Tuesday, February 10, 2009

Today I saw a young man who was all painted in red. He was red from head to toe. Three men brought him in to the casualty department. They carried him into the exam room and lay him on the table. He was pale and hot to the touch. The red paint came off with the alcohol pad I used to clean his hand so that I could place an IV. The red paint is part of the traditional Lesotho medicine and is used in circumcision rituals. Part of the frustration I feel here is that many of my patients present after the Lesotho Medicine has failed. By this time the possibly simple and straight forward problem has been given weeks to worsen. This patient had a small wound on his right foot but when I touched his foot it was rock hard. Without the ability to drain the wound our only option was to start IV antibiotics and hope that he improves.

What an odd day. I began working in maternity with one of the Registrars. The first patient we saw was in labor and fully dilated but the baby was not descending. The nurse told us that the head was still very high and that the membranes were still intact. The registrar did a vaginal exam to assess the fetal position and after this evaluation decided to rupture her membranes to help the labor progress. The patient was lying on the table and we placed a black trash bag around her bottom to collect the fluids. First she tried to rupture the membranes with her gloved hand. That didn’t work so she asked me to get her a needle. I got an IV needle because it was considerably longer than the straight needle and thus had more chance of actually reaching the membranes. She inserted the needle into the patient’s vagina and easily ruptured the membranes. I just stood there dumbfounded. What if she had punctured the child on accident? After she ruptured her membranes I removed the trash bag from underneath the patient and carried the dripping bag to dispose of in the trashcan. Meanwhile, on the other side of the curtain a lady was in active labor. I had seen her walk in the door and lift herself up on to the delivery table. She was alone and undressed herself and suffered alone throughout the contractions. She began screaming and waving at me with her hands gesturing for me to come over. I was the only other person in the room but I was definitely not ready to deliver a baby on my own. I poked my head out of the door and called for Dr. T to come quick. Instead of Dr. T a young nurse all in white came. She quickly put on a plastic apron and approached the lady in labor. I came to stand on the other side of the bed to help out if needed.
There was a black plastic bag on the stand next to the patient’s bed. It had a roll of thick cotton wadding, a white towel and two pairs of sterile gloves along with the patients Bukana.
The Bukana is the patient’s medical record. It is a green notebook that holds a record of all her medical visits and treatments. There are no office files or central record. The patient is responsible for keeping their Bukana on their person and this is the only “chart” that doctors and nurses use.
I opened the bag as instructed by the nurse and started to unroll the cotton. When I turned around the baby’s head was already out and one more strong push and the baby was on the table. Luckily the baby came out vigorous and screaming. As the nurse clamped and cut the cord I began drying the little purple baby off. I was rubbing the feet and patting the back to make sure that the baby was alert and taking deep breaths. Another nurse came in at that point and we transferred her onto the clean towel and the nurse took her away. I was smiling and turned to the mother to say congratulations but she looked at me plainly and without emotion. The baby was out of the room. Then the nurse delivered the placenta and after it came she checked the patient for any tears or lacerations. The patient had been lucky and had none. The nurse then removed the plastic bag from under the patient and gave the patient a piece of cotton. The patient folded it into a pad that she placed between her legs. She sat up and stepped off the bed. She then used one of the white towels and wiped the blood off of the table that had escaped from the plastic bag. After dressing herself she walked out. This all happened in a matter of minutes. She left the labor room walking on her own and returned to her room. I couldn’t believe that this woman did all of this on her own. She had no one with her to help her or support her. It was the business of birth.
I left the maternity floor with Dr. T and had to return to my normal duties on the Female Medical Ward. I went to see my patients and one of my patient’s beds was empty. I had talked about sending her home the day before and assumed that someone must have sent her home without telling me. As I was writing a note on another patient I noticed the supposedly discharged pt’s daughter sitting on the bench across from me. I wondered what she was still doing at the hospital. After rounds one of the doctors told me that the patient had actually passed overnight. She hadn’t been sent home to continue with her life she had passed. No one told me and I didn’t know to say anything to her daughter sitting right in front of me. I felt so bad. I had told the daughter the day before that the patient was doing well and was ready to be sent home. The daughter had resisted and I had told her she was already on treatment and she could continue the treatment at home. By the time I had found out that the woman had passed the daughter had gone.
After lunch I caught up with one of the doctors and she told me she was going to be performing a vacuum abortion on a woman who was having a miscarriage. The procedure is known as an MVA here. The patient was called into the exam room for the procedure. I helped the patient get situated on the table and hooked up the straps to hold her legs up. For pain control the patient was given 50 of fentanyl. As the doctor started the procedure I knew that the 50 would not even touch the pain. The patient was staying quite still on the table but crying loudly as the doctor used the vacuum over and over again to evacuate the contents of her uterus. I couldn’t stand the screaming. I wanted to ask the doctor to stop, to end the patient’s pain. The attending doctor and I were each holding one of the patient’s hands as she cried in pain and I could see in his face that he too was uncomfortable with how things were progressing. When the attending doctor finally asked her why she hadn’t used a different procedure, under general anesthetic, she replied that she wanted practice with the vacuum and had chosen this procedure instead. My jaw almost dropped. In a place where we can do so little to ease the suffering of our patients she had had an option to make this easier and hadn’t taken it because she wanted practice. The screaming finally ended. I helped the patient off the bench and helped her to find her underwear. I gave her a piece of the surgical gauze to help absorb the bleeding. As she walked in front of me I saw a fresh blood stain across the back of skirt. I felt sick. I walked her to her bed and helped her in. Woman should not have to suffer like this. I felt like I was traveling back in time to when woman in the states would have to seek out back alley abortions because they had no safe option. I returned to the room and the doctor was washing the medical instruments. She was only using the hot water because the cold water faucet only has mud.

Last week four of my patients died. I didn’t send one patient home healthy. I sent them all home on stretchers. It wasn’t anything I did or didn’t do it was the pure lack of resources that lead to their deaths. My role has mostly been to be a witness to these patients suffering. I am with them at the end and listen to their words even if I can’t understand what they are saying. Some of my patients loose their ability to communicate towards the end and are unresponsive but others seem to be completely aware up until their last breath. I imagine that I would prefer to be aware until the end but it is so hard to watch. I have been working in the Casualty unit for a couple of days and it has been a whole new experience. I have become used to the patients that slowly die in front of me on the wards and haven’t had to be confronted by the more acute and serious injuries. On my first day in casualty I put stitches into a woman’s scalp. I am still very slow at stitching and not very skilled with a needle. The needle was so large that the doctor working with me scoffed at me as I picked up the needle drivers. He insisted that I just use my hand to drive the needle through the tissue. I was completely uncomfortable with that idea which is one of the reasons why I only did two stitches. Today in casualty I was working with a new doctor and watched him put four stitches in a man’s lip without any anesthetic. I couldn’t believe it. With each stitch the patient wriggled his legs and moaned. Most things are in short supply including Lidocaine so some just go with out.

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