Today is another national holiday. We didn’t know about it until yesterday. I’m not sure if it’s just declared by the government at the last minute or whether MSF hides the information from us until the last minute. Either way I’ve got this place to myself for the day. No meetings, no conferences, just cover labor and delivery until tomorrow morning at 8am.
I don’t think I ever appreciated how great we had it in surgery at St. Edward’s. If you drop the electrocautery on the floor you just open a new one. If the suction doesn’t work you get a new unit. If the gloves don’t fit you find a bigger pair. It’s a different ballgame over here. The gloves are one size too small for me and since we have to double glove my fingers are pretty numb by the time the procedure is over. They tell me that they’ve ordered bigger gloves but it could be weeks or longer before they arrive. (My guess is about three months; they’ll probably show up the day before I leave.) The suction is a reusable unit and the vacuum on it isn’t very powerful. If you get into any serious bleeding you can forget about the suction and just start soaking it up with sponges. The drapes, the gowns, the aprons are all reusable. And the instruments are just barely enough to get by with. The pick-ups are all very small, like the kind women pluck their eyebrows with. There are 4 towel clamps, one scalpel, one suture scissor (dull, dull, dull…I think I could cut the suture quicker with my teeth), and one very dull tissue scissors. As a result I've started cutting almost everything with disposable scalpels which, thankfully, are always sharp. There is usually just one assistant who helps provide exposure, holds retractors, cuts sutures and passes instruments. One of the labor and delivery nurses (all of whom are also midwives and do most of the routine deliveries themselves) is in the room to open sutures, take the babies when they’re delivered, and generally function as the nursery nurse and the circulating nurse during the whole procedure. For my money she’s the one that works the hardest.
Yesterday we had a ruptured tubal pregnancy that was almost 14 weeks along. The fetus was well-developed and about 8cm or 3 inches from head to toes. The placenta was big enough to fill a large serving spoon. And the mother had about 4 liters of blood in her abdomen. She didn’t have any blood donors available so we auto-transfused her with her own blood. This was a first for me and it was pretty basic, nothing fancy. We used a ladle to scoop blood out of her abdomen and pour it into a container then ran it through something like a cheesecloth to remove the clots and then poured it into some blood transfusion bags and starting running it right back into her veins. Her hemoglobin was 3.2 when we started the case, very low. When we checked it afterwards it was almost 6, still low but double what it was before. I was pretty impressed with the whole process. It’s not an option if the mother has a fever because you don’t want to be putting infected blood straight into her veins but in cases like this one it can literally mean the difference between life and death. Barring any complications she should do well and walk out of here in pretty good shape, anemic still but with iron tablets she’ll build her blood back up to normal levels within a few weeks.
I’m just three hours into my day on call today and the day’s already off to a busy start. Shortly after I got here a 19 year old girl came in by ambulance in labor and with a baby’s foot, a pretty good-sized one, presenting outside of her vagina. A quick ultrasound showed the baby to be about 34 weeks, still alive, and with a second twin, also breech, waiting in line. We got her back to the OT pretty quickly and delivered two healthy baby boys who are still screaming their heads off. I can hear them making a racket in the next room.
It’s not convenient and it’s far from ideal but it’s also kind of satisfying to realize that even without all the fancy accoutrements I always took for granted that it’s still possible to do the things that need to be done and do them pretty well. I do miss skin staples but a well-done subcuticular closing stitch will always be a thing of beauty even though, in my hands at least, it takes about 10 times as long.