Cowboys and catheters

Cowboys and cathetersDeprivation is worst in “ex-homeland rural areas” according to a range of DHB indicators that covered income, unemployment, living standards and education

Rural health can get rough. Making the cut as a doctor may be equal parts experience, ingenuity – and knowing when to call a friend when you’re out there on your own.

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pregnancy and stethoscope IRIN
“If you’re mid-way into a Caesarean section, elbow-deep in blood, and completely over your head and panicking, tying a Foley catheter around the neck of a haemorrhaging mother’s womb could stem the bleeding…”

“Sometimes you make mistakes and people die,” says the man running our obstetrics workshop.

He doesn’t pause to let it sink in, but it sticks with me nonetheless. It’s blunt, cutting and honest.

I’m certain that I’ve heard it before. There’s a whole host of these pearls that are dished out free or charm at medical school, like “if you haven’t cut through the bladder, you haven’t done enough Caesarean sections.”

Or my personal favourite, “if you haven’t killed someone, you haven’t been practising medicine for long enough.”

I’ve been subjected to these shock tactics before but something tells me that this man is speaking from experience.

Having made his point, he moves on to describe how when you’re “out in the sticks” a catheter could save a mother’s life.

If you’re mid-way into a Caesarean section, elbow-deep in blood, and completely over your head and panicking, tying a Foley catheter around the neck of a haemorrhaging mother’s womb could stem the bleeding long enough for you to call a friend.

And you had better hope you have a friend to call.

“If that doesn’t work, just get in there and hold the aorta,” he says. “Or get someone else to hold it whilst you try find the bleeding.”

Foley catheters are flexible tubes with an inflatable balloon tip designed to be inserted into the urethra. The devices have a myriad of “off the label” uses in medicine – from using to inflatable bulb to dilate the cervix in an induction of labour, to preventing blood from flowing down the nasal passage into the mouth in a severe nose-bleed.

Some textbooks refer to this as a “salvage” procedure. “Salvage” is an interesting word choice. “Salvage” is most frequently used to describe the process of recovering cargo from a shipwreck.

Its use here begs the question: “What is it that we, as the surgeons, are trying to recover?”

The ship is already wrecked, but maybe with this rubber band fastened around the uterus, we’ll be able to patch up the grounded vessel. The patient will almost definitely lose her womb, but she may get to keep her life.

Essentially, it’s a last resort.

Books can only take you so far

[quote float=”right”]”I’m surprised by how much of obstetrics I remember, and alarmed by how much I don’t know”

After our weeklong training, I have been reallocated to a new ward in the hospital catering for sick pregnant women as well as new mums who delivered via Caesarean sections and stay with us for a short period of observation.

It also houses a Kangaroo Mother Care ward, where moms take the place of incubators and sleep on their backs with their tiny preterm babies lying naked between their breasts.

Babies tend to do exceptionally well when nursed like this and I can understand why.

One can almost imagine how comforting this must be – reverberating with every beat of your mother’s heart and rising and falling with every breath she takes.

I’m surprised by how much of obstetrics I remember, and alarmed by how much I don’t know.

Of the sick patients I see, I worry only about the young pregnant women with malaria. She doesn’t look too ill but her blood results are bad. When I put my stethoscope to her chest, I hear crackles on both sides of her lungs, similar to what one would hear in a patient with heart failure. In severe malaria cases, the infected red blood cells can cause damage to all the organs, clogging up the small capillaries and causing fluid to leak into the lungs.

For now, she doesn’t appear distressed. I leave her on a quinine drip and watch her closely in the coming days. At lunch, I pull out a copy of the textbook Harrison’s Principles of Internal Medicine and read through the chapter on malaria, focusing on what I should monitor during her admission.

The wild, wild west

[quote float=”right”]”You’re out here on your own, roaming across this remote land like a lone cowboy crossing border lines to lead the herd to safety”

It’s such a different way of learning than what I’m used to. At the big academic hospitals, there’s always someone to ask. In fact, before you even have a chance to ask, there’s usually some professor leading the ward round and rattling off the intricate details of almost any condition. Their years of experience supersede anything you can read online or in a textbook.

But, out here it is solitary learning. You’re out here on your own, roaming across this remote land like a lone cowboy crossing border lines to lead the herd to safety.

You have to be disciplined if it’s going to work.

So I’ve decided that if I have to be a cowboy, I’ll just have to be the best cowboy.

As far as I’m concerned, that’s a cowboy with a cell phone, and an entire crew of people to call when the proverbial excrement hits the air conditioner.

After dinner, I take out my phone and start building my lifelines, reconnecting with all the doctors I know and respect.