First do no harm, part 2

First do no harm, part 2

1^st September: In the evening we went to the delivery ward to see if there was anything going on. There was 1 lady who was having her first child and was fully dilated when we arrived but the baby’s head was not fully engaged in the birth canal. 3 hours later the doctor came and examined her and the baby still had not descended and the membrane had not yet ruptured (in other words her waters had not yet broken) and decided if the baby had not descended within 3 hours then they would perform an emergency c section as they thought there may be cpd (babies head too big for mums pelvis). About an hour later the membrane did rupture spontaneously but there was meconium (foetal stool – it is a bad sign because the baby can swallow it leading to foetal distress) in the waters, the midwife examined the mother again (it was hard for her to feel the head before as the membrane was bulging and in the way) and decided that there was no way the woman was going to be able to deliver vaginally and she would definitely need a caesarean. With this statement made the midwife sat back down and didn’t contact the doctor…

We were very confused because if the patient was definitely going to need a caesarean plus with the meconium in the water there was a risk of foetal distress, then why wasn’t the midwife calling the doctor to get the caesarean done sooner than 2 hours time – surely there was no point the patient having to go through another 2 hours of unnecessary labour pains when she wasn’t going to be able to deliver vaginally anyway. We tried to tactfully say this to the midwife and ask if she was going to phone the doctor (trying to phrase this in a way where we did not seem bossy/ rude). The midwife did not seem to understand us when we said it would save the patient a lot of pain, I really don’t think maternal pain is something they take much into account here, and she basically just said that the doctor would be back of her own accord at some point. Finally about an hour later the doctor did come back and agree the patient needed a caesarrean but sadly for the patient by the time her blood had been taken for blood grouping and the stretcher had just arrived (the patient was literally about to sit on it) another patient came in who needed a caesarean and needed one more urgently than the first patient.

The second patient had had 2 past caesarean deliveries and had presented very late to hospital, you could literally see the baby’s head on examination already, but the baby was not coming out on pushing and instead blood was indicating that she was probably having a uterine rupture due to the scar from her previous caesareans splitting. So this patient was rushed straight to theatre and the first patient had to wait even longer for her caesarean – which was frustrating because she could have already been finished in theatre by this point if the doctor had been contacted when it was first clear that a SVD (spontaneous vaginal delivary) was not possible.

We went to surgery with the second patient, the emergency caesarean was clearly very necessary as when they opened her there was a lot of blood already pooled beneath the surface. When the baby came out he was very blue, not breathing and when I checked his heart rate it was beating but initially definitely below 60bpm (guidelines say that if a newborns heart is 60 beats per a minute then you should initiate chest compressions). So AJ and me and a midwife intiated resuciation, suctioning (the baby had a lot of secretions in his lungs) and rubbing/ lightly pinching the baby to try and stimulate the baby into taking a breath. When it came to cardiopulmonary resusciatation I was doing the chest compression and the midwife bagged him for a bit before the midwife was needed elsewhere and then AJ took over the bagging and the midwife occasionally came back over to check everything was going ok. To be honest it was better when it was just AJ and me doing the resuscitation because the midwife was instructing us to do the wrong CPR ratio’s – we had looked up the current guidelines for newborn resusciatations following the caesarean the other day when the other medical students had ended up doing CPR on that baby. The midwife didn’t even have the ratio the right way round and was instructing us to do far too many breathes through the bag and not enough compressions. There’s no point putting an excess of oxygen into the baby if the heart is not pumping enough for the oxygen to reach the babies brain! This is the second time we have experienced staff seeming to be unaware of the most efficient CPR protocols since we have been here which is a bit scary seeing as it was only the fourth day and as they do not have advanced resuscitation equipment here, basic CPR is something they really really need to get right. I don’t blame the staff, I think this is probably a case of poor medical education and not being able to easily keep up with current guidelines (trust me getting on functioning internet here is akin to getting blood from a stone, which is why my blogs are very dull without pictures at the moment – will try and fix this when I can!). But as someone who is aware of the cpr guidelines, I think I probably have a responsibility to try and educate the staff about these but I have no idea how on earth to do this in a way that staff might actually listen too and follow the guidelines in the future and how to do so without causing offense to staff and making an awkward atmosphere. If anyone has ANY ideas about how we could do this, please comment below J .

We eventually managed to get the baby breathing and his heart rate was going at a much healthier 120, SUCCESS! Unfortuantely though he still was breathing a bit wheezily and was floppy and yet to cry. There wasn’t much more we could do though apart from wrap him up tight to try and keep him warm and try and stimulate him a bit more into crying but sadily he still hadn’t cried by the time he was taken from us to go to the baby room, so after checking someone was definitely keeping an eye on him we went home. Came into see him early Friday morning before the meeting and was pleased to see that he was in the middle of a full scale cry :D, for once was very happy to hear a baby crying!

The second caesarean (of the orginal patient) happened whilst we were still trying to resuscitate the baby so we didn’t get to see this birth, but I didn’t mind as was just very glad that the patient was finally receiving her caesarean after all that waiting. Her baby also initially had some problems but was breathing slightly from the start and we heard the baby give a nice loud cry whilst we were still trying to resuscitate the other baby

I’m aware my last two post are very critical, and I hope I don’t sound like an arrogant medical student, far from thinking I know everything I am very aware how little I know, but it was just scary how many simple mistakes/ things that even I could see were bad clinical practise have occurred during the last couple of days and indeed entire week. As of yet no one has died from any of the mistakes (though I am worried about the bowel obstruction patient as I can't see how she will not obstruct again) as I think the stroke patient would have died even if the CPR had been done perfectly, but I am terrified that at some point a patient will while I am here. This is only the end of the first week :S ...

First do no harm

First do no harm

1st/ 2nd September 2011: The last few days have been quite frustrating from a medical perspective. I knew when I came here that the quality of medical care wouldn't be anywhere near as good as it is in England due to lack of resources, but I don't think I had considered the impact that possibly poorer medical education of the doctors, nurses and midwives would have on the quality of care. I'm not sure all of the mistakes I have seen in the last few days can even be accounted for by inferior education (possibly - I’m assuming so due the country being a lot poorer and so having less money available to train doctors) though; some of them seemed to be due to just poor judgment and arrogance/ laziness on the part of some of the doctors. I don't like to be so harsh but I really have seen some shocking clinical practice in the last couple of days.

Will have to split these mistakes up I think or this post will be farrrr to long. :S. So starting with Thursday morning:

Thursday morning we were all due to watch an exploratory laparotomy on the patient mentioned yesterday who had a bowel obstruction. This was meant to be happening first thing and by about 9.30am the patient was ready and lying in the operating theatre. So far so good.

Unfortunately for the patient before the operation could start, another patient was rushed in to the other major operating theatre for an emergency c section because the patient had taken local herbs (this seems v.v common) and they were worried about fetal distress. Apparently there were not enough staff available to fill 2 operating theatres today because it was a public holiday. This meant the patient had to wait lying on the operating theatre for was almost another 2 hours whilst they performed the caesarean. Not ideal, in England public holiday or not, enough healthcare staff have to be available to safely run the hospital and this is what you sign up for when you train in a healthcare field. Still I don't blame the staff for this, this just how the system is arranged here. Also obviously the emergency patient had to take priority, but what I don't understand is why the staff left the poor patient just lying in the theatre waiting for two hours when there was a room just opposite with sofas etc which surely would have been more comfortable and less frightening for the patient. When the operation finally did start the patients BP was very very high (210/160 ish) even though it had been on normal range when she was on the ward. The anesthetist even said that maybe this was because she had been kept waiting in theatre so long, so they obviously do understand here the effect that fear can have on patients general conditions so I don’t understand why they had not taken just a little bit of time to make sure she was more comfortable. As it was, the operating theatre she had to lie in was connected to the operating theatre that was in use by an open doorway listening to the operation going on which I imagine must have been terrifying! Still this wasn’t a life threatening aspect of clinical care, so it wasn’t this in itself that really annoyed me. Side note, we also watched the c-section and when the baby came out she was not breathing, the other medics resuscitated her and she was breathing but not very well and not properly crying when she was taken from them to go to the warm baby room, here there were no staff to observe her condition and the baby was going to be left completely on her own there if the students hadn’t decided to stay and look after her until the family arrived to take over.

It was what occurred during the operation that scared/frustrated me. When the patient was opened up it was clear just how obstructed she was – her bowels were so filled with air that they literally looked like balloons. Firstly the doctor thought the bowel obstruction was caused by adhesions which are a common cause of obstruction (although are usually caused by past surgery which this patient hadn’t had) so she removed these and compressed the bowels to try and deflate them. They didn’t deflate so rather than thinking that there must still be an obstruction somewhere further down which realistically must have been the case or the bowels would have deflated on compression, the doctor decided to puncture the bowel and deflate the bowels that way and then close up the patient because the adhesions were gone… Mistake number 1 and 2. I’m pretty sure that puncturing the bowel is something that you are meant to avoid at all costs due to the infection it would most likely cause and even if I’m not right about this (AJ and I both think we remember this from our G.I surgery placements but that was a while ago)the logic of assuming you have fixed the problem when the distension cannot be pushed down the bowel (when closed!) and out is very very odd. I don’t think I’m explaining the scenario very well, but basically if the bowl is still distended then there must be distension still further along the bowel and the doctor hadn’t even checked for this before assuming everything was ok and she was going to close the patient up. It was only because we asked well why is the large bowel still distended (it was the small bowel she had punctured and emptied) that she decided to look closer at that bowel and then said she had found a mass below the sigmoid colon. However she was still just going to close the patient up and refer her to see the specialist who was visiting in about 1months time... Again I get that they don't have the resources to do that much here and there are things they cannot treat but without some kind of treatment the patient would just obstruct again and so the surgery and the pain associated with it would be for nothing. I think the surgeon noticed our shocked faces at this because she asked us what we thought she should do. We asked if they were able to perform colostomys (where part of the bowel is brought through the skin of the abdomen and opened out so can be attached to a stoma bag and stool will pass out of this opening into the bag, rather than through the rectum - so an area of blockage in the bowel beyond the stoma can be bypassed and so bowel obstruction prevented) at the mission hospital, she said they could and after deliberating eventually called the doctor on the team who specialised in colostomys.

By the time the colostomy specialist had arrived the patient had been on the table for quite a long time. During this time (and at times during both the first and second part of the operation) the patient’s blood pressure dropped dramatically several times and it was obvious she need more fluid to compensate for the blood loss caused by the operation and a couple of times the patient would either move or grimace in pain indicating the anaesthetic was wearing off. Whilst there was an anaesthetist in the room, he seemed to pay very little attention to how the patient was doing and was not very good at checking these signs. Several times AJ and I had to go tell him that either the BP seemed very low or the patient was moving (he was frequently standing at the window looking out rather than observing the patient) and only then would he give her either more fluid or more anaesthetic. Mistake number 3 :S.

The colostomy didn’t happen in the end because they could no longer feel the mass they felt before and decided it had just been a kink in the catheter, they removed some more fistulas they found lower down but the bowel remained distended. At this point they decided to do a PR examination (feeling in the rectum with a gloved finger – not nice but necessary) to check there wasn’t a mass or something in the rectum. I can’t believe they hadn’t done this before doing a full exploratory laparotomy!!! In England all junior doctors are taught that if you don’t put your finger in it you put your foot in it – in other words potentially this very scenario, don’t open up the abdomen if there’s potentially something that could have been fixed without doing so in the rectum. They didn’t however find anything on this occasion, but that for me doesn’t change the fact that they could of and that the patient could have been going through all this pain for nothing, also the original doctor very arrogantly stated that “It's not a doctors job” which annoyed me no end. It might not be a job that we enjoy doing, but it is checking the patient’s health so it IS a doctor’s job. In the end they closed up the patient whilst her bowel still looked very distended declaring that fistulas were the cause, regrettably I don’t imagine she will have a great outcome but I really really hope I am wrong.

Patients seen on a typical day on a tanzanian ward

Patients seen on a typical day on a tanzanian ward

31st August 2011: Very tired today from the events of yesterday and lack of sleep but with help of Kahawa (coffee) managed to be vaguely alive in time for the 8am meeting. Less descriptive post today and more of a list of conditions I saw or was told about on the ward round. Lots of obstetric cases because manily obsteric ward round today. Warning, probably of not of interest to those from a non medical background!

Patients

• Human bite to lip/jaw - caused by husband!

• Malaria
• Female adult with partial intestinal obstruction- gas on percussion, diminshed high pitched bowel sounds, dilated loop of ?small bowel (doctors unsure as to which bowel!)on abdominal x ray. Commonest cause bowel obstruction in adults here = volvulus (twisting of the bowel) , kids = introsusseption (the telescoping of one part of the bowel into another). Patient going to theatre soon.
• PID - pelvic inflammatory disease (caused by STI's)
• Meningitis
• Bleed from R. Inguinal area unknown cause.
• Patient recovering from Perineal tear from labour, and pph (post partum haemorrage).

• Inevitable miscarriage (due to premature labour start) which occured yesterday - stillborn breech at what then was thought to be 22weeks but based on the size of the baby the doctor thought perhaps 29 weeks (I think this is perhaps even more tragic, because possibly in the UK this baby could have been delivered by an emergency c-section and with the resources available in England would have had a good chance of surival).
• 13 year old boy with peritonitis (inflammation of one of the membranes in the abdomen)
• The patient whose baby I delivered yesterday. I think she was still in so the baby could be observed for a bit longer because they had said that normally here woman who have given birth leave within 4 hours and when we saw her on the ward round today she had already been in for about 11 hours since her daughter was born.
• Patient who had a c section a few days ago due to Cpd (cephalo pelvic disproportion, basically babies head too big for the mum)
• Patient who had a C section on 27th - indicated due to previous pregnancy scar.
• Pregnant patient with ?malaria

• Recent C section - indicated due to big baby and poor progress of labour (4.6kg!) - due to gestational diabetes.
• Patient who had a C section 6 days ago due to foetal distress where baby hard to extract, lots of blood loss - pph, resulted in subtotal hysterctomy being performed (subtotal = cervix and ovaries left behind) - very young patient, 19 and was first baby.
• A patient who was on her 8th preg but of these had only had 1 svd (spontaneous vaginal delivary) and the other pregnacies had resulted in 4 miscarriages and 2 premature labours (which I think were too early to be viable). Was admitted to investigate cause of previous failed pregnacies in order to try and prevent the recent pregnacy progressing same way. The cause was found to be due to rhesus incompatibility. This is when the maternal and foetal rhesus factors are mismatched (rhesus factor is one aspect of some ones blood group - blood groups can be A, B, AB, O and then in addition rhesus positive or negative). Rhesus incompatibility occurs when the mother is negative and the foetus is positive.The foetal blood and maternal blood mix during birth and so if the foetus is rhesus positive and the mother is negative the maternal immune system views the positive factor as foreign and so produces antibodies against it. These antibodies cross the placenta in subsequent pregnancies and so if future babies are also rhesus positive the maternal immune system attacks the babies red blood cells causing rhesus haemolytic disease of the foetus. The first baby therefore escapes this disease (which is why the patient had one svd and since has been unable to carry a baby to term). The current pregnancy was successful so presumably this baby was rhesus negative like the mother.

In England rhesus status is checked as a matter of course and if the woman is negative she is given prophlactic anti-d to prevent the formation of the antibodies in the first place.

• Next patient was 5 month pregnant, slight contractions - salbutamol given to try and prevent full labour, membranes had ruptured so antibiotics given to stop infection.
• A patient whose due date was apparently 2nd august! This is dangerously late so hopefully date mix up. Baby alive and does not seem big so date mix up likely.
• Lady admitted 6th june - 2 month amenorrhea, admitted because no babies - bad obsteteric history. 2 miscarriage at 2 and 3 months. Impression: cervical incompetence. Admitted for complete bed rest (only allowed up for toilet), also receiving salbutamol. Now 24 weeks and feeling foetal movements. Homesick but husband visits every day.
• 7month pregnant patient admitted 2 days ago because abdo pain and thought maybe labour but now abdo pain subsided.
• Patient who was 4month pregnant, low abdo pain 2/7 prior admission, no bleeding. Past ob hist: 1st = miscarriage, 2nd= baby, 3rd= miscarriage. So bed rest and awaiting proper obstetric examination. ?cervical incompetence.
• Patient whose obstetric history was: 1st preg = c section, 2nd svd but child died shortly after, non pitting oedema on hospital arrival, lmp (last menstral period unknown but fundal height suggests term. Advised to stay and await labour.
• Patient who had suffered from uterine rupture due to obstructed pregnancy. Catherterised but still wetting bed, suspected fistula formation.

I found the obstetric ward quite shocking today as its was very overfilled - not only were all tne beds filled but there were 5 other mattresses on the floor (even though there was very little space between beds as it was), 1 of which was underneath another bed so the patient couldn't even sit up and wad forced to lie down at all times. One of the patients who was on the floor was the woman who had had the stillbirth yesterday. Not very nice for the grieving mother. On the otherhand I don't know what else they could have done - overcrowding is probably better than sending away patients in desperate need and the only ambulance here is broken so its not like tney could easily transfer patients to a different hospital.