Louise Kenny’s longest night

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.