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.
1 comment:
Praying total protection over you, Scott. Peace and protection be yours!
Post a Comment