Some cases and random thoughts . . .

Interesting few weeks. Some tough decisions. It is hard to be in charge, to be the expert, to be the one making the calls. For me the decision does not end with a plan of action, it starts. From there the question changes from should we do that to should we have done that. It is how I learn. It is a tiring process. Compounding this are my emotions, right or wrong.

30 year old lady pregnant with twins. She comes to us for her first visit at 32 weeks gestation. All is well except for a blood pressure of 200/140. We admit her, rule out pre-eclampsia and start medications. Within a couple of days her blood pressure is down to 160/100. We are happy. At 33 weeks gestation, despite medication, her blood pressure begins to rise. After a couple of days of IV medications we call it, we make the tough decision of early delivery knowing that although we may be helping mom, we are putting the babies at risk. At 33 weeks and 2 days there is a good chance these babies will not survive due to immature lungs –that was two weeks ago. Today, mom is doing well. Her blood pressure on medications is 140/90. Unfortunately we lost twin A on day of life 3 secondary to respiratory distress/ failure. Twin B is still with us on day of life 18. We have started him on nasal gastric feeds and hoping and praying he has turned the corner. Good decision? Technically yes, but if we lose the second baby it will not feel that way.

10 year old boy brought in unresponsive secondary to an “accidental hanging”. He is placed on a bed. I confirm no pulse, no respiration; however, he feels warm. My guts says pronounce him there is no hope. I am hesitant. I call a code for multiple reasons . . . for the family, for the practice, he is warm. I do not call it because I believe he will survive. After two rounds of CPR we re-establish a pulse, but no respirations. Shortly after, he begins to breath. He lives for two more days and then passes away. The family is at a loss. Now they are burdened not only by the loss of their son, but by a hospital bill that will strain them financially. Was I selfish?

35 year old male vomiting blood. He is signed out to me on rounds. The bleeding is believe to be secondary to esophageal varies secondary to cirrhosis caused by Hepatitis B. My first reaction, why did we admit him. We cannot treat this here, he needs to be referred. I discharge him on Sunday with instruction to follow up Monday morning for a referral to Lomé. He is brought back to the hospital hours after the discharge secondary to vomiting blood. I explain to the family, there is nothing we can do here. We keep him for the night. He is discharged in the morning to Lomé. Two days later we hear that he died on route to Lomé. What could we have done better? Would the referral on Friday have made the difference?

28 year old lady pregnant at 25 weeks and 4 days. She comes to us for her first visit. All is well except for blood pressures of 240/140. She is admitted to the hospital. Over a three day period, we rule out pre-eclampsia and reduce her blood pressure to the 150’s. She is discharged with close follow up. Three days later, at 26 weeks and 4 days, she is back in our clinic with blood pressures in the 200’s and strong fetal heart rate. We readmit her for blood pressure control. During the night fetal heart tones are lost, baby has died. Now she is an induction for fetal demise. I am quietly relieved, God forgive me.

A 20 year old male with an electrical injury comes to us 1 week after the fact. His right and left arm and back are badly damaged. This is a loss. We should do nothing. The fact that he is still alive is a miracle. His condition is discussed with the family by the surgeons. There is no hope, we cannot do anything here. They want us to try. We do. His right arm is amputated below the elbow, his left is taken below the shoulder. He lives for a few more days. The night of his last day he is making a lot of noise, moans and groans. I think he knows his time is coming. The nurse tells me he wants his oxygen mask off. I respond without compassion “that is alright with me as it will not make a difference”. I catch myself before the nurse tells the patient, and with my hand on his shoulder I rephrase it as such “explain to the patient the oxygen is there for his benefit. However we do not want to force any treatments on him that he does not want, thus if he wants the oxygen removed, we will remove it”. He decided to keep the oxygen. I think I lost my spine that night.

25 year old female, pregnant at 27 weeks, unable to swallow. We admit her, scope her, take biopsies and place a gastric tube. Prior to discharge and at the two week follow up, she is gaining weight and feeling better. At the 7 weeks follow up, she has lost weight and the pathology report is back, she has esophageal adenocarcinoma. The baby is 34 weeks and 1 day and growing well. She needs a specialist, an oncologist –there are none available in Togo. The patient cries silently as I explain the situation. With no clear option, we decide to keep the baby in mom until around 37 weeks. After that, we will deliver and work on a plan to try to find a solution to her cancer, but there is not much hope. As mom leaves the clinic, dad is standing in the corner silently crying.  There is no noise, just tears flowing like a water fall. He looks at me and in broken words asks if there is anything I can give her to make her better, anything I can do. The simple answer is no. The complex answer is yes, I can become mad.

On and on it goes. It does not feel like a normal hospital here. It feels like a crisis center, a death service. There are no simple admits. If there are, nobody is calling me on them.

At the worst of times, it is discouraging, it is hard to blog. What do I say? How do I blog? How do I tell their stories here without sounding negative, discouraged, beaten, mad at this place they call “the modern world”? How do I put a positive spin on what I see? I cannot. And for that I apologize.

At the best of times there is a relationship, a moment of time where a connection is made between you, the patient and the family. Something, in the depths of this all is realized, somebody is trying, somebody is holding their hand, somebody cares. At first I think I, in my pride, and they, in there nonbelief/loss/ grief, think it is “we” making a difference. As they continue to watch us, see us in our struggles our prayers, I think and pray and hope “we” come to see it is not “we” but God who is making the difference. I pray that “we” come to know God and/or if “we” already “know” God that “our” faith is strengthened knowing that this is not the end but only a beginning.

Do not get me wrong, I am happy to be here. I am a better doctor for it. I would not trade this experience for the world. And yes we are leaning towards full time missions, but this does not change what I see or what I feel. It does not change “the worst of times”. Surely we can do better than this. Surely with God we will.

God Bless

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