. I take down her history, and I find out that this is her 5th pregnancy; all prior pregnancies had ended in normal deliveries, but they had yielded only girls! So here she was hoping that this particular pregnancy yielded a boy so that she could call it quits procreation-wise. By all accounts everything's normal, until I dig out the fetoscope to listen for the fetal heartbeat: not a sound, no matter what position I checked for it. Undeterred, figuring that the problem was my technique, I called in one of the senior nurses to assess for the fetal heartbeat. She too couldn't find the fetal heart.
Unfortunately for us, the fetal doppler probe was not available, so the only way we could confirm the presence of a fetal heart was to perform an obstetric ultrasound. As a double misfortune, the sonographers were also not available at the hospital after 4.00 pm, so we basically had to arrange for her to be transported by ambulance to a reputable external radiology centre to have an obstetric ultrasound done. At this point, I'm really hoping that the ultrasound will prove that there's a fetal heartbeat so that I can schedule her for an emergency caesarean section (C/S) as soon as possible; worst case scenario is that she's had an intrauterine fetal demise (IUFD), and in that case I would not need to saddle her with an unnecessary surgical scar.
We arrange for the ultrasound, but end up having to wait for the ambulance to return from another emergency. Theater staff have been informed about a possible C/S being performed, but we've currently hit the magical hour: 5 - 6 pm...shift change-over time. Basically, nothing gets done during that period, and we end up having to pool our surgical cases until the anaesthetist-on-duty shows up. I keep doing the rounds on the other patients, but also take the time to read the nurses' cardex for Edna's case. During that interview, Edna had reported that she had experienced some vaginal bleeding prior to coming to the hospital (a detail she omitted when I queried her about any danger signs that she may have experienced). Around 5.30 pm, the ambulance becomes available and I'm looking forward to having some clarification on the matter. I've already discussed the option of a C/S with Edna and her husband, and they've suggested that a Bilateral Tubal Ligation (BTL) aka "tying her tubes" be performed; I've even joined up as a member of "Team Edna", and I'm really hoping that the baby is a boy and in optimum condition. And then, it happens!
A sizable amount of blood gushes from her vagina, soaking the sheets! I see the colour disappear from her face, and forget all about the ultrasound; by this point it's very clear that I have to get her into theater immediately. The nurses attempt to stabilize the patient, while we hurriedly prepare blood, get consent, alert the theater, the anaesthetist and my immediate superior (a Medical Officer). The Medical Officer gives me the go-ahead to perform the case and tells me he'll be coming in eventually just in case I might need any help. I counsel Edna's husband again about the emergency situation, and let him know it's the only option that we have left.
Under normal circumstances, I would just perform the C/S myself, but Fiona happens to be around at that moment so she makes the decision to step into theater with me for the case, which affords me several advantages; Fiona and Lucy basically taught me how to perform C/Ss. In addition Fiona is left-handed; basic rule of surgery is that the primary surgeon stands on the side of the patient which allows them the most ease to operate - so, a right-handed surgeon would stand to the right of a patient and vice versa for a left-handed surgeon. Working with Fiona thus felt like having two primary surgeons on the table at the same time, and the responsibility could be shifted without us having to reposition ourselves at the operating table.
Everything is ready for us very quickly. We jump into theater, and in a break from the norm, we are scrubbed in and gowned before the patient has even been wheeled into the theater. Soon as she's placed on the table and anaesthetized we get to work. We sacrifice most of the presurgical skin disinfection for the sake of speed, and start hurriedly. I make a wide incision and slice through skin, fat, fascia and muscle, making my way to the uterus; during this time, she barely bleeds. Once I'm through the peritoneum, I come across a pale white uterus! Gone is the pink colour of the vitalized uterine tissue that I encounter during routine surgery; the inside of her is just as pale as her extremeties.
In one swift move, I'm inside the uterus and we visualize the baby's placenta detached from the uterine wall and accompanied by a massive blood clot...Placental Abruption! Quite the atypical case because the bleeding was concealed and Edna did not experience the usual cluster of symptoms. There was nothing that could be done for this BABY BOY. With one life gone, we concentrate on Edna. With the uterus taken care of, it's time to perform the BTL. All things considered, and with the haste needed post-operatively for the patient (including the most important issue of the blood transfusion), I opt not to perform the BTL, and close her up layer by layer. Soon as we're done, the anaesthetist lets the blood run, trying to reperfuse the patient as quickly as the blood can flow.
Our part as surgeons is done, and we step away from the table to assess the patient whose life entirely relies on the anaesthetist's manipulation. Never would I have thought that the patient I met a mere 3 hours earlier would have taken this eventual turn. As if by design, her breathing ceases, and shortly thereafter her heart stops. We're ready for it when it happens and we jump in to resuscitate her. We aren't able to achieve anything meaningful, and I lament that her husband isn't around to say any sort of goodbye. A 100% fatality rate in an Obstetric procedure.
We clean her body and place her accordingly. We then silently walk out of the operating room into the adjacent corridor, each one of us pondering the experience. We have theater notes to write, and still have more cases to perform; but more than that, we have to inform the father of four of his wife and child's demise. He's not in the reception area when we come out, but undoubtedly, he'll be arriving soon. I try to organize my thoughts so that I can deliver the news in an informative yet sympathetic manner, but I can't lift my gaze from my hands as they lie idle in my lap. In the end, I'm glad when the anaesthetist picks himself up and ends up relaying the information to the bereaved. I was within earshot of the conversation, but I don't remember hearing any wailing or sobbing from Edna's husband. He calmly stepped out of the reception area, and, as with countless cases, I know nothing more of what happened to him or his family.
With every loss you encounter, you're supposed to be able to detach yourself from the situation enough that you can function adequately come what may. After all, the work never ends and though one person's life has been brought to a standstill, the rest of the world need to move on. Even if it may not be required of you, every death is a chance for you to reflect on what you might have missed, what you might have done wrong and what more you could have done; and after that, the harsh lessons inform your practice in regard to subsequent patients.
Every doctor (/medical practitioner) you've ever met probably has a couple of these jarring experiences that they could quote for you if you gave them the chance. We carry many of these scars with us, but rather than break us, these scars make us resolute. We spend a lifetime poring over our mistakes, so that we don't repeat them to your detriment or that of your loved ones. Us asking for you (through the government) to avail us the tools to stave off death for another day is something that we are duty-bound to do. We would love the chance for every one of our patients to have therapeutic options available to them at a rate that they can adequately afford; that they would stand the same rate of survival regardless of their economic endowment.
As with all things in this life, we do our part, but we recognize that in the end God provides the true healing. In the end, He's all we really have.
God Bless.
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