This week marks my return to L&D (or as Mulago calls it, the "Labour Suite". So fancy). After spending a single day on the Suite during my first week, when all the house officers were gone, I was sort of dreading going back. It felt like so much chaos, so many patients I was losing track of and offering only substandard care, so many seemingly inefficient systems I just didn't understand.
But you know? Today wasn't that bad. I ended up manning the Admissions room with two other house officers, seeing an endless line of patients with aggressively pregnant bellies, and I actually felt like I was helpful. It definitely helps to have the house officers back. And it also turns out that Obstetrics everywhere is kind of the same, no matter the surrounding chaos. There are only so many pregnancy-related medical problems, and there are even fewer potential treatments (to wit: deliver vaginally, deliver via C-section, or watch longer). At this point in my training, I've seen enough folks that I can at least confidently funnel patients into "concerning" and "unconcerning" categories. And that's enough to be useful in triaging.
And sometimes, when a true, true zebra comes in, house officer knowledge and UCSF resident knowledge can be quite complementary. Around noon today, the Admissions door slammed open and two terrified young men appeared pushing a barely conscious, gasping woman with a giant distended belly. The rest of her, however, was completely emaciated, and the intern and I were able to hoist her easily onto an exam bed. Her wide-eyed relatives were able to tell us only that she'd had a baby the day before, at home, and had suddenly taken a turn for the worst that morning.
Our first thought: she was having a postpartum hemorrhage and bleeding to death. The intern confirmed anemia just by looking at her eye sockets. (They're masters of physical exams here, not having easy access to blood tests.) And her belly looked huge, suggesting that her uterus might be distended and hemorrhage-y. But her current bleeding didn't really seem that bad, and her belly, though huge, felt strangely squishy - not uterus-like at all. Weird. After getting her some oxygen and some IV fluid, we decided to roll over the ancient ultrasound machine, and I took a peek inside her belly. (Bedside ultrasound seems to be a relatively new addition to the Mulago house officer repertoire - most of the house officers rely on formal ultrasounds for managing patients but don't get any consistent training in using them.)
Inside her belly was a tiny, well-behaving postpartum uterus, and...fluid. Liters and liters of clear fluid filling her abdominal cavity, something you'd expect to see more with patients with heart or liver problems. And then one of the house officers asked the right question to her relatives: Had she been tested for HIV? She had, in fact, just two months ago, and was found to be positive. Furthermore, her immune system was suppressed to the point that she'd been recently started on medicine, which they don't do for just all HIV+ patients in Uganda; you've got to be in a pretty bad spot to merit meds.
So all of a sudden it turned out that our postpartum hemorrhage was actually more likely an AIDS-related complication - it just happened in a patient who'd recently delivered a baby, which brought her to us. Definitely not your typical US triage patient. But I was proud of us, really. We figured out (generally) what was going on, stabilized her, and started the process of getting her into the right hands; I hope the Infectious Disease people tell us what's up.
And then, of course, another five laboring women piled in the door and our marathon continued for a few more hours. But with those little satisfying bursts just often enough. Looking more forward to getting back into the fray tomorrow.
[While writing this, a woman I chatted with over the weekend knocked on my door and gave me a teeny perfect homegrown mango! Huzzah! Excellent gift.]
But you know? Today wasn't that bad. I ended up manning the Admissions room with two other house officers, seeing an endless line of patients with aggressively pregnant bellies, and I actually felt like I was helpful. It definitely helps to have the house officers back. And it also turns out that Obstetrics everywhere is kind of the same, no matter the surrounding chaos. There are only so many pregnancy-related medical problems, and there are even fewer potential treatments (to wit: deliver vaginally, deliver via C-section, or watch longer). At this point in my training, I've seen enough folks that I can at least confidently funnel patients into "concerning" and "unconcerning" categories. And that's enough to be useful in triaging.
And sometimes, when a true, true zebra comes in, house officer knowledge and UCSF resident knowledge can be quite complementary. Around noon today, the Admissions door slammed open and two terrified young men appeared pushing a barely conscious, gasping woman with a giant distended belly. The rest of her, however, was completely emaciated, and the intern and I were able to hoist her easily onto an exam bed. Her wide-eyed relatives were able to tell us only that she'd had a baby the day before, at home, and had suddenly taken a turn for the worst that morning.
Our first thought: she was having a postpartum hemorrhage and bleeding to death. The intern confirmed anemia just by looking at her eye sockets. (They're masters of physical exams here, not having easy access to blood tests.) And her belly looked huge, suggesting that her uterus might be distended and hemorrhage-y. But her current bleeding didn't really seem that bad, and her belly, though huge, felt strangely squishy - not uterus-like at all. Weird. After getting her some oxygen and some IV fluid, we decided to roll over the ancient ultrasound machine, and I took a peek inside her belly. (Bedside ultrasound seems to be a relatively new addition to the Mulago house officer repertoire - most of the house officers rely on formal ultrasounds for managing patients but don't get any consistent training in using them.)
Inside her belly was a tiny, well-behaving postpartum uterus, and...fluid. Liters and liters of clear fluid filling her abdominal cavity, something you'd expect to see more with patients with heart or liver problems. And then one of the house officers asked the right question to her relatives: Had she been tested for HIV? She had, in fact, just two months ago, and was found to be positive. Furthermore, her immune system was suppressed to the point that she'd been recently started on medicine, which they don't do for just all HIV+ patients in Uganda; you've got to be in a pretty bad spot to merit meds.
So all of a sudden it turned out that our postpartum hemorrhage was actually more likely an AIDS-related complication - it just happened in a patient who'd recently delivered a baby, which brought her to us. Definitely not your typical US triage patient. But I was proud of us, really. We figured out (generally) what was going on, stabilized her, and started the process of getting her into the right hands; I hope the Infectious Disease people tell us what's up.
And then, of course, another five laboring women piled in the door and our marathon continued for a few more hours. But with those little satisfying bursts just often enough. Looking more forward to getting back into the fray tomorrow.
[While writing this, a woman I chatted with over the weekend knocked on my door and gave me a teeny perfect homegrown mango! Huzzah! Excellent gift.]
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