I have become quite the native. I walk to and from town/work, am well versed with riding a moto, and finally have Rwandan franc ($$$)! Today started like usual, snoozing alarm 3 times, subsequently running late to morning report. MOTO! Bosco (security guard) looked in shock as I hopped on the back of the moto with a black dress on and placed a helmet over my freshly coiffed hair. WHATEVER. Au revoir sucker! Jean, the weekend security guard wasn’t this judgmental and encouraged me to ride the moto to work!
In any case, made it to work with 3 minutes to spare. It’s a 30 minute walk and I frequently don’t have 30 minute commute time budgeted into my morning routine. I always walk home though (mostly because I cannot explain in Kiryarwanda where the house is). I took my helmet off and didn’t have enough small bills to pay him, he took what I had so as to not over charge me. Merci! I quickly walked towards the entrance of the maternity ward. All I kept hearing are “pssssssts” behind me. I turn around with a dirty look on my face only to find some stranger holding out my earring! THAT HAPPENS EVERY TIME I TAKE THAT DANG HELMET OFF! “Merci bien!” This is how the people in Rwanda are for the most part, kind and always willing to lend a hand. I’ve had people walk me to an establishment because I’m so lost!
Just on time for morning report which is my favorite part of the day. It’s a nice way for me to hear about all the patients, see how they manage things, and even ask some questions (usually quietly to the resident sitting next to me of course). There were 3 interesting cases today.
First, was a septic abortion at 13 weeks. Aimable explained to me later that this is very common here, stating that many times when these patients go to the OR, twigs and wood are removed from the uterine cavity!! Termination of pregnancy is only allowed for life threatening maternal status or lethal anomalies. So frequently these are performed illegally. The residents overnight presented the case and the plan for antibiotics and exploratory laparotomy (atypical for this diagnosis). The plan was essentially to open her abdomen, because they were concerned there may have been a perforation and abscess in the abdomen after this sub par procedure. Diomede (head of the department) disagreed, I echoed his sentiments. She needed a vaginal procedure to evacuate the uterus, not an abdominal procedure. Plan was made to re-evaluate today. Diomede was annoyed that no consultant was involved in the decision making – but I must say in the few days I’ve been here other than Dr. Liza I’ve seen very little consultant involvement with decision making. In any case, Bridget and I did a manual vacuum aspiration to evacuate the uterine contents later in the day. (A bedside aspiration of the uterine contents to get all the infected tissue out).
The next interesting case was a 27 weeker with either superimposed pre-eclampsia or worsening chronic hypertension (essentially her blood pressures were high and it was unclear why, but it may warrant delivery if it can’t be controlled). She also had absent end diastolic flow on Doppler’s (abnormal perfusion of the baby). Otherwise her BPP was 8/8 and her NST reactive (all other markers for assessing the baby were normal). Plan was made to deliver today as she completed her steroids (to help the babies lungs develop in the case of a premature delivery). I was climbing in my chair! Dr. Blaise (4th year resident beginning his shift) was the first to challenge this plan (he believed that since her BPs were normal and all other baby testing normal she did not warrant immediate delivery. I agreed). Aimable (4th year resident overnight) stated she needed to be delivered. The attending agreed. I HAD TO SAY SOMETHING. I raised my hand and suggested that we continue expectant management until we have a more compelling reason to deliver. A 27 weeker in a 3rd world country is no joke!! I recommended bi-weekly BPPs and Doppler’s with labs and delivery for worsening maternal/fetal status. That didn’t fly. “What is she seizes? Or develops pulmonary edema?” “Then we deliver her.” I said. I knew she wasn’t making it to term but I thought we could at least buy her a few weeks. It makes a huge difference with neonatal outcomes. No one was on board with this plan- I think they see too much here. Every patient is a ticking time bomb to these guys. Ok, new suggestion, “why don’t we repeat the BPP and Doppler’s and reassess this morning?” There we go , everyone could wrap their head around this short term plan. Absent end diastolic flow can be transient and in a baby with all other normal testing, I just felt optimistic. Moms blood pressures were normal and I wanted her to get more time. The consultant asked Bridget (2nd year resident) her thoughts, she said ” I would deliver her. We have to consider Mom over the baby. She may decompensate if we don’t deliver her.” Ugh Bridget, I thought we were friends. In the end, the consultant agreed with repeating ultrasound today. I went with Bridget to do the Doppler’s. 1) I’m so impressed she can do them 2) I most definitely cannot (I’m spoiled by official ultrasounds and reads by our MFMs). Thankfully I can do an estimated fetal weight ! SHOOT, Still absent end diastolic flow. At this point Blaise and I throw in the towel and admit defeat. Bridget called the consultant to update and agree to plan for delivery.
The last case that was interesting was a 21 year old who delivered the day prior to presenting who was transferred from a district hospital after having convulsions with elevated BPs. She was bag mask ventilated and brought to CHUK. Overnight she deteriorated and became hypotensive and tachycardic. Now on pressors. She has dilated pupils and the picture Aimable painted was of a very critical patient. There are no beds in the ICU so she is on a ventilator in the recovery area of L&D. There is some concern that this may be a stroke. There was a thought overnight to get a CT scan but since she’s on the vent, she can’t be moved to radiology. One of the consultants chimed in to say, “what’s the point in wasting the family’s money on that, she is going to die.” OUCH. Aimable responded that they have insurance and everything is 100% covered. Sigh, I’ll be surprised is she is still alive tomorrow.
After the heated morning report, one of the other female residents came to me to commend me on my plan in there. I was surprised. We chatted a little about how we would manage this patient and then parted ways. I spent a lot of time with Bridget today on L&D. We talked about her child, and why the field is so male dominated. It seems like it’s lifestyle related according to her. I explained to her the make up of my program and she was very surprised. We ate lunch in the restaurant (she had to explain every food to me though 😬) and Aimable was there too! He worked overnight but was still lurking around the hospital all morning and afternoon looking for the CT angio read for the patient yesterday who was scheduled for surgery for GTN but may have had a PE. I offered again to go to radiology to get the read so he could sleep, but instead we went together. Yep, she has a PE. Surgery delayed for at least a few months. If I am to say anything about this experience thus far, it is that the residents are world class here and the patients are really lucky to have such a hard working and dedicated group of physicians caring for them.
I think that’s enough for today.