Tuesday, June 15, 2010

Know Your Limits

One of the most important things any resident learns is to know their limits. Some people don’t learn that lesson, and they are scary. But most of us learn it.

First and foremost, we are taught that in an emergency, you need help. You can’t do it alone. Even if you know what you are doing, you need another pair of hands there, just in case. It is the first thing taught in CPR classes, and it is the first thing every intern should learn.

When I was an intern and working with a team I liked, my chief resident and attending challenged me with a hypothetical scenario one night on call. “Your attending and both senior residents are upstairs in the main OR, and you are on the labor floor alone. You are watching the fetal heart rate tracings, and you see a deceleration. You call us, but can’t each us. The deceleration goes on and on. You try to resuscitate but it doesn’t work. The baby is going to die. What do you do?”

I thought about it, slightly panicked, both over the hypothetical scary situation, and the desire to get the right answer in front of my chief resident and my attending.

As I thought it through, they pushed me more: “Do you go ahead and do the c-section? You have nurses here.”

Could I actually do that? I had only done a few c-sections, I really didn’t feel comfortable. I cringed and answered honestly: “No?” Were they going to laugh at me?

Both of them smiled. “Right. You don’t do it. Because you could kill the mother. That baby might die, but you have to keep trying to get us, even if you have to run upstairs to the main OR and drag us down.”

Later, when I was a chief resident, I designed a lecture for the incoming interns on how to handle obstetric emergencies. In order to help them remember what do to, I created the three C’s: Call for help, Call for help, Call for help. They laughed as we reviewed it on the powerpoint slide, but it stuck with them. (Laughter is the best mnemonic.) Later, when working with one of the interns, I was pimping her on the maneuvers to relieve a shoulder dystocia. “What’s the first thing you do?” I asked. I was looking for “Put the patient in McRobert’s position.” Instead, she smiled and said “Call for help, call for help, call for help.” (Excellent!)

Many times in Uganda I have been faced with situations in which I almost had to decide whether I would do something I am not comfortable with or experienced enough to do.

I have often written here about things I have done here that I had “never” done before – but in reality, they are variations on things I have done before. The cornual ectopic, the abdominal pregnancy – those are situations that I haven’t actually seen, but had been well-prepared for in my training. In fact, I had never even operated on an ectopic pregnancy through a laparotomy – only laparoscopically. But I had done ectopics, and I had done laparotomies, so it isn’t a far stretch to put those two things together into one surgery.

But then there were situations that were less clear. On occasion, I have suspected a patient might have appendicitis. Would I be able to do an appendectomy? I have done quite a number of appendectomies in patients with cancer and it was actually remarkably simple – but their appendices were normal. Would I be able to do the same in an infected, inflamed appendix? I don’t know. Fortunately, none of the patients ever turned out to have appendicitis.

One day, I walk into clinic and see a wheelchair in the hallway (those are rare around here), and a hospital nurse inside one of the patient rooms. There is a young boy lying on the exam table, and an anxious-looking man sitting on a chair – the boy’s father. P, one of the study doctors, is examining the young boy, and asks for my help.

He tells me the situation. The boy is 12 years old. Two days ago, he fell off a bicycle, and the pedal punctured his abdomen, and his intestines came out. He was taken to a Level 3 Health Center, where they pushed the intestines back in, and stitched the hole closed. Since then, he has not passed stool or flatus, and he has severe abdominal pain and fever.

On exam, the boy looks terrible. He looks weak and dry, his eyes are sunken and he is clearly in pain. On the left side of his abdomen, the skin over the injury had been bunched up and stitched with silk suture – which needs to be removed at some point. When I palpate his abdomen, it is obvious that he is extremely tender everywhere, although too weak to make a lot of noise despite excruciating pain. There is also the distinct crackling sound of crepitus when I press on his abdomen. I try to do an ultrasound, but I can’t see anything and it causes him even more pain.

P and I consider the situation. When an abdominal injury causes the bowel to come outside the body, it is called an evisceration. In that case, not only the skin has to be sewn closed, but the fascia (the firm white internal sheath that holds in the intestines and abdominal contents) also needs to be closed. Did they close the fascia? We don’t know. In addition, once the intestines are exposed to the outside, there is a high risk of infection. He is on antibiotics, but the coverage is insufficient (which is ironic, because usually they give extremely broad coverage for every non-bacterial ailment here).

P and I agree that the boy needs an exploratory laparotomy. But who is going to do it? Neither of us is comfortable with extensive bowel surgery. It is hard to know exactly what we will find once the abdomen is open. There is a strong chance that the boy might need part of his bowel resected and re-anastomosed (reattached), or even a colostomy.

At home, I would call general surgery to see the patient immediately. Even if I didn’t expect to find a bowel injury before operating, I could call an intraoperative general surgery consult, and they would be there within minutes.

There is a regional hospital an hour away in Mbale that is much better staffed and equipped, and even has specialists. But if we send him there, will he make it? He would have to go in a matatu – I cringe just thinking about this poor kid suffering through a matatu ride in his condition. I can barely tolerate them when healthy. In addition, if he makes it to Mbale, will they treat him, or will they ask for a bribe first? His father looks extremely poor. Will referring him there be a death sentence?

P and I discuss the options. It’s possible that one of the two doctors here is comfortable with bowel surgery; they have seen it all. I try to call both, but their phones are off.

Plan B: There is an orthopedic surgery camp taking place in the theatre all week. Some consultant orthopedic surgeons came from Mulago Hospital in Kampala to work on children with orthopedic deformities. Possibly one of them might be able to assist with bowel, even if we open up the abdomen first.

I dash over to theatre to ask them. They are very nice about it, and agree that the boy needs a laparotomy. Still they are vague about their exact comfort level, and how much they would be able to help. They tell me to bring the boy. I’m not sure about this, but it might be his only hope. I don’t know.

I head back to the clinic and tell P what they said. “Dr. Veronica, I am not in,” he says.

He is right. We have no sense of whether the orthopedists would be able to help us, we have no other backup, and none of us are comfortable doing this. If we open his abdomen, we could kill him.

On to Plan C: Transfer to Mbale. I know that the hospital has an ambulance, and there might even be fuel in it. If we can transfer the boy in the ambulance, that might increase his chances of making it there, and of getting treated. I call the Senior Hospital Administrator, but his phone is off. I walk to the administrative offices of the hospital to find him, but every door is closed. What’s going on? It’s a Wednesday. Then I realize that it’s a national holiday, and everyone is gone.

As a last resort, I call the Junior Hospital Administrator, a young man who has always been friendly and helpful. He answers. He is around the hospital grounds. I tell him that I need his help with an emergency. “I can be there in 20 minutes. Is it OK?” It will have to be.

10 minutes later, I go to check in on the boy, but the bed is empty. Where has he gone? I find P, and he tells me that Dr. W, one of the hospital doctors, showed up on the ward, so they took him back to the ward to be evaluated by Dr. W, and possibly operated on. I am greatly relieved. I like Dr. W very much, and if he is able to operate on the boy, then he will be OK. I try to call Dr. W’s phone, but it is still off.

The Junior Hospital Administrator finds me a few minutes later. I explain the situation and tell him that things are probably OK, but that if the boy needs to be transferred, I will call him again. He explains that the ambulance is available and has a driver, but no fuel. If we can provide the fuel, then we can send the boy.

Sigh. The usual. I know that if the boy needs transfer, we will find the money for fuel. Maybe we will use money from the poor patient fund, or my own money, or whatever, but I will not let this boy die for lack of fuel. I thank the JHA and tell him I will contact him if the boy needs to be transferred. I don’t hear anything that day, so I assume that Dr. W was able to operate on him.

The next day, I decide to find out what happened to the boy. Dr. W’s phone is still off. Since the boy is 12, he would not be in the pediatric ward. There are so many patients admitted aged 5 and under that the huge pediatric ward is filled with them alone. Children over 5 years are admitted to the adult wards (if they are still quite young, then they are admitted to the female ward with their mothers). He must be in male ward.

I go to male ward, and scrutinize every patient there. It isn’t very hard, because there are no young boys. I walk through the entire ward, but I don’t see him. I find two nurses and ask them for help. I explain the situation. One of them goes out to the ward to announce the type of patient we are looking for (which would have been kind of funny if I had not been really worried about this kid), while the other one helps me search each bed.

The boy is not there. Both nurses agree that they have never heard of such a child, but there is nowhere else he could have been admitted. Disappointment.

I go back to our clinic and mention this to P. He tells me that the boy is in Mbale. Apparently, one of the other study doctors has an aunt who is sick and admitted in Mbale, and he went to visit her there. While there, he happened to see the boy, who was waiting to go into surgery just then.

I am relieved to hear that he made it to Mbale. I know that we did the right thing – if we had operated, we could have killed him. In my desire to save the boy, I considered it briefly, but it would not have been the best thing for him. The study doctor who saw the boy knows the surgeon who was going to operate, and promised me that he would find out what happened. It was hard to let go of a patient not knowing whether someone else would be there to help him. I will feel much better once I know the outcome.

1 comment:

Clare B said...

Love the new layout V. Looking forward to seeing you in a few weeks too. You did the right thing. You're a women's doctor, not a 12 year old boy abdomen doctor. Even in Uganda