lifes little adventures

4-10-08 warning!… medically explicit material. So let me just tell you how the small insignificant things in life sometimes become larger things when you least expect them to. For those who don’t know we have a puppy. Aldo’s favorite thing to do is chew on my arms. She doesn’t do this to anyone else in the family, just me. I like her so I oblige the mutt, thinking that she will grow out of it and we all like attention even if it’s negative. Harmless, right. Well the result of this playfulness is multiple excoriations on both of my forearms. Those of you who are reading this are asking about now; what does this have to do with his trip to Kenya? Well I’ll explain. So tonight I’m hanging out at labor and delivery and I am summoned to the delivery room where the midwife (we act as consultants to the midwives and interns) has just delivered a patient precipitously (fast) and she now is hemorrhaging. Right about then is where I wish I had one of those Bakri devices that Dr Gamble talked to us about at the conference. So I put on a pair of gloves to explore the lower uterine segment and start to remove a large amount of clots as well as some retained fragments of placenta. I am basically up to my elbow. I look down at my arm only to see that it is covered in blood. Now you know where I am going with this. Those cute little puppy bites which have not completely healed are covered in blood. I then get the bright idea and ask the midwife about HIV status of the patient. "Don’t worry "she says with a big smile, "she is negative", then she seems to casually mention that the husband is positive..…. remain calm…..clarify the question, maybe there was a miscommunication…..no the husband is positive... "well how do you know the patient is negative," I ask will trying to control my anxiety. "She was tested at the beginning of her pregnancy," says the nurse still grinning. I wish she would stop grinning. So here I sit, midnight, waiting for her rapid HIV test. And don’t worry, I’ve already reviewed the post-exposure prophylaxis in Sanford. I’m so glad I thought to bring that little book.
While I’m waiting for report on that patients HIV status I’ll also tell you my first cesarean section experience here in the developing world. The victim, I mean patient, is 27 years old primiparous female who arrests at 9cm dilated. She is taken to the “theater”, that is what they call the O.R. here in this former British colony. Spinal anesthesia is administered. I then scrub, with soap and water, no scrub brush, just soap and water. I move into the “theater” where I proceed to put on a reusable gown that is probably left over from the Lister era (19th century). It practically disintegrates as I pull it on. Not to mention that I am bigger (read wider) than most Kenyans so I’m pretty much bulging out of it. We then prepare and drape the patient with multiple reusable sterile towels, more on this later. Then, I don’t know if it’s their practice, as this is a mission hospital, or if it was their lack of confidence in me, but before we started the “theater” circulator asks if we can pause to pray. Hey I’ll take any help I can get. The cesarean pretty much is going according to plan until we get to the uterus and come to find out the suction has stopped working. Remember the sterile drapes? Reusable ones don’t seal. Therefore as the uterus is entered the combination of lack of suction and non-seal drapes results in amniotic fluid spilling everywhere, and I mean everywhere. We are practically swimming in it. So the boy is delivered and then the fun begins. She starts to bleed, and I mean bleed. No suction means very difficult to see anything, they also use reusable laps (towels). I now know why we don’t use these in the states. After something has been washed and sterilized a couple hundred times it loses its absorbent capacity. So basically I can’t see a thing. The problem stems from the fact that the patient is found, upon exteriorizing of the uterus, to have a bicornuate (two horned) uterus. An obvious predisposing factor in uterine atony and subsequent postpartum hemorrhage. Well the long and short of it is thanks to some pitocin and hemabate and not in any small part, I'm sure to that initial prayer we got her uterus to contract down, closed her up and she is now doing well.
Page goes off at 2 am. The nurse at the other end informs me the patient is negative…ah, now I can sleep...