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Louise Kenny’s longest night

30 Sep, 09 | by BMJ Group

Before I arrived here, I was concerned about quite how bad my first on-call could be given the new environment, the language, and the vastly different presentations that I could see.  I’d done my homework, I knew that Guatemala ranked highly in both maternal and infant mortality rates, but I’m not sure I’d taken the time to consider how I might personally react to an horrific on-call.  The transfer of a numerical statistic to human contact is a difficult step to take.

I’m struggling today, after my 4th on-call, as the last 24 hours have been both eye-opening and devastating.  Emily, a 4th year medical student, and I, were on shift from 7.30 yesterday morning until this morning.  The day started badly when I put a carton of milk in my bag. Never put milk in your handbag.

We spent the day calmly seeing a few minor ailments, playing scrabble and repairing my milk-sodden ipod.  Until about 7 in the evening when a family turned up with a dusky, unconscious, grunting 1 month old with saturations of about 40% and a tense, swollen abdomen.  His pupils were fixed, his jaw rigid, and his body floppy.

It was quite clear from the word go that this was a fading-fast situation and we rang the paediatrician for help.  “Run, we’re bagging and masking him.” Despite every effort with airways, fluid and antibiotics, we could do nothing but place him into his grandmother’s arms to die. 

The history was confusing. The grandmother told me he had suddenly become unwell just a couple of hours before. The mother said he had been grunting during the day and so they had taken him to the doctor.  When we undressed him, his body was covered in herbs, the doctor’s apparent cure for his ailment. 

We sat with the family and tried to answer their unanswerable questions.  There is no reporting or investigation of deaths here, and so the family left for their home with the body.  As they prepared to leave, the guardian added up their bill.  Here is your child, and here is the bill.  Less of a shock for the American doctors amongst us, although still gut-wrenching.  Much more of a shock for us used to just filing paperwork, making tea, and offering condolences after a death.  I had never before thought about how much it costs to try to save a life, and how much it costs when everything fails.  Turns out its 119 quetzales, or about £9.

It was almost a relief to see an exacerbation of COPD and a patient with diarrhoea after the family left.  Gateshead taught me how to deal with an exacerbation of COPD in my sleep, and the mind-numbing distraction meant I had little time to dwell.

At 7.30 in the morning, a familiar face turned up.  As seems to be the case fairly regularly, we didn’t have an obstetrician last week and so it was left to us to run the ante-natal clinic.  I saw a 27 year old who was almost 9 months pregnant.  She was well, had no abdominal pain or bleeding.  Her BP and sugar were normal and the baby was moving, with a heart rate of 150.  She had been scanned a month before, and the obstetrician at the time had documented her due date as 3 days from when I saw her in clinic.  I organised an appointment for them to see the obstetrician the following week but advised them to return should anything happen in the meantime and we would organise transfer to an obstetrician if necessary for delivery.

She hadn’t felt the baby move for 3 days when she arrived this morning and when the obstetrician arrived within a few minutes there was no heartbeat on USS.  She delivered a term stillborn girl after induction with misoprostol.

Despite long discussions with the obstetrician, I can’t dispel this dreadful, heavy feeling of responsibility.  I can’t stop thinking about what else could I have done in the clinic.  I have been reassured that there is nothing more I could have done in this environment, especially with my minimal background training in obstetrics.

It turns out, that for some reason the previous obstetrician, who has now left, changed the estimated date of delivery based on a late ultrasound and that this lady was perhaps at 41 weeks when I saw her in clinic.  Maybe if I had questioned his dates I would have thought about the risk of her being overdue.  Perhaps if there had been an obstetrician they would have picked up on some subtlety that I may have missed.  All I had was the report of an obstetrician telling me to wait a few more days, alongside a well woman and a live baby. 

It;s one of the problems with having such a transient workforce here, there is little by means of continuity of care.  I picked up her notes and read a scan report suggesting that she was 39 weeks, examined all parameters within my capabilities and reassured the patient.  There is no option to bleep the doctor who assessed or scanned the patient and say: “Just to double check, is this what you meant?”

We are all reliant on the skills, expertise and documentation of other professionals who we have never met or had the opportunity to gauge against our normal expectations.  I know of consultants back home who remain dubious about the opinion of other senior, highly trained specialists after working alongside them for many years.  I’m not sure how to approach a situation in which I can’t form an opinion of the professional upon who I am relying to provide me with essential information.  Should I trust no-one?  As I am unable to double-check foetal ultrasounds, should I not take responsibility for antenatal patients?  There is a discrepancy between my skills from back home and my responsibilities here. It is a challenge to care for patients knowing that I cannot provide the same service that they should receive.

We’ve talked about it plenty since and amongst all the doctors here there is a feeling of always having to work outside of your experience, and do things that you would never do unsupervised back home.  The paediatrician, a resident from the States, is doing ketamine sedation for children for procedures, and told me today that she would never do these alone back home.

When asked to do the antenatal clinic, I explained to the staff my lack of experience, but the expectation, and reality remains, that in this setting I’m better than no one.  After my night I’m suffering the wretched, self-absorbed feeling that anyone would be better than me.  Is an inexperienced doctor better than no doctor at all?

Louise Kenny has completed F2 year in the Northern deanery and is now working in Guatemala.

The patients’ consents were obtained for this blog.

 

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  • Jules

    Wow. It is an amazing story. I am just a student at the moment, and I have to say that some of my colleagues do not realise that as doctors they will have to face a lot of pressure, confusion and that they will need to take responibilities for their actions. I wish they all read your story.
    I think you could not have done more than you did, and yes unexperienced doctor is better than no doctor! This is the real world. In the UK we are used to having free healthcare, our cosy hospitals (at least most of them) and still loads of people manage to complain about the doctors, about the standards. Yes, we all make mistakes sometimes, but lets face it- in places like Guatamala people simply die, as they cannot afford to go to a hospital; which even with unexperienced doctors are thier best chance of survival.

  • Dr Katherine Sevar

    Hi Louise, whilst I think that your decision to work in the developing world is in many ways commendable I believe the question you ask at the end of you blog is worth taking time to consider.

    Life is life and just because it is lost more often in a certain country does not make it any less precious, or the degree of loss felt by the remaining family, any less potent. Asking whether through inexperience you may contribute to that loss of life is a question worth asking and I acknowledge, a very troubling one to consider.

    If you were to return to work in the developing world then I would suggest you had at least 6-12 months experience in both paediatrics and obstetrics because this is the bulk of the workload on-call, even if your job is only technically meant to be in general medicine. The diploma in tropical medicine from Liverpool/London would also be extremely useful. You probably already know these things, and maybe you’ve already done them but if not it would be great a great idea for you as it is just horrible to feel out of your depth and although there’s no way of guaranteeing you’ll always make the diagnosis, or commence the correct treatment, these placements would give you a good framework.

    Whilst working in this position allows you to use all the skills you currently possess, and bring in skills from the UK, what will remain when you leave? Is there a programme of education for the Guatamalean staff? Does your working in this position as a foreign national allow the government to continue to not pay, or not provide conditions in which it’s own doctors are encouraged to remain in Guatemala, or work in the hospital system?

    I’m not suggesting I have the answers to these questions but I do believe they are worth considering, as reflecting upon them could inform the rest of your time there and any further decisions you make about working in the developing world.

  • http://BMJ Leanne

    Louise I am a consultant obstetrician in UK and just want to reassure you that you did all you could. You did not have the appropriate information and the person who scanned her did not pay attention to detail. It is commendable that you are reflecting, asking questions and thinking about what you could have done differently. This is a case you will never forget and you have learnt something in the process – 1) always ask the woman her expected date of delivery (she may not know, in the UK they do – believe me) and 2) the NHS is pretty special…..
    Good luck

  • Just Athought

    Louise, thank you for sharing your story. I think it is unfair for you and the patients involved to be put into this situation from the start.

    The question is not weather an inexperienced doctor is better than no one. As the only answer to this issue, based on any minimal justice, is that these sick people deserve a fully qualified doctor treating them and nothing less.

    There is a problem with the UK medical system that it encourages medical students to go to such places and “get experience” with no adequate supervision.

    The obvious solution to this is to make it compulsory for all fully qualified consultants as part of there job requirements to work in such places, even if it’s perhaps “less convenient” as it’s at a later stage in the medical career ladder. Don’t you agree?

  • Dr Muhammad Wahedi

    Response to “Louise Kenny’s longest night

    Its great when you feel you require to know and do more and can’t do enough but see people dying. Its the situation in many parts of the developing world , where people has no other way but except accept death because born in a developing country; ruled for years by many developed countries and also being ruled now by many rulers supported by the developed.

    In bangladesh 80 % of treatment is provided by the quacks, healers; traditional birth attendents conduct delivery who never had any institutional learning.Common causes of deathe are preventable. “No doctors” is never a good anwswer than a less skilled , people needs some one do something, atleast try for helping or supporting to survive. I read a writing on the wall of a post mortem when I was in medical school saying , Death Delights the living”. This longest night perhaps will create a place in your heart that you need to think , think beyond your books and classess to be amidst the people of developed world. As a doctor you can do a lot , lot by learning , helping , working among the people who really needs doctor and dying without a doctor.

    I Wish Louise Kenly to go and face more such nights ,and think and do more in these situation. Hope to see your effort to work to face, not to retreat and withdraw. You be there or not , patiens will be there and perhaps will be fighting and dying from non dying disease.

    Wahedi, Bangladesh
    october 1st, 2009

  • Sophie Unell

    Hey Louise,

    I’m a fourth year just finishing up an elective in a little emergency dept in Mexico, and very sympathetic to the 24hr shift situation! I also felt very conscious of my limits in terms of skills and knowledge, and the fact that I’m not a doctor. Med students here have a lot more experience earlier in their training, and a hell of a lot more confidence to take a patient and write up drugs for them whether supervised or not. While I personally wasn’t comfortable with that, I think perhaps in cultures strapped for medics it’s probably normal for medics to leave their comfort zone of experience and ‘go for it’, and if things go wrong it’s put down to the hard school of experience. Any doctor is always better than no doctor, especially when no doctor might mean no doctor for miles and miles and miles. You did your best, and no-one can expect any more than that.

  • louise kenny

    I’d like to say thanks to the response I’d had to the above blog. I’m sorry i t has taken a few days to get back to you all.
    Part of my writing during this job is of course as self-reflection, and to provide a structured log of my experience and response to it. For this reason, I’m surprised to have provoked such replies.
    In response to Dr Sevar – thanks for the advice. You are of course right that obstetrics and paediatrics make up a large bulk of the work, and without a doubt a job in obstetrics prior to leaving the country would have been ideal. I didnt have the opportunity to select my choice of jobs in the 2 years since I graduated, it was an ‘out of the hat’ pot luck, with obstetrics being one of the most popular choices. The jobs I did do have undoubtedly come in useful, but I think one of the failings of foundation training, or at least in the trust I worked at, is the lack of flexibility to experience a certain field, except fot he 10 days of ‘taster courses’ offered.
    I have always wanted to work in the developing world – in is in fact the reason I went into medical school, but I think the training in Britain is lacking in facility to train for such jobs – without becoming a GP trainee, or opting out of a training program and taking stand-alone posts, it would not be possible for me to work OB+GYN and paediatrics for extended periods of time.
    I understand this is for logical reasons in the UK (so we don’t all leave!), but it is a shame for those of us wanting to work in a slightly different field.
    Is there anyone who feels they have received adequate training for a job such as the one I am doing now? and if so, how did they achieve it?

    Leanne- thank you, kind words. And yes you are right, I have certainly learnt from it, although the difficulty frequently arises here that women simply do not know the date.

    Just Athought – interesting. I do agree that people here deserve only a ‘fully qualified doctor’, but where do you draw the line? There is a limit to what can be provided in this, and other developing countries in terms of training, and a ‘fully qualified’ Guatemalan doctor, refers to generalised training, much like the level reached after foundation school in the UK. I have been a doctor in Britain for 2 years. While every job I have worked, I have always had seniors to supervise, I also have seen many patients and made decisions regarding their care without supervision.
    The UK medical school I went to was keen on encouraging students to gain experience during electives, but was also insistent and strict regarding supervision of students in such placements. We have a number of medical students here at the hospital, from the UK and USA, who are closely supervised and always work with a qualified doctor in clinic or in the A+E. Likewise if we have problems regarding a patient, there are 3 senior Guatemalan doctors who are, for the most part, available to consult. The failing here is a lack of specialists.
    I’m not sure I could agree that it should be compulsory for consultants to work abroad once fully qualified, would that not be forced labour? I believe that it has to be a personal choice to move to another country to work, even for a short period, especially one which may not be deemed ‘safe’ by international standards.

    Dr Wahedi – thanks you for your support. While I hope not to face such long nights again, I have no plans to withdraw. You are right that here, as in situations back home at times, is far beyond books and classes, and I am learning to think on my feet and use resources wisely.

    Sophie, your final sentence has given us all a bit of a lift. Perhaps the problem is that I expect more than that? and that I feel the people here deserve more than I can offer?

  • Tom Nolan

    Hi Louise. I’ve always been quite sceptical about the value of relatively junior docs (like me) working in developing countries because of the reasons discussed above. However after reading your blogs I think I’ve changed my mind. You’re clearly doing a lot of valuable work.

    I’m really enjoying the blog and look forward to future posts!

  • Josh Brostoff

    Hi Louise,

    You did well. I also worked in Guate (small hospital on the shore of Lake Atitlan) for a little while, albeit a few more years into my career than you. I wish that I had done even 3/12 of O&G, as my med school in no way prepared me for doing solo clinics and deliveries. And nor would I expect it to.

    Yes, an inexperienced doctor – who is aware of their limitations – is definitely better than no doctor.

    Keep up the good work, and if you happen to be at Hospitalito then send my regards to Dr Chuc,

    Josh

    PS
    As for the comments by ‘Just Athought’ – how do you propose to force consultants in the UK to work in the developing world? As for it being ‘unfair’ to Louise and to the patients – dude, what are you on??? Your comments betray either a touching naivete or a massive reality gap with what the world is like.

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