Mission Impossible

“Your mission should you decide to accept it . . . “

Mission impossible, this is how it feels most of the times.  During residency and fellowship in the States I used to get tired of the routine cases such as hypertension and diabetes.  Now I have a craving for them.  Do not get me wrong, we do get routine stuff here, however, it is the minority.  The strange, bizarre, and “too late to treat, but I will try” feels like the norm.

On Friday night, after having finished a very busy week on OB and after having cleaned out the labor deck, I headed home with the goal of getting some sleep.  Just as I laid down I got a call from the labor deck.  A transfer from an outside clinic had come in with elevated blood pressure.  “Je viens” I said.

As I walked to the hospital I reflected on the “most likely diagnosis” of elevated blood pressure and the work up that needed to be done.  Twenty minutes I thought, twenty minutes and I will be back in bed.  Nope, try five hours later.

This 22 year old lady who was by her last period 38 weeks pregnant had high blood pressure, but this was not all.  She also had 4 plus protein in her urine which gave her the diagnosis of severe pre-eclampsia, a potentially deadly disease of pregnancy that warrants the delivery of the baby ASAP.  Her history was not impressive, however, her physical exam opened up a can of worms.

First and foremost her fundal height, which is the distance from her pubic bones to the top of her belly, was only 29 cm.  This height should equal her gestational age in cm, which was 38.  Why is it so small?  Are her dates correct?  In reviewing her pregnancy record from the outside clinic it became clear that her dates were correct and that up until her last visit at the outside clinic which was the end of June the baby was growing normal.  However 8 weeks later and the baby appears to have stopped growing.  What now?  I need to see the baby myself.  To the ultrasound machine we go.  I fuddle through the exam noting the condition of the placenta, the position of the baby and measuring the baby’s age.  I think the baby is about 33 weeks in size.  Diagnosis, intrauterine growth restriction.  If there was any doubt to how sick she was before, there was no doubt now.

Second, this 22 year old lady could not move her legs and was unable to maintain a sitting position.  What?!  A detailed neuro exam with Dr. W revealed a loss of motor function of lower extremities, weakening core muscles, but good sensation and good rectal tone.  And a urinary cath showed she had been retaining urine.  Out come the books, the phone and a prayer.  There is no option, I accept the mission.

What is the cause of this?  Does she need steroids?  Does she need antibiotics?  Does she need a lumbar puncture?  Can she deliver vaginally?  Will she be able to push effectively?  Should we just do a c-section?  What is actual age of the baby?

 “As always, should you or any of your IM Force be caught or killed, the Secretary will disavow any knowledge of your actions.  Good Luck.”

Mission Impossible, this is how it feels most of the time.  During residency and fellowship, my treatment plans and courses of action were reviewed and approved by attendings and specialists.  All actions taken were in due process questioned and discussed.  This process stopped me from making a bad decision and protected the patients from my inexperience.  That does not exist here.  I am the attending.  I am the specialist.  It is uncomfortable, but yet I feel comfortable.  I feel at peace and am left to question why.  I think there are two answers.

The first answer is the “shoulders we stand on” being Christ and our colleagues.  We have been blessed with a great set of colleagues that are answering our emails and phone calls, giving us directions and pointers.  There is no doubt that these colleagues are helping to bring us peace in the decisions that are taking place.  The other and more important answer is Christ.  In openly praying for our patients two things are achieved, a glorification of Christ and not only an openness to the uncertainty we face, but also an openness of our love and desire for the patient to get better.  Here it is OK to say “I am not sure what is happening, but here is what we are doing for you” and “let us pray”.

The second answer is the Togolese’s people.  Unlike patients in the US who demand perfection and have unrealistic expectations of what a doctor and or medicine should do for them; the Togolese do not live under this delusion.  It is almost the opposite.  In discussing a patient’s condition and the options at hand with patients here in Togo, the response is for the most part “whatever you think is best doctor”, “please do all you can” or “it is in God’s hands”.  And when failure in the form of death comes they morn and cry like anyone, but they also take the time to thank you for what you have done.  It is an interesting contrast.  I feel burdened/weighted down by the expectations of the American system, but feel energized and motivated by the grateful Togolese.

Update

Jesus looked at them and said, “With man this is impossible, but with God all things are possible.” Matthew 19:26

After 46 hours of induction, the 22 year old lady delivered a healthy baby girl weighing 1.95 kg.  The baby today is doing well, breast feeding and eating like a champ.

Mom continues to get stronger.  After the initial deterioration of motor function that spread from the legs to the core muscles, the patient started to regain strength.  Prior to the delivery she was able to sit up and move her lower extremities.  Today she is able to walk with assistance.  Our last challenge is fever.  She started developing a fever just before delivery.  She has had three fever spikes over the last 4 days, the last one being more than 24 hours ago.  We unsure of the source, but do have her on rocephine, flagyl and cloxacillin.  The overall good news is she is healthier today than she was a few days ago.

Lord God we thank you for this mom and the safe arrival of her child.  We pray for mom’s recovery, her salvation, and that she can spend many more years here on earth with her new child as a testimony to you.  We pray for the child, this new life that she is called by you and that she will grow up surrounded by love and peace.  We pray this in Jesus’s name, Amen.

Once again thank you for your prayers and support.  With respect to this case in specific, thanks to Dr. Stocks and the attendings/OB doctors at St. Elizabeth Family Medicine Residency Program for taking our calls.

God Bless