Friday, 2 September 2011

For every death theres a birth. A very eventful day

For every death theres a birth. A very eventful day

30th August: Today I saw a patient die for the first time. We had been waiting for the morning meeting when one of the doctors came in and asked us to come with her to see a patient. Assuming she was maybe taking us to see an interesting patient for a teaching opportunity, all 5 of us went along.

The patient turned out to be the lady whose GCS we had checked yesterday. It quickly became clear that the doctor had been called because the patient deteriorated rather than this being a teaching session. The patient was gasping for breath and her GCS was now only 3/15 as she was no longer responding to pain. The doctor listened to her chest and took her blood pressure and then without saying anything started alternating between pushing on her chest and suctioning the patients mouth. It took us a while to realise she was doing chest compressions because to be honest she wasn't doing them correctly (or at least not how we are taught to in England) and how many compressions she did in each set varied and seemed a bit random. To start with I thought she was just massaging the chest to try and loosen secretions so she could suction more fluid out or something. When we realised she was doing some kind of CPR one of the other medical students took over chest compressions and AJ and I alternated pumping the suction pump (unlike the UK its manual) so the doctor could concentrate on just suctioning. However after no more than 10 minutes of this, the doctor decided the patient was not going to recover and stopped rescucitation. No oxygen or adrenaline was given and defibrillation was not attempted(we are not sure if they have a defibrillator here). Very unlike England, but with a GCS of 4 yesterday I am not sure the outcome would have been any different even with a more thorough rescucitation attempt.

To start with I have to admit I didn't feel as sad as I thought I would seeing a patient die and I actually felt quite guilty and inhumane for not feeling more when a relatively young woman has just died. But I think this was because knowing the woman's GCS, there was a great sense of inevitability about her dying and it sort of seemed like it was for the best as she probably wouldn't have recovered a good quality of life after so severe a stroke. Also the whole thing seemed to happen so fast that it was really surreal that I had just watched someone die. I hope this is why I didn't feel too affected by the experience anyway because I don't want to be some kind of horrible doctor who doesn't care if their patients live or die. However I was on the ward waiting for the ward round to start when the patients relatives came to say goodbye. They were very distraught and four of them had to be physically supported in and out of the ward. She was clearly a very loved lady. I didn't feel nothing when I saw their pain though and whilst it doesn't feel right to talk about my feelings when their feelings and grief is far more important, it was very very sad indeed. Maybe I'm not completely desensitised to peoples pain yet.

The doctors told me that although the patient was a known hypertensive, she rarely took her prescribed anti hypertensive medication and didn't attend check ups which was why her blood pressure was so high causing her to have a stroke (systolic BP was 210 on admission). I imagine this makes the death even harder for the relatives as whilst her death is not their fault it must be easy to slide into thinking "if only" and potentially blaming themselves for not making her take her medication.

After the relatives had said goodbye I helped some of the staff prepare the patient for taking her to the morgue. As the woman was unclothed beneath her blankets this involved dressing her before wrapping and tying sheets around her. This was was quite a weird process - its half a good and respectful thing that the patients dignity is preserved in death by not just taking her body to the morgue naked but on the otherhand as I discovered dressing a dead body is not a very dignified procedure at all.

I later found out that the lady was a nurse from nearby and a lot of the staff at the hospital knew her and so the hospital was very understaffed the rest of the day as many people went to pay their respects. Not all the other staff were sensitive of this though, during the morning meeting the doctor who had been running the CPR stated when someone referred to the lady as the patient that "It's not a patient, its a dead body" and several other staff laughed in response. Horrible.

The rest of the day

On the Paediatric / female insurance ward round I saw lots of cases of gastroenteritis/suspected malaria; some suspected enteric fever (AKA: typhoid); a case of dysentery; a 10 year old boy with paraphimosis ("retraction and constriction of the foreskin behind the glans penis" - oxford medical dictionary!) who I felt v.sorry for as his mum wasn't waiting with him and he was clearly very embarrassed at having to show his penis to strangers. Finally we saw a middle aged lady who had trachoma which is a severe chronic form of conjunctivitis which can lead to blindness, in this patients case it definitely had as her eye had been completely destroyed - if there was any eye left it was completely obscured by swelling and pus. Although the patient had insurance she had left her infected eye for 5 months before coming to see a doctor which is why the damage was so progressed. Hard to understand why someone would let an infection progress so far without seeing a doctor, it must have been very very painful but maybe this was due to a cultural difference - here people often try traditional medicine before seeing a doctor.

After the ward round I went to OPD - out patients department where I sat in a consultation with a clinical officer student. Here even students run consultations, make plans and prescribe drugs on their own. I was shocked when I suddenly realised during the session in OPD that the clinical officer student wasn't asking me questions to quiz me but because he was genuinely asking my medical opinion and was sometimes basing his plan/what he did on my impression of the patient / differentials - eek!

OPD was very different to in England, much less structured. Here as soon as one patient left, the next patient would come in, with no time between consultations. No idea if they were actually the next patient in the queue or not! Sometimes patients would not even wait for the patient before to be finished and instead would stand in the room while the consultation went on - so much for patient privacy!

After OPD I went to maternity to see the others. Discovered while I had been in paediatrics and OPD the others had been very busy in the delivery room. 3 of them had been helping deliver a premature breech stillborn (see later blog ) and AJ had delivered her first baby herself! The baby was fine but from all accounts the doctor (same on as mentioned earlier re CPR..) had delivered placenta badly leading to a massive hemorrhage. AJ went to theatre with the patient to try and stop the bleeding, which fortunately was successful and the mother was ok.

Was happy for AJ but also a lil bit jealous as was yet to see a fully natural birth (nearest I had seen to natural needed forcep assistance) let alone deliver a baby myself! However my jealousy was very shortlived...

We decided to go back into the hospital in the evening as we thought maybe a lady who had been there during the afternoon would be ready to give birth later that night. We were right!

This was the mothers 3rd pregnancy but the last birth had been at home and the baby had died shortly after birth. I think this was the only reason she had come into hospital as in general she didn't seem to like medical people interfering with her labour and she seemed exceptionally keen to preserve her privacy and the midwife kept yelling at her not to cover herself up when they were trying to examine her. Meant it felt a but awkward just being there as a medical student and I wanted to ask her if she was but I did not know how to in Swahili (and the healthcare Swahili dictionary had nothing about asking for consent in it - not sure it is done here, think things are still a bit old school and consent is assumed). We asked the midwife if she could ask if was and she said the mother was glad we were there, but she didn't seem to ask anything so I hope this was true.

The labour was quite strange in that men/relatives are not present during Tanzanian hospital births and so the woman receives very little in the way of emotional support. The midwife did not really give her much emotional support either as she seemed to be going for the "tough love" approach and when the woman was saying that she was in too much pain/ too tired, the midwife would yell at her and sometimes lightly slapped her on the leg. Found this a bit shocking because I am used to UK birth where woman have birth plans saying exactly the kind of experience they want from their labour and some woman bring in things like relaxing music, and changing colour light cubes to create a more serene at her atmosphere. Not too mention usually having at least 1 person with them (and sometimes entire families!). Very different.

- Part of the labour ward here. The small red incubator is now basically just a movable cot - whilst it has a plug, I have never seen it plugged in so I assume it does not work!

When it came to the actual birth the midwife asked which of us wanted to deliver the baby and as AJ already had she said I could. I GOT TO DELIVER A BABY!! I read up quickly before hand how you should manoverue the baby if it doesn't come out easily but when it came to it she came out really easily and I didn't need to do much beyond support her head. The midwife told me to put the baby on the mothers abdomen (N.B. fresh newborns are really slippery, she kept slipping down!) but she didn't start to cry so we had to take her off and rub her to try and stimulate breathing but it wasn't working so the midwife had to quickly cut the cord so we could take the baby to the rescucitation table. I felt so sorry for the mother as no one was explaining to her what was going on but I could not due lack of language ability which was very frustrating. She must have been terrified because she would have been able to hear things like the suction pump but not able to see what was happening.

I helped try to resuscitate the baby for a bit but then it was time to deliver the after birth do I had to leave AJ and one midwife to it. Capable hands but I hated not being able to see/know how the baby was doing, but not as much as the mother I am sure. When the placenta was delivered it was quite an unusual colour (a bit greyish) and the midwife immediately asked if she had taken local medicine to cause her to go into labour. The woman admitted she had and the midwife immediately started telling her off and telling her this is why her baby was struggling. I thought this was a little inappropriate when her baby was yet to cry as she must have already been really worried and probably already feeling guilty about taking the herbs. Fortunately soon after we heard the baby cry - such a relief!

The mother was bleeding slightly so I had to remove blood clots and try and stop the bleeding - so first actual vaginal examination done as well! After the mother was ok and dressed I got to have a photo with the mother and the baby, all in all definitely an experience I will remember forever.

When we went to leave the midwives asked us who was escorting us home which we were really confused about because the house was literally 2 minutes away and although it was about 12.30, there were two of us so we figured we would be fine. We found out why when we got home. Apparently whilst we had been gone there had been a lot of commotion at the house....

The normally calm housekeeper had started freaking out and locking all of the doors and was telling the other students that thieves had gone to one of the other houses in the village with weapons and they would be coming to our house next as they will have heard that white people were living there. The other medics called the main doctor here and explained about the housekeeper and so he came round very quickly with several men with guns who shot around the building to scare any thieves off. Its pretty terrifying to think we have made the house such a target by being here.

Apologies for massive excessively long post, but as you can see, it was a helluva a day!

Backnote: 10 minutes after we finished writing up our experiences (AJ is keeping a journal) and turned off our light, we distinctly heard what could only be someone having a try at picking the lock on the back door. Terrifying. Needless to say we didn't sleep well! The hospital have now supplied our house with a guard at night though.

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