Lessons Learned

After four years as a resident, working an average of 80 hours per week (much more if you’re on labour ward), you tend to think you have seen it all. I have done more vaginal deliveries, cesarean sections, and vacuum-assisted vaginal deliveries than I can count; managed more non-reassuring fetal heart rate tracings, shoulder dystocias, diabetics, and hypertensives than I can remember. It becomes second nature. It becomes your sixth sense. You develop your intuition and you learn to trust it. You develop your skills in using all of your available tools and you trust them. But throughout that you have the reassurance of back-up. If your intuition, skills and tools do not give you the answer, you call your attending. Even when you are completely sure of your decisions, you still call them. But when you begin to practice independently, you don’t have anyone else to call. You have to make immediate, life-altering decisions.

What if you don’t have your usual tools? Then on what do you base your decisions? Intuition can fail you. If you’re interested in this concept, read the book Blink: The Power of Thinking Without Thinking by Malcolm Gladwell. It is eye-opening and riveting. We are constantly taught to second-guess ourselves. We are told “don’t judge a book by its cover” and “think before you act” etc etc… When you begin to think and overthink your intuition, you think of many ways in which to break down your initial judgment. Every argument has a counter argument and you begin finding every piece of evidence that shows you why your intuition is wrong. But there is a reason something is made clear to you by your intuition.

You must learn to trust yourself. I often get compliments about my confidence and I think of it as one of my stronger personality traits. Of course, like everything else in the world there are pros and cons to confidence. I can come off as over-confident, smug, superior, etc. But when confidence is honed by learning, hard work, practice, experience, and hardship, it can be your most important skill. It helps others believe in you, allowing you to be a good leader. It allows you to remain calm and elicit calm from others in difficult situations.

Here, the registrars (residents) do not have back-up. On labour ward they are lucky if they have a consultant (attending) who comes in once or twice a day to round on the patients and make plans. Then they are left to carry out those plans, whether or not they have been taught what to do or how to do it. I am constantly reminding them to call their consultants for help- for their own safety and for the patients. In turn, they constantly remind me that any time they call for help the response is “Why are you calling me? Can’t you deal with it yourself?” (If not worse.) They are often put in situations where they do not have the tools and have not been taught the skills that will give them the right answer. The hierarchical system is such that if there is a bad outcome they will be berated and reprimanded for what they have failed to do correctly before they have ever even learned what the correct thing is. When this is the only system you know, it is difficult to find your own intuition. It is difficult to become confident in your skills and in yourself.

This is an interesting point of distinction from the modern American system of education and medicine. I have asked people here where it comes from and they have told me from the UK system, the system in which everyone here is trained. In the US we have worked so hard over the past 10 or 20 years to dissolve that system, though I don’t know about the modern UK system. As medical students and residents now (or recently) we see the last vestiges of it in certain “old-school” attendings, but for the most part it has been systematically broken down by consciously and actively changing the way in which we interact with each other and our patients. We take classes in ethics and discuss how rigid hierarchical systems in medicine hurt everyone involved, including our patients and ourselves. We are taught that there is a better way to do it and we strive to embody that in our practice. 

These are some of my abstract thoughts at the end of a long day in response to a very difficult clinical situation. The details are not important and I am still struggling to understand and believe them myself. Suffice it to say, I am reminded to always trust my intuition, because my tools and skills may fail me.  When the line between right and wrong is so blurred and when the situation can be so unclear, as it often seems to be here, your intuition and confidence in your ability to be a leader, as well as a team member, are all that will carry you through.  Every day I am trying to teach these skills to the registrars and although the outcome today was bad, I believe the lessons they (and I) have learned from this will make them (and me) better physicians.

The first two pictures are the courtyard in the hospital- it is always filled with people enjoying the sun and fresh air. It is my favorite place to see interesting faces and beautiful children who love to shout "hello!" to catch your attention then grin & giggle & dash away.  The last picture is the beautiful Hindu Temple that I walk past on the way to the hospital every day. 

The Reward

This week was long & exhausting, but it was one of those weeks where I get to remember why I do what I do.

One of the patients I have been taking care of for 2 weeks was incredibly sick. She is 21 years old & came in at 34 weeks pregnant in respiratory distress. Her chest x-ray was horrible & we started treating her for pneumonia while awaiting her tuberculosis testing (I naively thought it would be negative since she is HIV negative). She was so sick & dehydrated we were concerned that the baby wasn’t doing well, so I spent half an hour doing an ultrasound to try to make sure it was safe to continue her pregnancy. She clearly was in no shape to go through labor as she couldn’t maintain her own oxygenation, and being intubated for a cesarean section (all of our C-sections are done under general anesthesia) wouldn’t be safe either.  The entire time I did the ultrasound she was having trouble breathing and coughing in the poorly ventilated room where I do ultrasound & fetal monitoring. She had low fluid but her baby was ok for the meantime. Later that day her TB test came back positive. She had been in a room with 5 other high-risk pregnant women, so they were quickly moved out and we began her TB treatment. But she didn’t get better. In fact, she became worse including being confused and pulling out her IV. We did a lumbar puncture and found she had meningeal tuberculosis as well. Over the next few days of treatment she began to improve but the fetal status deteriorated. On the next ultrasound there was no fluid around the baby and by the next day we decided we needed to deliver the baby as soon as possible by cesarean section. I left that day assuming she was “next in line” for the theatre, but came back the next day to find that the anesthesiologist didn’t think it was safe to put her under general anesthesia, and there were no beds in the ICU in case that she couldn’t be extubated. By the next day her respiratory and overall status had improved enough that they agreed and she underwent a cesarean section. I wasn’t there for it, but the following day I went looking for her to find out how she and the baby were. She looked better than before, no longer required oxygen, but said she hadn’t been able to see her baby yet. Can you imagine, after going through all of that & not even seeing your newborn baby?? She was still very weak so I supported her arm as we walked down the stairs from the postpartum ward, through the labour ward & into the newborn unit. She had to wear a mask, but they let us in for a moment to see him. I will never forget the look in her eyes when she first saw him, put her finger in his little hand, caressed his little foot & wondered at his five little toes. He was the most amazing thing she had ever seen. The nurses quickly shooed us out, and we walked upstairs in silence together.

Today I saw her smiling for the first time, practically running through labour ward on her way to the newborn unit to see him and my heart was bursting with pride that I had helped care for her and her baby, that she had gotten through her terrible illness, that they were both alive and healthy.

My other long-term sick patient was transferred from another hospital a week after delivering twins. They sent her overnight with preeclampsia and when she got here they gave her blood pressure medication that precipitously dropped her blood pressure. When I saw her that morning she was practically unconscious. We resuscitated her with IV fluids and quickly sent her for a CT scan of her head. She had had a large ischemic stroke. The next day she was still curled in bed in the fetal position, unable to say much. But over the next few days she began to improve and I realized she spoke English very well and had the greatest sense of humor. Trying to explain what had happened to her and her family was incredibly challenging. She said she didn't understand why the scar on her belly where she had had a c-section was healing, but the thing that was wrong in her head wasn't healing. I explained that it was healing, but that it would just take more time; that while she could see the scar on her belly healing she couldn't see this scar, but that her moving every day was showing us it was healing. 

The first thing I heard her say, and every day after that, was “when can I go home?” I would tell her when she can walk out the door she can go home. The laughs of her and her family egged me on, wanting to get more laughs out of them. I said, “you can leave when you can walk out the door, down the sidewalk and get in a matatu with your babies.” They all doubled over laughing, hearing this muzungu doctor talking about matatus (those dangerous taxi vans stuffed to the brim with passengers). She would grab both my hands in hers to lift herself up in bed (she weighs all of 100 pounds) and attempt to swing her legs to the side of the bed to show me she could walk out the door. At first this didn’t work at all as her one leg was too weak to move. But slowly, over the course of the past week, she has gotten to the point where she is now walking out the door (of her room, anyway). In the course of our testing we have found out she has atrial fibrillation and had a blood clot in her heart that caused the stroke. Now she can’t leave the hospital until she is fully anticoagulated so this doesn’t happen again.

Through this all her family has been with her every single time I’ve gone to see her. Her sister stays overnight with her & helps her take care of the twins, who sleep in baskets on the counter in the room. Keep in mind she is in a room with 5 other high-risk postpartum women with all of their babies (and some women who have lost their babies).  Today I went to see her and she was lying down, breastfeeding her baby boy while her sister had the baby girl bundled up. I admired them both and told her how lucky she was to have two beautiful, healthy babies. She asked me, “where’s your baby?” and I smiled and told her “next year.” She laughed and said, “you can have one of mine.” Her amazing smile, sense of humor, and generosity in the face of such an unfair, nearly deadly, condition that she will have to deal with for the rest of her life is inspiring and humbling.

The Good Life

My new pleasure is yoga in the garden. I had tried before in our living room here but without a mat my feet slipped along the tile floor. In our local grocery store called the Nakumatt there is an upstairs area filled with curtains, clothes (the selection is pretty entertaining…), and exercise equipment, including yoga mats. But due to import taxes they have been marked up to a whopping 3000 shillings (more than $30), so it hardly seems worth it, especially when I have a beautiful green grass covered area. The ground underneath my feet feels good and I figure the odd stone I step on only improves my balancing skills. In plank or child’s pose by face gets close enough that the grass tickles my nose. I watch a mosquito persistently trying to bite me through my yoga pants and I can stay still, knowing I’m protected. The ants scamper over my feet and between my toes in their search for something good to eat. Staring at the beautiful hibiscus plant directly in front of me and the Nandi flame tree overhead relieves my boredom in long poses. As the clouds roll in and the breeze picks up, the afternoon is cooler than the hot mid-day and perfect for being outside and moving my body. Close by the birds are chirping and in the distance I can hear the basketball bouncing and celebratory shouts from the men playing nearby. I have found my sanctuary where I can relieve some stress, build my body’s strength, re-center myself when needed, and feel the muscles I have been straining while working. It reminds me of my mom, who I always gain strength from, and I hear her voice guiding me through the poses.

My new ritual is grocery shopping on Sundays. It is less busy than Saturday as everyone is at church, but still crowded. And there are plenty of muzungus (white people) there- more than I have ever seen in Eldoret before. I wonder out loud where they are from & someone tells me that most are missionaries or work for NGOs in the rural areas around here. On Sunday they are coming into the “big city” to stock up on non-perishables and experience the relative luxury the city has to offer. The aisles are filled with pretty much anything I could want and there really isn’t anything I am missing (yet). But first we stop by the produce market where very nice young men compete to tempt you with all of their delicious fruit & vegetables- I usually get bananas, mangoes, pineapples, cauliflower, green beans, and broccoli.  Everyone in the organization I work in also has a garden with lettuce, carrots, beets, & plenty of herbs, all free for the sharing. Our garden is only in the beginning phase, so nothing much yet but I have high hopes for our arugula and basil.

I have also discovered I have a skill at driving here- it’s actually kind of fun. I think the only thing that makes me a good driver here is my lack of fear and my fairly aggressive driving. The fun part is the challenge. There are no lanes, so whenever the road gets a little wider a car instantly appears along side you (on the right or the left, doesn’t much matter) and when it gets skinnier you have to merge again. The motorcycles and bikes are constantly swerving in and around you and people are walking scarily close to the side of the car, seemingly about to run into your side mirror, and crossing the street every few feet or so. No stop lights or stop signs at the intersections, but because everyone is fearless and aggressive somehow it works out that you all just drive through & once in a while you slow down for someone to go past you from the other direction. The chaos that clearly works kind of makes all of the structure and stopping in our road system seems pointless and wasteful. There are so many fewer accidents here because everyone has the right of way so everyone goes, just a little bit slower so you don’t hit anyone. Whereas in the US when it’s “your turn” you just speed through & if someone is in your way, you’re going to hit them.