Access thebmj.com - The BMJ logo

Louise Kenny’s drawer of misunderstanding

A few years ago I lived in a flat with a dear friend Hannah, who like me is a collector of junk and disastrous at keeping things such like wires, lids, buttons, remote controls where they should be kept.  

For example, I would ask: “What does this cable do?”

Hannah: “No idea, but maybe we need it?”

And so was born “the drawer of misunderstanding.”

I’ve been working as a doctor at the Hospitalito Atitlan now for just over three months and I’m beginning to reach a point where I feel somewhat overwhelmed by it all. I have so many interesting cases to write about and so much clobber in my head but never enough time to sit, reflect and compose an article that makes sense.  It feels like I’m living in the drawer of misunderstanding.

I’m surrounded by a jumble sale of half formed ideas and suggestions.

Partly this is because of the frustration of working in a resource depleted area, and the constant nagging question: “What can I do to make this better?”  Every patient who requires a transfer either for investigation or treatment is a complicated, multi faceted negotiation which leaves me feeling a failure for not being able to provide the necessaries here.  Every such interaction begins with an apology: “I’m sorry but we can’t deal with this here, you need to go somewhere else.” 

While we do make the arrangements, the family always has to foot a bill for the care that we cannot provide, either by paying for a transfer or for investigations.

Then there is the baby with bad lungs, the man who got hit by lightning, the cyanobacteria in the lake, the daturi poisoning and all the other stories that I’m desperate to tell but have no time to get down on paper.  Someone tell me which one to start with!

At the same time, I’m trying to focus on December 18.  This is the closing of applications for specialty training, and what do I want to do?  I wake up every morning with a firm 65 words in my mind, subsequently followed by a completely different 65 the next morning.  Sixty five words, really? What’s a girl to do with 65 words?

None of this has been helped by the fact that it has been a particularly difficult two weeks due to some complicated obstetric cases.  As I sat outside Roosevelt hospital in Guatemala City two days ago eating fried chicken after transferring someone who had suffered a respiratory cardiac arrest on the operating table I realised that if I had my passport on me, I wouldn’t look back.

One of the main problems with a hospital that is predominantly staffed by short term volunteers is the differences in both individual and international practice.  While each new arrival is given an orientation manual, shown around and given the opportunity to ask questions or ask for assistance whenever required, sadly it is often not until a crisis arises that the new doctor realises quite how disorientated they are.  As doctors, we are trained to make decisions and act quickly, but our conclusions and actions in the western hospitals we train in are often not transferable to the developing world health care system.

In the last week we have had two emergency c-sections.  The first for a pre-eclamptic pregnancy. The patient arrived at the hospital with no pre-natal care, hypertension, edema, proteinuria and labouring.  Decelerations and eventual loss of foetal pulse occurred due to placental abruption and sadly despite rapid sequence induction, intubation and surgery, the baby could not be resuscitated.  The second case was a breech baby with late and sustained decelerations to 60bpm.  The obstetrician made the quick decision to proceed to emergency surgery.  Despite a pro-kinetic at induction and cricoid pressure, the woman vomited and aspirated.  She became extremely hypoxic while we fought to suction, intubate and ventilate.  Equipment here is frequently a collection of donated goods, and therefore often does not fit together precisely.  By the time we noticed the oxygen attachment had fallen loose of the ambu-bag, explaining her profound hypoxia, we had started advance resuscitation to regain a cardiac output until her saturations were adequate.

Post-operatively the decision was made to transfer her, intubated under propofol to the nearest hospital with an Intensive care unit rather than run the risk of extubating her to discover respiratory failure and have to reintubate.

I’ve think I’ve already talked about the difficulty of transfers here (or is that one of the half-written articles?), given that the “ambulances” are minivans with no equipment, and the road to Solola is a nauseating, hair-raising rollercoaster.  Despite being as prepared as we possibly could, we only managed 20 minutes of the 90 minute journey before we hit a bump, lost both IV access points, and the top of the oxygen tank broke clean off.  Of course without IV access, we had no way to keep her under, and had to extubate in the back of a mini-van with a syringe and tube for suction, and no oxygen.  It seems unreal when I think back to it.  Having now intricately dissected, and reflected upon the situation with all of our staff, I’m now trying not to think about it, and to move on.

While we returned to the hospital, the decision was made amongst the directors to arrange a helicopter to Guatemala City, a resource I had not been aware of before.

Once the patient was restabilised at the hospital here in Santiago, we left.  I explained to our now awake and communicating patient, that we would not be able to hear her in the helicopter, and that she should squeeze my hand if she needed anything.  Thankfully she remained stable throughout the journey.

We arrived in the City hospital to be greeted by hostility.  Outside the hospital was a paramedic checking his watch and lazily bagging an intubated and unmonitored woman who appeared to have been stabbed or shot.  The corridors were full of patients in several stages of consciousness on trolleys and staff seemed hard to come by.  I don’t suppose it’s any surprise that when we did find the doctor contacted prior to leaving Santiago, she wasn’t too friendly or interested at our pushing more work her way.

The happy ending to this story is that both mum and baby girl are recovering well. However the reality of the situation, is that we are all left feeling, that while complications occur everywhere in the world, and are at times unavoidable, a crash c-section perhaps shouldn’t have done in a place where complications cannot be managed.  And where the choice has to be made, an intrauterine death is always preferable to a maternal death.  There has been much discussion about this, and one of the issues stems from the difference in aggression of treatment, and the different attitude toward loss of fetal life.  As an American or British obstetrician, it would be unacceptable and unheard of to stand back and allow a term fetus to die where intervention was possible.  As our obstetrician here said, as far as she is concerned, she has two patients to treat, and the loss of either is a failure of her work.   There has been a lot of confusion as to the opinion of the permanent staff but the general feeling is that a less aggressive approach should have been employed.  This would have resulted in a dead baby, but likely avoided the maternal risk and consequent events.  It has since been suggested that a protocol or guideline be drawn up for new staff regarding such emergencies, so that nobody is left to make the decision in the crisis minute whilst watching foetal heart rate drop.  In such a situation, the instinct instilled in us doctors during our training takes over, and the automatic stance is to take action.

It is never black and white, and there will be situations where a c-section, or some other emergency intervention is the only option despite the risks involved due to anaesthesia, surgery or lack of facilities for pre, peri and post op care.  However, at least a protocol would mean that the new, unaccustomed, disorientated volunteer is not left feeling culpable for a decision which may or may not be in accordance with the local medical culture.

There is a term here “cabeza fria,” which literally means “cold head” and refers to those who are new to something.  The morning after the dramatic events this term was thrown around the table plenty in way as an explanation for the disparity of opinions as to what should or shouldn’t have happened.  Given the difference between how volunteers and locals react in a certain situation, I wonder whether “cold heads” should be in a position to make decisions.  Because, as with any disorientated hiker without a map or guide to explicitly tell us to turn round or even just to stop, we will always keep plodding in the direction we recognise or which seems right based on experience.  Of course this means that at times in our endeavour to do the right thing cultural boundaries are going to get trampled on, which makes for an uncomfortable and regretful situation all round. 

Part of me feels that given both mother and child survived, perhaps the ‘cold-head’ made the right choice.  Part of me feels that those more accustomed to this environment, and who clearly know the limits of both culture and safety, should be regarded as gospel.  It’s just sad that it takes a desperate situation to highlight the disparity, to force the boundaries to be clearly defined, and to prevent them being breached in the heat of the moment.

I’m hoping that when I leave Guatemala, I might have been able to rearrange a few of the mismatched ideas both around me and in my own head and turn them into something positive.  I’ve started small and rejigged the oxygen tubing, and fixed up a second suction machine.  Small steps.

When Hannah and I moved out of our flat, we couldn’t face the impending doom of opening the drawer of misunderstanding.  To this day perhaps it is still crammed full of the cables we spent the last few years looking for and never knew we needed.  Perhaps, I hope, it made more sense to our landlord than it did to us.

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

The patients’ consents were obtained for this blog.