Furrowed Brow

A fellow Einstein resident used to point out with amusement that when someone would say something inane or incomprehensible, I (apparently) would make an expression of confusion consisting of a furrowed brow. Yesterday was the day of the continuously furrowed brow.

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I arrive on labor ward yesterday.

MIDWIFE: Hello Doctor! Maybe you can come and review this patient. She has cervical prolapse. We were going to refer her to St. Anthony.

We start walking toward Antenatal Ward.

ME: Cervical prolapse? I can see her. But why is she on Antenatal Ward? Is she pregnant?

MIDWIFE: 32 weeks.

MY INNER THOUGHTS: Cervical prolapse in pregnancy? Can that exist? Is this one of those Only-In-Africa things? How am I going to manage this? Who can I email for advice? Oy.

At the midwives’ table, I meet a medical student, who says he is a fourth year student. Medical students here do clinical rotations twice – once in third year and again in fifth year. In my experience, they are generally much stronger than American medical students because so much is demanded of them. So he should know something about Ob/Gyn.

The patient is sitting on a bench. She is sent to her bed for me to examine. The nurse brings gloves.

I look at her external genitalia, which are normal. I don’t see a prolapsing cervix.

ME (to the student): Where is the cervix?

MEDICAL STUDENT: It is inside. Examine and you will feel it.

ME: Inside where? Inside the vagina?

MEDICAL STUDENT: Yes.

ME: (Furrowed brow)

ME: Then how is it prolapsed?

MEDICAL STUDENT: (Silent confusion)

ME: What was her presenting complaint?

MEDICAL STUDENT: She came in with APH [Antepartum Hemorrhage]

ME: She was bleeding?

MEDICAL STUDENT: Yes.

ME: Did you do a speculum exam first?

MEDICAL STUDENT: No.

ME: So she was bleeding and you put your fingers inside?

MEDICAL STUDENT: Yes.

ME: (Furrowed brow)

ME: When did the bleeding start?

MEDICAL STUDENT: 5 days ago, when she arrived.

ME: She’s been here 5 days, bleeding?

MEDICAL STUDENT: Yes.

ME: (Furrowed brow)

ME: Is she still bleeding?

(Discussion in Japadhola)

MEDICAL STUDENT: No, but the water.

ME: Water? What water?

MEDICAL STUDENT: The water was still coming, but now it’s not.

ME: When did the water start coming?

MEDICAL STUDENT: Before the blood. The same day.

ME: So she’s been leaking water for 5 days?

MEDICAL STUDENT: Yes.

ME: And you put your fingers inside?

MEDICAL STUDENT: Yes.

ME: (Furrowed brow)

me: She has water leaking. What does that make you think of?

MEDICAL STUDENT: (Silent confusion)

MIDWIFE (shouting from outside curtain): Ruptured membranes!

ME: Exactly, ruptured membranes. So examining her could cause infection, or could cause her to bleed if she has placenta previa. Ok, I can’t do an exam. I need to do a speculum exam.

MEDICAL STUDENT: There are no speculums.

ME: What do you mean, there are none?

MIDWIFE: They are not sterile.

ME: Ok, let’s put them in the autoclave.

MIDWIFE: We cannot use the autoclave.

ME: When did it break?

MIDWIFE: It is not broken. We cannot use it.

ME: Why not?

MIDWIFE: There is someone sleeping in that room.

ME: There’s someone sleeping in the autoclave room so we can’t sterilize speculums?

MIDWIFE: Yes

ME: (Furrowed brow).

ME: Who is sleeping in there?

MIDWIFE: Someone.

ME: Who?

MIDWIFE: Someone.

ME: (Furrowed brow)

MIDWIFE: So we cannot use it. So we have no speculums.

ME: (Continued furrowed brow)

MIDWIFE: We can get one from theatre.

ME: Ok, do that.

MIDWIFE: Or maybe we bring her to theatre.

ME: Ok, that’s fine. We’ll examine her there. I’ll go get the ultrasound.

The nurse in-charge arrives.

ME: Hello Sister. I have a question. When will we fix the autoclave?

IN-CHARGE: It is not broken.

MIDWIFE: No, but he is sleeping in there.

ME: Who?

IN-CHARGE: Someone is sleeping in there, so we cannot use it.

ME: Who is sleeping in there?

IN-CHARGE: Well, the cleaner.

MIDWIFE: And he is smelly, so we cannot use the room.

ME: The cleaner is smelly?

MIDWIFE: Yes. (waving hand in front of nose).

ME: (Furrowed brow)

ME: And he is sleeping in the room where we sterilize instruments?

MIDWIFE: Yes.

ME: (Very furrowed brow).

ME: We need speculums. He needs to sleep somewhere else.

IN-CHARGE: I will tell him to move tomorrow.

On arrival in the OR with our ultrasound, I see a kidney basin with sterilizing fluid, half a vaginal retractor, and a ring forceps.

ME: What is that?

MEDICAL STUDENT: That is a speculum.

ME: That’s not a speculum, that’s half a vaginal retractor. Do we have a speculum? Or the other half?

MEDICAL STUDENT: No, we don’t have.

ME: (Furrowed brow)

I try to start the ultrasound.

ME: Is there gel?

MEDICAL STUDENT: Yes, there is gel.

15 minutes later, the medical student and OR tech have searched everywhere.

MEDICAL STUDENT: There is no gel.

ME: No gel.

MEDICAL STUDENT: Well, there is gel, but the anesthetist has locked it in the cabinet.

ME: They lock up the gel?

MEDICAL STUDENT: Yes.

ME: So we don't have gel, and we don't have a speculum.

MEDICAL STUDENT: No, we don't have.

ME: So why did we come to theatre?

MEDICAL STUDENT: (Silent confusion)

ME: (Furrowed brow)