Saturday, June 2, 2012

Make Me a Monday


Picture compliments to the talented photographer, Tabitha Schumacher


A/N: This past Monday was a particularly busy day with so many little incidents - some sad, some funny, many just ironic – that I decided to write a series of short memoirs on the day to share with you all. I'll post the whole series over the weekend. There are six chapters. Enjoy!



Introduction

Pens -  check. Phone - check. Letters for the staff addressed to P.O. Box 33 - check. Keys for pharmacy and laboratory - check. Clinic mobile phone - check. Notebook - check. House keys - not check!

Ahhhh! I’m already late for morning staff worship. Where are my keys? Eventually, I find them by the bed and head out the door to worship.

I arrive at worship in just under 60 seconds. My daily commute to work is a whopping, 100 feet from the front porch! Sliding in beside my hubby, Bill, I’m just in time to catch Helen’s devotional thought of the day. Every morning we have staff worship in the clinic, employees lead out in the worship on a rotating schedule.  Two hymns, a devotional, and prayer - simple but sustaining for the day. Patient-clients and their families often join us. During prayer request time, ‘Mom’ Regina speaks up. “Pray for peace.” Over the weekend, a fight broke out in town between a Cameroonian and a Nigerian man. Sadly, one man killed the other with a broken glass bottle. This morning, many of the people in the neighborhood are still filled with fear. They have stayed home and closed their shops. Tensions are tight.

“Lord, please bring peace among the people. Give the peace that passes all understanding. Bring healing to the bereaved. Help them to forgive. Give the police officials wisdom to manage the situation and handle the prisoner.”

Worship finishes. Everyone says good morning and welcome in both French and English. The workday begins. Bill marches back to the house to continue various last minute businesses since he is leaving tomorrow for a study tour with his PhD class. I remain behind to prepare for the day’s consults.

Monday has begun.

Chapter 2. The Singular Case of the Disappearing Stethoscope

I scan the top of my desk for those, tiny, pesky ants that love to crawl everywhere, especially as the rainy weather amps up a notch. Today, there aren’t any, at least, not yet! My humble desk is actually an old table. It has a wood veneer finish that is chipped at the corners. The legs of the table are a bit loose allowing it to lean like a parallelogram when inspiration strikes it. A place mat with a world map imbedded, gives the desk an international flavor. Also inhabiting the desktop are an assortment of pens – half of which write on any given day – a reflex hammer, letterhead paper for prescribing outside laboratory tests and procedures, several reference books – the most important being a dermatology book for the tremendous array of rashes and “itches” that people get in the tropics – a business card stand that holds a cardboard sign reading If you do not understand the doctor, please ask her to slow down or translate, and finally, a large flip chart with the page perennially open to a diagram of the female pelvic anatomy.

Just before I’m ready to call the first patient into the exam room, I realize, “Oh, no! I forgot my stethoscope! Where did I last leave it?”

Lucky for me, it’s just in the next room on the countertop. I reach out to sling it around my neck when, suddenly, I realize something’s wrong with it. The plastic diaphragm that covers the bell of the device is loose. It falls of in my hands when I pick it up. The rubber adhesive that glues the diaphragm to the metal portion of the bell is gone! Vaporized! Frankly, I’m flabbergasted. What could have happened? How can the rubber tape just disappear?

I know my ‘scope was fine when I set it down on the countertop after work on Friday. I start to examine the area around the spot where my stethoscope has laid all weekend. I don an imaginary detective cap and search for clues in the mysterious case of the disappearing rubber. My eyes spy a few minutia, bits of rubber looking material, nearby. The color matches the missing rubber’s hue. One or two black flecks, different from the rubber bits, are present too. “Mystery solved! My rubber seal was eaten! The evidence, those little flecks of black, reveal the whole story. The thieving bandits were actually cockroaches. They ate the rubber seal. (Gross, I know! And, yes, we clean the rooms every day, including the countertops.) My thoughts toward the cockroach, and his family, were not particularly angelic!

Of course, I’m horrified to deduce that insects, cockroaches no less, have eaten my stethoscope. I can’t hide a wry smile though, in spite of everything. I wonder - does Littman’s warranty cover cockroaches?

Ultimately, I wrap up my poor, flea-bitten stethoscope in a little plastic bag and set it aside. Such a brave little soul that survived medical school and residency only to succumb to the appetites of insatiable, fierce, African bugs.

I grab a flimsy, black replacement. It’s lightweight and the bell tends to flip around at awkward moments leaving me to wonder, “Does the patient really lack breath sounds in his left lung or is it my stethoscope, again?” It hangs limply, incongruously around my neck. I feel out of sorts without my comfortable, trusty listening device hugging the nape of my neck.

Monday, Monday, what’s gonna happen next?
 
Chapter 2. Rear Ended

Mondays can present a broad spectrum of problems. This morning it’s starting to feel a bit anal.

“Tell me about your problem,” I address the first patient of the day. P.R. is a young male in his late twenties. He is well groomed with jeans and button down, collared shirt, neatly shaved hair, and deeply pigmented brown eyes. I have seen him before.

In answer to my question I get a pleasant, blank stare.

I repeat, “What is your problem, how can I help you?”

“Doctor, I’m not fine,” he says.

“Can you tell me a little more?”

“I have fever. I’m weak. My waist pains me.”

I ask a few specifics - details like how many days has he been having fever, how high is the fever, what treatments has he already taken…?

He suddenly remembers a second concern. “Doctor, I still have the same problem.”

“Which one?” My last note lists several diagnoses including hemorrhoids.

“I see blood when I go to the toilet.”

“Can you describe it to me?” (Don’t you just love the conversations doctors have?)

I will spare you details of our intimate conversation about poop and blood. The final result was that I needed to examine the anus. (Those glamorous moments of medicine rarely discussed!). In medical terminology we say, D.R.E., abbreviations for Digital Rectal Exam. “Rectal exams - always a wonderful way to start a Monday,” I tell myself, with not a little sarcasm, as I wash my hands afterward.

Patient number two sits down across from me. She’s a short, muscular, slightly overweight, woman in her early twenties. She has a high-pitched, musical voice and cute baby cheeks that give her a very youthful impression. “Doctor, there’s something coming out of my anus,” she begins the conversation with a perfectly serious expression, pointing with her finger to the offending place. “It pains.”

“Another D.R.E. to continue my day,” I inwardly groan and resign myself to my fate. I wonder if the old axiom that problems come in threes will hold true today.

 Patient three is a darling, two year old boy with way too much energy to be sick. He squirms and whines when his mother holds him on her lap and prevents him from slipping down and investigating the fascinating doctor’s office!

Under chief complaint is written “Cough and catarrh”. Turns out he has an upper respiratory infection. Mom is reassured that he doesn’t have pneumonia. A malaria smear rules out the blood parasite’s presence.

Two more children with fevers and variations on the theme of cough, runny nose, and stomachache are next.

 Patient six though is a young man brought in by his worried mother. He leans back in the chair with an air of exhaustion and passivity.

Inviting the mother to sit down in the adjacent stool, I turn to the patient, T.P., and ask, “What’s wrong? Tell me about it.”

“My body’s weak. No appetite. Fever.” He states bluntly and succinctly. He slouches in the chair with an expression of defeat on his face.

Before I can ask any more specifics his mother jumps in, “He took two drips but he’s still not strong. I want tests to see everything to know what the problem is.”

Apparently, a neighbor, who is a nurse, gave the man two doses of quinine and two bags of intravenous fluids over the weekend.

“Any vomiting?”

“Yes, he vomit,” she’s quick to reply, nodding her head enthusiastically.

“How many times?” I specifically address T.P. to try to engage him in the conversation that concerns his health.

“He vomit once after the drip,” his mother answers. Despite the fact that her boy is now a 21-year-old man, she maintains her mother hen protectiveness and makes sure I understand that her son is ill. “I want all tests to see what type of sickness he has,” she emphatically tells me again – putting extra emphasis on the all. “He never go stool,” she continues. “He never chop (eat).”

On the exam table, I question T.P. a bit more about his digestive processes. He confirms that he hasn’t eaten much in the past few days. He has had a few small bowel movements, the last being yesterday.
Without asking, I know he won’t be able to provide a stool sample today. “Third D.R.E. today,” I inwardly observe.

An Anal Monday.

Chapter 3. Miracle Drugs

When you inherit a clinic from an obstetrician/gynecologist and you’re a female doctor, patients tend to assume you can treat every feminine disease to afflict the gender – irregular periods, infertility, chronic pelvic pain, and pre/post pregnancy complications, to name just a few. While I am flattered, there is a limit to my training and competence.

“Why can’t you prescribe a medication to get rid of the fibroids?” It’s such a common question I should have a pre-printed reply.

Sitting opposite me today is a woman in her thirties who suffers from infertility.  She gives me the results of her hysterosalpingogram. “The results say that your tubes are blocked.” I scan the report and review the x-rays then look for any signs of comprehension in her face.

I get a blank stare.

“It means that the egg from your ovary cannot pass through your tubes into the womb. Your eggs cannot reach the womb. If it cannot reach the womb, the sperm cannot reach the egg, and no baby can form.” I pick up my handy flip chart already open to the details of a woman’s anatomy. I point out the tubes, the ovaries, and the womb. With my finger, I trace out the path the egg should take in its passage to the womb. “This is where it’s blocked,” I point to the fallopian tubes on my diagram.

There’s no change in the lady’s facial expression. She nods her head as I explain a third time. 

I briefly mention a few options that have such a poor chance of success that it’s almost not worth discussing. I doubt she understands more than a few words when I describe terms like in-vitro fertilization, laparoscopic surgery, and tubal reconstruction.

I stop talking and endeavor to read any signs of emotion in her face. It’s impossible. I sit up and set my pen down then fold my hands on the desktop. “What questions do you have?”

“So, no drug, doctor?” she innocently queries.

“I’m sorry. There is no drug to open up your tubes. There is a small chance surgery might help. It’s not very successful though.”

“What should I do, Doctor?”

The conversation could go on in circles like this for several more hours. However, there are many impatient patients waiting on the benches outside. I can hear a toddler howling as he gets his vital signs measured.

She shuffles out of the exam room with the references I’ve given her for a few infertility clinics that attempt the high-end treatments. She seems a bit disappointed in me. She cannot understand why I refused to treat her blocked tube problem.

I suspect she will make her way to the next new doctor in town searching for a cure. Chances are slim that she will actually see the specialists I Douala that I’ve recommended. The costs are astronomical and few could ever hope to afford such.

Bad news, Monday

 
Chapter 4. Agony of the Unknown

“I had some bleeding yesterday, today, just a few spots. Should I be worried? Is it normal this early in my pregnancy?”

“Well,” I reply diplomatically, “Sometimes there can be a little spotting in pregnancy when the embryo embeds itself in the lining of the uterus. We call that implantation bleeding. It can come at the time of a woman’s expected menstrual cycle.”

“Are you having any cramps?”

“No.”

“That’s reassuring,” I comfort her as I see her worried expression. “ We really need to do an echo (ultrasound) to see what’s going on with your pregnancy.”

“So, should I be panicking yet?”

“Well, the amount of blood you describe is more than usual. It’s not a good sign. I cannot tell you more until we do the ultrasound though.” I realize it’s a very noncommittal answer.

During the ultrasound, her husband arrives. All three of us view the ultrasound screen’s image with anxious curiosity.

“You can see the gestational sac, a sign of pregnancy,” I point to the screen at the dark circular object within the uterus. “I cannot tell if the embryo, er…baby, is healthy or not. It’s too early.”

I cannot see any fetal heart beat, hopefully because it’s too early in the pregnancy.

“We need to repeat the ultrasound in a week,” I inform the couple. “I wish I could tell you a more definite answer, but it’s just not clear now,” I shake my head. “Don’t panic.”

The couple leaves the office with questions about the viability of the pregnancy still looming in their thoughts.

Oh, Monday! Why does everything seem to go wrong on Monday?


Chapter 5. Boy or Girl?

“But, Doctor!” An eager faced, Cameroonian woman, dressed in a colorful, cloth wrapper, non-matching T-shirt neatly tucked in at the waist, and a head scarf to match, approaches me as I dash between my office and the pharmacy.

She holds out her medical booklet and points emphatically to her belly.  She is noticeably pregnant. The 1.5 liter water bottle at the foot of her chair is almost empty. It is not hard to deduce the reason for her visit. She is here for an obstetric ultrasound (echo).

I nod and smile at her, then continue back to the rather alarming pile of medical books representing patients waiting to be seen.  Despite my efficient histories and physicals (at least in my opinion!), the stack increases rather than decreases. The eager, little, lady drinking her water and filling her bladder for an ultrasound fades into a distant memory as I press on with consults.

Several coughs, runny noses, itchy rashes, stomachaches, fevers, and chest pains later, TeClaire, our pharmacist/cashier, knocks on my consult door.

“That lady who came for echography, she says she has to pee.”

I look at the number of patients still waiting to be seen.

TeClaire has already noted the numbers in the waiting room. “Should I tell her to pee now and drink more water.”

“Yea, that will be a good idea.” I sigh as I look at my watch. I am sorry I cannot get to her sooner. The lady was warned when she came today that I would only have time for her echo in the afternoon. I prioritize normal consults because most the people will need lab work done. If I don’t see them in the morning, they won’t be able to get their labs completed. I’ve made it a standard policy but occasionally patients choose to wait, on the slim prospect that I might have an opening and squeeze them in sooner.  Our dedicated pregnant woman has selected this option. The difficulty arises in the delicate timing of a full bladder and my availability to do the echo! If I’m delayed, the woman’s bladder might explode first. If she pees and then, unexpectedly, I get a break, then we have another problem. (In case you’re thinking, why not tell her to empty her bladder partially – tried it; didn’t work!).

Sometime in the early afternoon and three liters of water later, I find time to do her ultrasound. She speaks almost no English; my Pidgin understands her but lacks the vocabulary to explain anything. We get on swimmingly! Before we start, she blurts out, “I want know boy or girl.”

I’m not surprised. I assumed it’s the main reason she is doing an ultrasound since medically, her pregnancy has been progressing normally.

I flip on the switch, pray that the electricity is stable and entering the electrical lines properly so that the machine can run smoothly, and press the buttons to obstetric parameters.  Calibration complete, I squirt gel onto my “probe”, the hand piece that contains the all-important crystals that transmit the appropriate wavelengths, and begin to scan her belly.

Bladder full. Good.” I continue scanning. “Cervix closed. No placenta covering the cervix  (A condition known as placenta previa).” I follow the curve of her belly upward. I halt abruptly in my standard scan routine. “Umm…is that an amniotic membrane shimmering on my screen?” I scan left and right. “Yep, it’s a membrane and it’s separating the womb into two compartments.” I start fanning out. As I expected, I find two heads. I double check by positioning my probe so that both heads project onto the screen together.

Convinced of my diagnosis, I break the news. “You have two pikins.” I smile at her.

She gives me a giant, toothy smile back. Without missing a beat, she asks, “Boys or girls”?

“I don’t know yet. I have to look more,” I reply.

Eventually, I get all my measurements made and determine that the twins are healthy and growing normally and equally. For a few seconds, we watch them on the screen as they kick and punch at each other through the curtain of the dividing amniotic membrane. They certainly appear to be interacting with each other, playing a game perhaps.

“You have a boy and a girl. A complete set.” I inform her. “Congratulations!”

She smiles and smiles. “Thank you, doctor. Thank you.”

Well, not everything bad happens on Monday.


Chapter 6. Of Headaches and Hope

My heart sinks. I look across the consulting table at Laurel* sitting in the chair opposite while her husband hovers next to her with a supporting hand on her shoulder. I know Laurel from her first pregnancy when she came to our clinic with a severe headache. She’s a wonderful, sweet lady. She is well educated, speaks and understands English perfectly, and has family in the United States.  Her husband is a professor at the University of Buea. This is Laurel’s second pregnancy.

The couple struggled with issues of infertility for quite a number of years. Through it all, her husband remained faithful. In a country that accepts infertility as a legitimate cause for divorce, his love stands out. After much prayer and surgery, she finally conceived and gave birth to a healthy boy. One cannot describe the joy the couple has over their little boy who is now almost 2 years old.

In January of this year, I had the privilege of diagnosing twins on an early ultrasound. The pregnancy was an unexpected, happy surprise. Learning that there were twins was an added blessing! Although Laurel was at high risk for complications, up until now, her pregnancy had progressed normally. She was now in her third trimester.

“So, what is going on?” I ask her. I notice that she seems a bit more out of breath than I would expect. Drops of sweat bead up on her forehead.

“I just recently started having this headache. And my legs and fingers are really getting swollen,” she answers.

“Has your blood pressure always been this high?”

“That’s the funny thing, Doctor. My blood pressure has always been normal. I had a check up in Yaounde two weeks ago and everything was normal.”

This time her headache is not a migraine. As most of you have guessed, she has pre-eclampsia. It is a disorder that affects pregnant women in the latter part of their pregnancy. It is generally regarded as a multisystem disease, affecting both the mother and the fetus. Without treatment, it can progress to maternal seizures and death of the fetus in-utero.

It’s not an easy conversation to break the news to Laurel and her husband. They ask many questions. I explain that they need to do more tests and have an obstetric ultrasound to measure the babies and see how they are doing.

“Doctor, can you do the echography today?”

I do many obstetric ultrasounds and normally this would be an easy question to answer yes to. However, there are several factors that make it an extremely difficult proposition. Number one, there are two babies inside – in the tangle of legs and arms it is not so easy to discern which belong to twin A versus twin B. Number two, because there is such a high risk of circulation problems, I want someone with more experience to calculate the flow patterns. And finally, number three; Laurel is not a small woman. She weighs more than our scale registers, which is 120 kilograms (264 lbs).

“Laurel, I don’t think I can do the kind of ultrasound you need,” I gently inform her.

“But, we just want to see if the babies are alright,” she pleads.

“You really need an ultrasound done by someone with a more powerful machine and more experience. I don’t have enough expertise to adequately measure everything and make sure all is well,” I answer.

“We were really hoping to do an echo today, though. Can’t you try?”

“I’m not trying to dismiss you,” I look at both of them. “I just want to make sure you get the care you need.”

“Just for today, though, doctor, could you do the echo?”

Their hearts are set on seeing the twins. They were planning on doing an ultrasound today even before they arrived.

My resolved weakens. I feel for their anxiety. I know they must be worried about the twins. They want to see, with their own eyes, that the babies look ok.

“Ok, I’ll do an echo today,” I look up, “but it will not be anything formal and you will still need to do another ultrasound to ensure the babies are growing fine. I cannot guarantee that we’ll be able to see much. We will just try.”

It was quite a comical sight when I performed the ultrasound! Christiane, my nurse, held up her tummy flap and attempted to maintain her grip despite all the slippery, ultrasound gel. I tried to maneuver the probe without running into her hands. Hands slipping and several awkward positions on my part to get the views needed, we managed to measure the twins’ heads, showing them to be almost the same size. The heartbeats were normal. Christiane and I were both physically tired when we finished!

Laurel and her husband were delighted to see the twins on the ultrasound screen. It gave them hope. I guess, in the end, that is what counted.

After a lot of counseling and questions on their part, they decided to go to a specialty hospital in Yaounde for the intensive care she needs. I am happy that she is able to get the medical care she requires. For most, the cost of treatment makes it impossible. Unfortunately, it is far too common to force labor or do a cesarean section, knowing that the fetus is not developed enough to survive, in order to save the mother’s life.

Monday draws to a close. So much has happened. I am physically and mentally exhausted. I thank God for the strength he supplied today. He was with me all the way - rectal exams, ultrasounds, and everything in between!

Time for Tuesday!

*real names have been changed.