Fridays are busy because the bulk of our OB-GYN Department spends the day in clinic seeing women with all sorts of sad and complicated problems – cancer, infertility, chronic pain and the like. Which leaves me juggling the chaos in Labor & Delivery. Not alone mind you – there’s a strong team of midwives and various trainees – but I’m the only “Consultant” around to assist in decision-making.
Near the end of our ward rounds, after seeing about 30 inpatients, I’m informed of a patient who just rolled in the door with fetal distress. “Thick meconium” is the presenting complication– a reliable sign that the baby is “not OK.” By the time I’m informed, the patient is already in the Operating Theatre being prepped for an emergency Cesarean.
I arrive and the Anesthesia Team is in Rapid Mode – drawing up drugs of various sorts into small syringes, putting in an extra IV line, a Foley catheter. Confidently and efficiently. There’s no panic here. We swiftly complete our pre-op Time Out review. Within 15 minutes, I am making the incision in the skin. Within 2 minutes, I’m extracting a baby covered in mustard-like slime – but the baby cries weakly. Ten minutes later the Pediatric Team comes back with a clean and restful baby who has been rescued from the brink.
We’ve just received a new set of Medical Officer Interns this week. These two young Kenyan doctors are halfway through their one year internship, but have minimal experience in obstetrics. It’s our task to transform these two into doctors who can confidently and competently manage women through their pregnancies and deliveries – including the skill of performing Cesarean sections independently – by the end of their three month block with us. So, I invite my assistant to switch places with me so I can assist her in finishing the closure on this Cesarean.
Closing the uterus is probably the most stressful stage of a Cesarean. You try to work quickly in a fountainous pool of bright red blood. The wound edges continue to bleed briskly until those edges are tightly sutured together. I dab with large absorbent gauze pads, suction with a weak catheter, and instruct where and what to do. Calmly, but firmly. I reach with the gauze sponge… she reaches with her needle holder…gotcha. The large suture needle catches my left index finger. Ouch. The surgical nurse sees it. “Go, doctor.” I walk out through the heavy swinging double doors, snap off my double layer of gloves and see the drop of blood oozing from my finger. Within ten seconds, I’m scrubbing with liquid soap, running water, and even splashing some alcohol rub on there for good measure. I see a puncture. Bummer.
The HIV prevalence in Kenya, is officially somewhere around 6%. That’s more than 1 million women in Kenya. Our hospital’s immediate catchment is probably a lower risk area, but we get a lot of women from Nairobi which is probably a higher risk area. Officially, the number of HIV+ women we deliver at Kijabe Hospital is relatively few – less than ten per month. But the risk is real.
So, I proceed to the ICU, which is the official keeper of the Post-Exposure Prophylaxis (PEP) Protocol and drugs. It takes about 30 minutes to find the right people, but we do eventually find the notebook with the forms (to be completed in duplicate) and the pills. Three monster pills – antiretroviral drugs - to be swallowed emergently until testing of the patient can be completed. I choke them down. Later we will have a more thoughtful and deliberate discussion and decision around the potential need to continue the drugs for a full 28 days.
So, I head back to the Theatre. My intern is still completing the case now with one of our docs who left the clinic to come and assist. I ask for blood to from the patient to be sent for HIV testing and it has already been done. Now I become the patient.
In the AIDSRelief Testing Center, I get my blood drawn and am tested for HIV. They know the drill. They are sympathetic and professional. My test is done in 5 minutes. Negative. Yay.
I now head for Medical Records to retrieve my Kijabe Hospital medical record. “We can’t find it doctor – that is a very old file number. Perhaps it was archived. (read: discarded).” No problem – I’m healthy and have no significant history. They issue a new one page Outpatient File and I head for AIDSRelief Clinic. I am now amongst a group I have worked with for many years – HIV+ women – and I am in their shoes.
The Clinic is spiff. Brand new, spacious, bright, and out of sight from the rest of the hospital. The patients seem comfortable sitting together and talking. I am not. I’m ushered into an examining room where a Clinical Officer (like a physician assistant) sits in the clinician’s chair with my file and I sit in the patient’s chair. He reviews the history and writes a prescription for the 28 days of antiretrovirals. It seems that even if the patient tests HIV-negative, there is always a lingering doubt about whether the patient could be in the “window period” - infected in the past 6-12 weeks, but not yet testing positive. We don’t have the HIV-RNA antigen test to exclude that possibility. So, I receive two big bottles of pills and leave.
By 4:30pm, five hours after my injury I receive the news that the patient is HIV-negative. Phew. But that window period. I consult with a lot of people – two of our Internal Medicine/Critical Care Consultants, our Senior Midwife, Head of Lab, our Hospital Chaplain…and Jennifer. We decide to interview the patient gently – no waterboarding here – we just want the truth. Have you had sex with anyone in the past three months? Turns out she’s not married, she’s a student. She insists she has not. So, should we believe her? Culturally, do women in Kenya have sex in the last three months of pregnancy? Most direct answer I could get was … maybe.
I looked at the Adverse Reactions for the antiretrovirals I’ve been prescribed: Lamivudine, Tenofovir, and Lopinavir/Ritonavir. The list of reactions can make your hair stand on end: pancreatitis, hepatic failure, vasculitis, nephritis, hypertension, heart attack…etc.
My final read…
- I was stuck by a solid needle (a suture needle), not a hollow needle (syringe needle). The risk is known to be much lower for this type of exposure.
- the patient tested HIV-negative. While there is the theoretical risk that the patient could be in the “infected, but testing-negative window”, I am inclined to believe her statement that she has not been having sex with anyone in her final trimester of pregnancy.
- I did take the “stat” dose of drugs which should have given me some protection.
So, I won’t be taking 28 days of those drugs.
By the way, that first dose was pretty miserable. The headache and nausea were considerable. Which brings me to a final reflection…
The doctor becomes patient. Certainly there were a variety of emotions. Anger. Angry with my trainee; with the system that puts me across the table with an inexperienced surgeon in a stressful situation. Fear. Of the uncertainty of a potentially-life altering fatal, stigmatizing infection. I navigated a complicated system of diagnostic testing and treatment. I struggled to judge the test’s reliability. I received a bowl full of blue and brown double-edged pills with the power to prevent infection – and the toxicity to burn up my liver. But there was also Gratitude. Through it all, though, the Kijabe Hospital staff was compassionate and kind. Of course, I’m aware I got lots of preferential treatment because I wore a long white coat with surgical scrubs underneath.
The enduring memory, however, of this stressful day continues to be rubbing shoulders in the lab and the clinic with patients who similarly struggle…with much less education and preferential treatment. To understand, to make decisions, and to hope. My experience - I pray - will spill over into my rounds on Monday morning – for the good of my patients and God’s glory.