Finding your armour
I’ve just read an entry from a blog called ‘The Secret Doctor’ which is featured on the BMJ. The article was about the ‘armour’ we apparently wear as doctors. The suggestion was that you sort of cope with most of the horrors that you come across at work, but every once and a while something hits you in a weak spot in your armour and manages to upset you. I can probably count on one hand the times I have genuinely cried about something that has happened to a patient. Crying in the toilet because you are over tired, or the charge nurse has once again been a total cow doesn’t count. I'm talking about the really raw, 4am resus calls stuff. About 40% of the genuine sad times have been in the past month in South Africa.
Today I arrived onto the ward and found a new admission in the nursery. A tiny baby who was still completely covered in hair and translucent. I could see all of his tiny veins across his belly. Instantly my good mood turned sour. What on earth was this baby doing here – we do not have the ability to care for a child this small. The baby needs intensive care. If I had a pound for every time I have had that thought since I arrived, well I probably wouldn’t afford very much ICU care, but I’d have a decent amount for sure.
After various scores were undertaken, I estimated the baby had been born about 30 weeks gestation. In the UK you can have a termination up to 24 weeks, and in Ethiopia they won’t resuscitate any baby born before 28 weeks, so you can imagine how small he was (the normal pregnancy lasting 40 weeks). I whipped him onto the scales and he was a grand total of 1200g (2lb6oz). Heart sink. Not a chance this baby was going to survive.
When he had been born, the doctor on call called the referral hospital to have him transferred – no beds, call back tomorrow. I called back approximately 3 minutes after I clapped eyes on the baby. The consultant didn’t answer all 4 of my calls. The registrar didn’t answer. Another number told me to call the first person, and finally the fourth doctor told me he wouldn’t be accepted without an XR, though couldn’t explain why.
I ran along to organise the XR. I then got distracted by a woman in premature labour. I scanned her and was able to estimate her baby was about 2.4kg. Chunky enough for me to manage here – I’m not going to stop and focus on the obvious – what business do I have scanning and measuring unborn babies, because that’s just the way it is – either I scan them or no one does. I’ve been reading and practising and praying a hell of a lot that I get things right. Finding a femur on ultrasound is about as easy as getting a CT scan on a Friday at 1630 when the radiologist has a stick up...anyway, I digress.
The premature baby was holding his own and I went to get lunch. When I came back after he wasn’t in his cot. I ran to the resuscitaire in labour ward where he was being bagged (having air pushed into his lungs by one of the nurses because he obviously wasn’t breathing by himself). Over the next two hours the baby continued to have apnoeic episodes – he would stop breathing from 30 seconds to 3 minutes. I called several other doctors for help, they all left pretty quickly after arriving – there was nothing to be done. I phoned the referral hospital who said if he could get to them, they would accept him for intensive care. The referral hospital is 3 hours away by ambulance. I spent 14 minutes ( I timed it) trying to get through to ambulance control. Eventually they confirmed an ambulance could come. If the baby stayed with me, I would have to bag him continuously and there was no guarantee he would ever become strong enough to breath independently. Like my last baby, he needed a ventilator until he was bigger and stronger. If he went in the ambulance then he might die en route, but he might make it and get to the holy ventilator at the other side. Selfishly, I pushed for transfer - I don't want to watch him die.
Not so fast.
A two month old baby in the paeds ward had contracted acute epiglottitis – a life threatening infection which is more or less unheard of in the UK due to vaccination programmes – this baby hadn’t had hers yet. She needed to go to the referral hospital. The ambulance had space for one baby, I desperately tried to let my head rule my heart which wanted to run away and pretend this wasn’t happening. A previously well child with a reversible infection trumps my baby every time. But what a horrific choice. One of the other docs told me he wouldn’t be able to make the call.
I sent the child with the infection. I still feel like a monster.
I headed back to labour ward. A mother in the corner, behind my baby on the resucitaire was delivering – she had meconium stained liquor. The baby was in distress and had passed the sticky substance from it’s bowels. Babies die in Africa everyday because of the infections it causes. I quickly set up to resus this baby. The baby was born and didn’t cry. I threw a pair of gloves on and scooped him up. His skin peeled off in my hand. The baby was dead. He had been dead for a while. I tried not to vomit – not at the decomposing baby, I’m used to that here. But at just how awful my Monday had become.
The premature baby continued to have apnoeas. I bagged his lifeless body on and off for another hour. An ambulance arrived – it was absolutely futile. He had now been hypoxic for too long and was not making any respiratory effort. I passed him to his mother who had watched me try and resuscitate him for several hours.
I went home at this point. My shift had ended, and my armour had all but disintegrated. On the way out one of my teenage antenatal patients pulled me aside.
‘Doc?’ she said,
‘I have to write my high school exams in three days time, my principal said I can come, I have been writing my English. Please can you give me a C section and bring the baby early?’
I really need to find my armour.
Comments
Post a Comment