2 Dec 2022

"Oh, we’re all broken, in some way. Broken and haunted. . . There is more though. It’s not all sad. . . There is magic too." -Rana Awdish, In Shock

The apparently-magical side of medicine welcomed me back to clinical work in the hospital today after a trip to Gabon for administrative meetings followed by a couple of weeks of vacation. An ultrasound kicked off this morning’s work—a special ultrasound because it was for our friend who works for us on the housing compound. We know all that can go wrong in this pregnancy, and we’ll be following her closely and praying for health for her and for this baby. It’s fun, though, to help take care of a mom who is so absolutely excited to be a mom again, in spite of having traversed the unbearable pain of the loss of her first baby so soon after taking her home from the hospital. How courageous of her to embrace the joy of this pregnancy so freely!

Marta—a volunteer midwife who just came to us from Poland—and I walked to the maternity ward. In the delivery room our midwife Baikao, chief of the maternity service, showed me the patient who had just arrived and whose amniotic sac had just now accidentally broken by examining her (unintentionally augmenting her labor). "How many babies has she had?" "It’s her first pregnancy." The visible baby feet sticking out left no doubt that this was a breech presentation. It would be tempting to think that this baby was so close to delivery, and she should just push and have a normal breech birth! But the risks of the head getting stuck on the way out are higher when the mom has never had a baby before, so we usually try to operate in this situation. "Get her labs started! I’ll let the operating room team know." So we rushed to the OR, and Stephen and I did the cesarean section. I guided the baby out through the incision, still in breech position, then waited to clamp the cord, commenting to Stephen that this brief delay should be especially beneficial to this baby since she looked a little bit premature. After handing the baby off to Marta, I moved to take out the placenta, but instead of placenta I saw a smooth sac full of clear fluid. I reached in and felt a baby’s head. I guided it out as Stephen pushed from above, and an amniotic sac full of baby and an attached placenta came out together. We punctured and peeled off the sac and stimulated the surprise second twin briefly until he cried and then handed him off to Marta and Rodrigo. The mom got to meet her two healthy twin babies before leaving the OR.

I felt a little rusty after being gone for a few weeks, and before that having been swamped by a preponderance of administrative work and other urgent out-of-hospital tasks for a couple of months, but this case—ending up with a healthy mom and two healthy babies—welcomed me back and reminded me how fun hospital medicine can be. Is there any work more fun than direct patient care—connecting with patients, doing procedures that help them, solving interesting problems, and being surprised by something every day? (Disclaimer: may be habit-forming. Significant, life-altering, and in some cases fatal side effects may occur. Ask your Higher Power if the practice of clinical medicine might be right for you.)

On maternity rounds, Baikao pointed out a patient who was waiting outside « sous véranda » (under the veranda—not acutely sick but waiting for surgery). "Do you remember her? The patient that you helped!" I glanced in the direction Baikao pointed. Of course I remembered her! She didn’t look like the patient who had languished with ascites and acute kidney injury and postpartum infections for days, left against medical advice, and returned emaciated to stay on our service again for weeks—the patient that Abouna and I had operated on and washed pus out of her abdomen which had become inflamed to the point of forming a solid impassable wall of tissue. I had never seen such bizarre complications from a normal delivery at home. After washout and packing open and dressing changes and antibiotics she had finally healed and been closed and now apparently had been eating well and gaining weight. She looked like a different person! Now she *just* had a fistula from her prolonged labor. Danae can do fistula repairs (I know often they’re hard, and sometimes the initial repair doesn’t hold if the tissue is bad, but with a smile like that, and looking so healthy, I can’t help feeling like the worst is behind her)! So much hope for her now after feeling so desperately hopeless for her a few months ago. Seeing her wide smile brightened our rounds and reminded me that even when I don’t have it all figured out, even the absolutely perplexing cases can turn out alright in the end, and getting to know and help patients like her is just an unearned gift.

"I put no trust in my [clinical judgment], my [scalpel] does not bring me victory; but you give us victory over [disease, death, and discouragement], you put our adversaries to shame. In God we make our boast all day long, and we will praise your name forever."

Adapted from Psalm 44:6-8