{"id":831,"date":"2009-09-30T10:36:28","date_gmt":"2009-09-30T09:36:28","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=831"},"modified":"2009-10-09T14:35:23","modified_gmt":"2009-10-09T13:35:23","slug":"louise-kennys-longest-night","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2009\/09\/30\/louise-kennys-longest-night\/","title":{"rendered":"Louise Kenny’s longest night"},"content":{"rendered":"

\"\" 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.\u00a0 I\u2019d done my homework, I knew that Guatemala ranked highly in both maternal and infant mortality rates, but I\u2019m not sure I\u2019d taken the time to consider how I might personally react to an horrific on-call.\u00a0 The transfer of a numerical statistic to human contact is a difficult step to take. <\/p>\n

I\u2019m struggling today, after my 4th on-call, as the last 24 hours have been both eye-opening and devastating.\u00a0 Emily, a 4th year medical student, and I, were on shift from 7.30 yesterday morning until this morning.\u00a0 The day started badly when I put a carton of milk in my bag. Never put milk in your handbag.<\/p>\n

We spent the day calmly seeing a few minor ailments, playing scrabble and repairing my milk-sodden ipod.\u00a0 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.\u00a0 His pupils were fixed, his jaw rigid, and his body floppy.<\/p>\n

It was quite clear from the word go that this was a fading-fast situation and we rang the paediatrician for help.\u00a0 “Run, we\u2019re 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.\u00a0<\/p>\n

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.\u00a0 When we undressed him, his body was covered in herbs, the doctor\u2019s apparent cure for his ailment.\u00a0<\/p>\n

We sat with the family and tried to answer their unanswerable questions.\u00a0 There is no reporting or investigation of deaths here, and so the family left for their home with the body.\u00a0 As they prepared to leave, the guardian added up their bill.\u00a0 Here is your child, and here is the bill.\u00a0 Less of a shock for the American doctors amongst us, although still gut-wrenching.\u00a0 Much more of a shock for us used to just filing paperwork, making tea, and offering condolences after a death.\u00a0 I had never before thought about how much it costs to try to save a life, and how much it costs when everything fails.\u00a0 Turns out its 119 quetzales, or about \u00a39.<\/p>\n

It was almost a relief to see an exacerbation of COPD and a patient with diarrhoea after the family left.\u00a0 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.<\/p>\n

At 7.30 in the morning, a familiar face turned up.\u00a0 As seems to be the case fairly regularly, we didn\u2019t have an obstetrician last week and so it was left to us to run the ante-natal clinic.\u00a0 I saw a 27 year old who was almost\u00a09 months pregnant.\u00a0 She was well, had no abdominal pain or bleeding.\u00a0 Her BP and sugar were normal and the baby was moving, with a heart rate of 150.\u00a0 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.\u00a0 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.<\/p>\n

She hadn\u2019t 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.\u00a0 She delivered a term stillborn girl after induction with misoprostol.<\/p>\n

Despite long discussions with the obstetrician, I can\u2019t dispel this dreadful, heavy feeling of responsibility.\u00a0 I can\u2019t stop thinking about what else could I have done in the clinic.\u00a0 I have been reassured that there is nothing more I could have done in this environment, especially with my minimal background training in obstetrics.<\/p>\n

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.\u00a0 Maybe if I had questioned his dates I would have thought about the risk of her being overdue.\u00a0 Perhaps if there had been an obstetrician they would have picked up on some subtlety that I may have missed.\u00a0 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.\u00a0<\/p>\n

It;s one of the problems with having such a transient workforce here, there is little by means of continuity of care.\u00a0 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.\u00a0 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?”<\/p>\n

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.\u00a0 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.\u00a0 I\u2019m not sure how to approach a situation in which I can\u2019t form an opinion of the professional upon who I am relying to provide me with essential information.\u00a0 Should I trust no-one?\u00a0 As I am unable to double-check foetal ultrasounds, should I not take responsibility for antenatal patients?\u00a0 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.<\/p>\n

We\u2019ve 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.\u00a0 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.<\/p>\n

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\u2019m better than no one.\u00a0 After my night I\u2019m suffering the wretched, self-absorbed feeling that anyone would be better than me.\u00a0 Is an inexperienced doctor better than no doctor at all?<\/p>\n

Louise Kenny <\/strong>has completed F2 year in the Northern deanery and is now working in Guatemala.
\n<\/em><\/p>\n

The patients’ consents were obtained for this blog.<\/p>\n

\u00a0<\/p>\n","protected":false},"excerpt":{"rendered":"

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 […]<\/p>\n

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