The Transfer Tango…and other fun things to do on a Friday afternoon.

13:30 Busy in Gynae OPD which looks nightmarish…too much work and not enough doctors has left a bit of a backlog. I got a call to say that an eclamptic patient has arrived from Carletonville
I find a rather robust but completely confused and uncooperative patient with blood pressures of 212/130 (that’s like aneurysm popping high). 22 years old, previous caesarean section, now best case scenario 31 weeks by sure dates, possible twins. Thrashing about, walking a fine line between the hyperirritable phase that precedes coma and death. It’s like rescuing a beached whale.
First tried to get hold of my consultant to find out what to give for the Blood Pressure since clearly the standard Adalat was probably not going to fly….No reply.
Phone slightly more senior MO…Labetolol, ICU, deliver.
Easier said than done.
14h00ish: Attempt to get labetolol from theatre: I’m not surprised, they said no: “we only have 3 vials left” (because you use it everyday?).
Plan B; phone pharmacy. First response, no we don’t have that. I’m not worried yet…theatre will just have to give. 4 minutes later...Pharmacy responds, sorry doctor, we do actually have it we just never use it.
Shot...get Labetolol. Read up in SAMF how to give it. Calculate…tell sister. What do you know…it doesn’t happen. Blood Pressure still 210/130.
14h30ish. Try to get old of senior anaesthetist. Voicemail.
Slightly senior anaesthetist available. “Ok, we’ll come and see.”
Phone ICU consultant….what do you know, ICU is full. “We can maybe move the paediatric organophosphate out but you have to phone Dr K.”
*sigh* Phone calls to him are laborious and non-productive. Dr K, makes a valiant effort to not move the child.
Phone Klerksdorp ICU…no beds.
Phone Tshepong ICU…no beds.
Phone my consultant on private number. “Stabilise, deliver, ICU….make it happen”. This said from the comfort of another city.
15h15ish. (I think at some point here, the VBAC (Vaginal birth after Caesar) at the back of the ward goes into foetal distress and doesn’t want a Caesar. I roll my eyes and get someone to translate…”you have two options. 1 – You have a Caesar now. 2 – you have dead baby or even worse a CP baby”….I make it seem like she actually has a say in the matter.)
15h30ish. when I phone the surgeon about the VBAC I mention the eclamptic.
“Linda, I think you must try and transfer her.”
S*@t…why didn’t someone senior just say this 3 hours ago!
Phone Klerksdorp…phone me back in 2 minutes…(2 minutes)…we have a high care bed but you need to discuss it with the medical manager. Phone not answered…thereafter voice mail…twice. Decision to abandon Klerksdorp.
16h00ish At least my 2 fellow obstetricians have managed to clear out GOPD and are now in the ward…I manage to explain that she hasn’t had any BP meds because she doesn’t have a second IV line up and apparently that is not a sister’s job. But is also not a sister’s job to phone around and find an appropriate centre to refer this patient too. I am good at multi-tasking, but since we don’t have cordless phones in labour ward, I am dial-up bound.
They are dispatched. The drip is up and then they dope her up to 1 level short of high heaven with Valium.
16h10ish. Ok…phone Bara…route to labour ward…route back to switch board…route to Gynae admissions…route to high care…route to registrar…” You need to discuss with ICU”…route to ICU…awesome reg on call. How do I know this…I’ll call you back Dr Riemer. Fanflippentastic.
17h00: (yes that’s right…50 minutes on the phone) "We have a bed, so we can potentially take her but she needs to come through obstetrics."
Phone back obs reg…Ok we’ll take her but you need to try get an obstetric ultrasound and some kind of foetal monitoring….are you kidding lady, I had to dope her with 10mg of valium just to do the ultrasound and it knocked her out for about 10 minutes…now you want me to do at least 20 minutes of CTG’s on 2 babies weighing about 800g’s each with an uncooperative 90kg (at least) mother.
Mmmm…maybe not hey.
17h30ish.Phone anaesthetist…Bara says we can send her (Imagine if Carletonville had just done this in the first place.) I can almost hear the happy dance on the other side.
No ambulances in Potch (there haven’t been since Tuesday…apparently they are all in for a service! What kind of chop sends all the hospital ambulances for a service at the same time; and what are they doing, reassembling them from scratch! It’s been a week since they went for a service.)
No problem…I’ll phone for a private ambulance. Get the medical manager’s permission.
Phone ER 24(lovely people, I have had to speak to them quite a bit this week).
Ambulance booked. Transfer booklet filled in.
Look in on foetal distress baby: 4.2kg …yup, you were never coming out ‘normally’.
18h00…Hayley shares her cupcakes (celebrating last day in TB ward!) Home. Couch. Drink. Back again tomorrow.

Musings on M&M's

Death is a humbling thing.
Because it levels us all I suppose.
Those who succumb quickly and those who fade slowly. Those who die with fluffy pillows and those who die on a casualty stretcher. The brand new baby. The tired old lady.
We all suffer the same fate.

Sometimes it encroaches on life…in the last week it has hovered around the corners of mine.
It was there while I was getting the presentations ready for our obstetrics morbidity and mortality meeting. The series of unfortunate events which eventually led to the death of post-dates baby because we didn’t realise just how much he was struggling inside…but we should have.
There was the 21 year old whose mother gave her some herbal tonic to induce labour, which it did but overzealously so that the contractions were too strong and so the baby was hypoxic and we realised it too late. How terrible to tell a mother that her baby is dead, how much worse because she unknowingly caused it. How terrible to know that I should have picked up the problem sooner.
There was the mommy who’s uterus gave us the impression that her baby was about 2kg’s, her membranes ruptured and we took her for a Caesarean Section but this is government and not everyone gets a scan so in actual fact her baby was only 900g and well, we couldn’t really put him back.
In the next room was Nombulelo; pregnant for the fourth time. Her first 3 babies were all pre-term and they all died. The same thing happened again. 1.6kg…big enough to survive but the placenta pulled away before the baby was born and again salvation came too late. She cried for 2 days.
And Aletta, who was discharged from ICU too soon (aren’t they all) and spent 2 days in my ward getting too much fluid while her kidney’s were shutting down so that when I walked into her room on Tuesday she said ‘Dr, I feel like I’m dying’…and she was literally drowning in her own body.
And then there was Tshidi who I saw about 12 hours into a 32 hour shift. She was 38 and diabetic and she arrived complaining of being tired and weak. I thought she had a chest infection and that was what was making her sugar’s all crazy. I stabilised her in casualty and sent her to the ward for observation. She wasn’t even in the ward for 10 minutes when they called us to certify her…and she was dead just like that. She was so well in casualty, no one could believe it.

What I’ve realised through all of this, and my consultant said it today as well: there will always be adverse events. Sometimes even when you do everything right you still miss things and they turn out to be important things.
Morbidity and mortality meetings are no ones favourite. They are generally protracted and boring if you are not involved and they dissect your faults under theatre lights if you are. But they have their place in therapy. They force humility, which is an underrated quality of a good doctor I think. They are an opportunity to step back and recognise that you are human like your patients and capable of error. Once you acknowledge the error you can learn from it and hopefully avoid it in the future.

It’s a tough pill to swallow – a real penicillin injection.
That being said: I will never forget now to not just write off severe pain in labour as just a low pain threshold, I will be less trusting of the size of a uterus and more insistent on a sonar. I will be more attentive to my instincts because they turn out to be surprisingly accurate.
And I will acknowledge my imperfections and be willing to learn from my mistakes and hopefully cultivate humility.