This is our emergency and procedure room. You're seeing the entirety of it right there: four beds, one semi-private space for pelvic exams (although I've tried; you can't actually do a pelvic in it unless you're Houdini), and a nurses' counter. For all minor procedures like I&D's and joint taps and lumbar punctures, you go to the ER, since that's the best space in the hospital to work. I used it on call night to do an LP on a new baby, who was born fine and then tried to stop breathing on the Health Center folks, so they sent him to us. He's been all right ever since then, although trying to get anything done around here is an adventure in creative thinking. Eventually, I scooped the baby up in his blanket and carried him down to the ER, commandeered a table without asking, told the nurse I was doing an LP and could she get me supplies now please, shanghaied a security guard into holding him for me, swabbed and tapped and bandaged and thanked everyone, then carried him back and deposited him in the warmer with his warmer-mate, who's doing quite well. Since then, he's done just fine.The other new baby night before last didn't do so well: born at home at about 6 months' gestational age and brought in at 1075 gm, he was just too small to survive. Our threshold here, if you're wondering, is 1kg and 28 weeks - no baby smaller or younger has made it home yet, and the kilo kids don't have a great rate. As I've said before, we don't have any surfactant, or ventilators, or anything more than one neonatal bag-valve-mask arrangement, some antibiotics and theophylline, and a selection of IV fluids. He came in at 6 PM and at 2 AM I was bagging him with the nurses and listening to his heartbeat slow and dwindle, feeling sick and helpless. There were agonal respirations every now and then, great gasping breaths involving his whole body, but after a while he stopped doing that, and then I put my stethoscope on his chest and heard nothing, and I shook my head at the nurse. "Stop."
And then I turned around and they needed me in the delivery room for a breech fetal demise, and I will never be able to forget the look of the grey thing that was delivered there, shaped like a baby, but also like the very essence of death, skin stretched over bones still soft and deformable, face expressionless and bland, flesh peeling back from the skull. It - he - looked as if he had come directly from the crypt. I didn't know what to do - nobody seemed to, really - so we cut the cord and wrapped it up like a baby, and when I left the room the nurses were explaining to the poor mother that her baby had been dead a long time, and that she could see it if she wanted.
So I didn't sleep well, after getting home at 2:30 AM, and I don't know that anyone could have, but there is no postcall day off in the Real World.and so I was back in at 8 doing rounds. And I stopped in on the patient with the placenta previa - we admitted her for bedrest and monitoring, but she wouldn't stay, she went home and came back the next day - my call day - after making some arrangements at home or doing whatever it was that was more important than maybe bleeding to death or having her baby die. Nobody had much hope that baby was going to live in any case: not at 25 weeks, not here, but we started steroids and IV fluids and got her family to come and donate blood so there would be blood in the bank for her, and ordered a type and cross (everyone is Rh-positive here) of two units.
Saw her in the morning, CBC got done at least, but nobody knew where it was. She said she was still bleeding. I gathered an army of student nurses around me and gave an impromptu lecture on placenta previa and vasa previa and why it was absolutely vitally important that they monitor her bleeding closely. Everyone was impressed with my drawing of a uterus, and they all looked very serious while I talked. Around 3 or so the nurses came and found me. "She's bleeding a lot." 2 pads an hour for 2 hours, then 1 pad in 2 hours. And I finally found her morning CBC: 6.7, down from 11 the day before. And I went to get someone who knew more than I did.
They did her C-section around 6 last night, with mom still bleeding a lot and blood bank seeming to not understand what "stat" means on a type and cross, delivered a baby that we still haven't weighed, because every time she comes off of oxygen she tries to die - estimated around 700-750 grams. One knee is bent all oddly because of the oligohydramnios. I didn't feed her, but we gave her IV fluids after Susan put an umbilical line in, and she's on all the medicines we have for tiny babies. And when I left this afternoon she still was pink and struggling, but I imagine that my "very early baby row" in the nursery will only have two babies when I get back on Monday. And I wish it weren't so.
It hasn't all been dying babies - it just seems like it sometimes. I'm more than a little emotionally exhausted by B ward all the time, but I find I still love what I do. And I finished my Friday with a C-section with Steph that went stunningly well, and I feel good about that.
Today I did a morning conference about TB which went quite well, and I learned a lot in the preparing of, and then I rounded on everyone and went to OPD for the day. Saw several very interesting cases:
This very nice 17-year-old girl has never had a period. She came with a primary complaint of generalized malaise which has forced her to miss enough school this year that she wants to repeat the 12th grade (apparently, this is common because there's no help to catch up). The primary amenorrhea was a "by the way" mention by her mother, who thought it odd that her eldest daughter was behind the youngers. And then the plot thickens: I go to do a basic examination and note the complete lack of secondary sexual characteristics - no breasts, no pubic hair. She can't tolerate much of a pelvic - only enough for me to determine that there's no imperforate hymen - so we went to ultrasound and I pulled Becky in and we could not find a uterus. We have a very limited set of available labs here: I got a sodium (147) and a potassium (5.2) and a blood pressure (120/80) and a CBC (normal). I've ordered the only hypothalamic-pituitary axis lab I can - a TSH - and I'll find out Monday if it shows up abnormal. I can't do any of the sex hormone studies or genetics that are recommended to rule out CAH or 17-hydroxylase deficiency. I could possibly do a bone age if that would be very helpful, but it would be expensive, and I've already charged this girl a lot of money. I'm going to re-scan for a uterus on Monday when the TSH comes back, I think - and look at the kidneys and try to see adrenals. We'll see where it goes.
This little guy came in on Wednesday with a horrible conjunctivitis and respiratory bug - his eye was swollen and glued shut with pus, so that I could barely peel it open to see the inflamed conjunctiva. Exam showed a preauricular node, but unilateral conjunctivitis that oozed pus constantly, so he got gatifloxacin eye drops and oral antibiotics and a "CSI" - a "skip the line and come see me" card for today. Eye is doing much better, decreased discharge, but his mother noticed a "white spot" on his eye - showing here to the right. It looks like a bacterial keratitis - apparently more common in the tropics, according to the book I had - so he got an additional dose of Tobradex (with fear and trembling, but the book said to add steroids after 2 days of antibiotics) and a referral pass to go straight to Hagen to the eye doctor, today. I hope I find out the end of the story.
And number three in the series is the girl who fell and hit her knee a year ago, but whose knee effusion has never quite gone down. I got a CBC, and a sed rate (both of which weren't done last I tried to get them) and an X-ray and went to tap her knee. I got nothing on the tap, but the X-ray gave the diagnosis. She'll be back on Monday for admission to have her chronic osteomyelitis debrided - and that big sequestrum behind her knee drained and scraped.
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