Monday, November 18, 2013

Day 8

Its another Monday morning...beginning with morning report at 8am (another mortality discussed), followed by Antenatal clinic, to be later followed by "being on duty" (aka a 24hr call). One thing I have really grown fond of is my daily discussion about medicine in Ghana with my attendings and co-residents.

My Monday "tradition" is going to the canteen with the senior resident for breakfast. He never allows me to today...I was intent on buying him breakfast. I informed him that Dr. Oppong had a project he wanted me to work on and so I would spend next week doing that. He asked about the project and my interest which I informed him was maternal mortality with a special interest in preeclampsia. This lead us to one of our many discussions about the differences in Ghanaian and American medicine.

I asked him what he considered to be the biggest factor of maternal mortality as it related to preeclampsia (which is the #1 reason for maternal mortality at Korle Bu). He made it very clear that it was about access to antihypertensives in the emergency setting, but that he believed the #1 reason was due to the lack of appropriate management from physicians and clinics/hospitals in "the periphery." He described to me that "the periphery" was basically made up of doctors doing their own thing and transferring patients to Korle Bu at times when it is too late and the patient shows up ecclamptic. I asked about access to Magnesium and if patients were loaded on their transfer and he said NO. At times, pt even transport themselves via taxi or personal vehicles and there is always a delay given traffic.

We brainstormed on interventions he believed could tackle this problem. He made a valid point about instituting workshops to help standardize (but really to teach) management of preeclampsia, especially at its onset; with special emphasis on when to recognize the early signs. He also informed me that magnesium was readily available at these peripheral clinics/hospitals but that many times the medical staff (physicians included) did not know who to administer the medication.

Just to give you a frame of reference: In Korle Bu, there are no pumps used in OB. Thus, Magnesium is given as a loading dose of 14 (4 IV and 5 IM x2).

We continued our brainstorm about how to institute workshops in our community and researching possible grants to assist in the access of IV antihypertensives in the pharmacy (as he made clear that quite frankly they have gone weeks without these medications at times). We finished our breakfast and headed to clinic.

I was seeing OB clinic patients by myself with my senior in our small clinic room (with one bed) that was set-up for two physicians at a time. He was seeing patients across from me. A junior resident comes in to inform him of a very sick patient. My senior resident goes to assist another resident. I head over to figure out what is going on. I turn the corner to a very narrow hallway (that leads to a small room that is the OB ER) and find a pregnant woman whom was more or less naked with another resident listening to her chest. I asked..."what is wrong with her" as I walked up to the junior resident; and he makes hand gestures suggesting that she is sleeping. I get closer and the other resident is listening to the patient's chest and pronouncing her dead.

"What happened?" I asked in a calm shock. "Probably a stroke," they responded, "she was a transfer." "What about the baby?" I asked in a shy manner. "Dead," they responded.

I eagerly grabbed the patient's chart looking for an explanation as the nurses started screaming that the patient was a DOA (dead on arrival), explaining how she fainted right outside and they lifted her and brought her to the OB ER. The patient BPs at this outside clinic/hospital was 200s/110s; no magnesium was initiated. She was only a 34yo primip. Upon further review I noted that just one week ago this patient had a mild range BP and was noted to be "well" in the chart and sent home.

My breathe was taken away, I was numb. I asked if they have ever seen a postmortem CS here and they said no. I remained numb; sadness filled me quickly.  I covered her with the traditional African cloth that was at her bedside.

I went to find the senior resident to inform him of what had just occurred. "It's exactly the same thing we discussed this morning," I said to him. He nodded his head in agreement and disgust. He continued working, everyone continued on to finish the clinic. I felt tears warming my eyes...I pushed them back where they belonged and went back to work.

"I am sad," I said to him. And we continued working...