A birthday, Versace, Walmart, and Seizures of Pregnancy

First off, HAPPY BIRTHDAY, SCHUYLER!

Second off, please click the “comments” link at the bottom and leave a little note when you feel like it. It’s nice to feel like I’m writing to people and I’ve loved the comments people have left on prior entries as well as the wonderful emails. I’d also like to know what else people would like to know. Weather? Cultural music (I’ll try to upload an audio file of the women’s support group who sing harmonized spirituals every lunch hour)? Hospital staff? Perspective on HIV? Basotho food options? Attitudes towards healthcare? Currency? LeBoHA program details? Travel options? Amount of sweat produced daily by the average visiting medical student? Flora and fauna of Leribe?

Third off, I gave out my first sticker today and will work hard to give out the 5,999 others that Laurel and Misko gave me. There was a 4yo boy riding the communal Motebang hospital black scoot-along plastic bike and I gave him a “favorite horses” sticker which he stuck on the back of his hand. I’ll take a picture of someone on the bike soon because there’s often someone scooting on it.

Fourth off, fun activity today: some time before I arrived Ethel and Kevin were picked up as hitchhikers by a man from Mauritius who runs the only profitable textiles factory in Lesotho. He employs 2,000 people, 90% female, who produce 1.7 millions pieces of clothing every month for Walmart in the U.S. It’s estimated that over 60% of his employees are HIV positive and, as he was losing 15% of employee time to medical appointments, he decided that he should employ a nurse full time to staff an on-site clinic. He invited them to bring colleagues to come to his factory for a tour. So today, after we finished rounds and urgent patient care duties, Ethel, Kevin, Phil (one of our two attendings, the one from Maine) and I headed off for a late lunch from Shoprite in the truck and took a quick ride to the factory in a neighboring town. The guard let us in the front gate, past the big sign in English and Chinese, and the owner met us at the door in his Versace jeans and led us upstairs past windows onto an impossible number of people in masks at rows of sewing machines to a conference room and offered us Cokes™. He seemed like a really good guy who has partnered with an NGO which looks after textile workers and their health, especially their HIV needs. After talking for a while and finishing our drinks, he took us on a tour of the facilities from the warehouse full of cloth from China, to the fabric mass-cutting area, through the long floor of piece-work sewers, to the ironers, to the spot cleaners (who must drink milk to clear the ethyl benzoate or something and who can only spend a month doing their job before rotating back to the floor), to the incinerator whose heat from burning cloth scraps powers the plant, and finally through the folding and shipping area. I felt like I was on an episode of “How It’s Made”, which was gratifying in its raw-materials-to-packaged-product fullness. We visited with the nurse who hangs out in a little garage across the parking lot, sees a full load of patients each week day, writes prescriptions for antibiotics, works with volunteer HIV staff one day a week (they can start anti-retrovirals and do on-site HIV testing), and has a good shelf full of female and male condoms (though I don’t know how many she ends up giving out). I can’t decide how I feel about this place. It provides 2,000 jobs for Basotho women, the manager credits his success to the “family feel” of the workforce and the company-wide communication, yet factory work sucks and I can’t imagine the employees make a ton of money. We headed back to the hospital with four free moisture-wicking shirts in our hands.

Fifth off, nobody I had met died today. That was great but doesn’t mean nothing awful happened. We’re doing a grand reshuffle of patients so that the medical students and our wonderful registrar (resident) Matheko are all carrying an evenish number of patients, all being overseen by Matheko who is building her necessary management skills for her future working in similarly overwhelming environments. So I was getting to know my two patients on the female medical ward when Kevin and I were called in silently and urgently to the maternity ward (though I didn’t yet know this was the maternity ward and thought Kevin was really clever to ask if she was pregnant. That’s not to say he’s not really clever, because he is abnormally clever, but this wasn’t the stroke of genius I thought it was). A 20yo girl who, by fundal (top of the uterus) height, was an estimated 22 weeks pregnant (a finger-breadth above the belly button) was having persistent but physically quiet seizures in her bed. In someone without a seizure disorder, this is mostly caused by eclampsia, characterized by high blood pressure, kidney failure evidenced by protein in the urine, and the potential for nasty hemorrhage in a variety of organs. The two of us and a totally beautiful person of a nurse held her safely, protecting her precious IV line, rolling her on her side so she wouldn’t swallow her secretions or block her airway with her tongue, and gave valium and then, when it was located, magnesium sulfate in her IV and both buttocks. For the non-first-aid crew out there, the ABC’s which dictate the appropriate order of emergency medical management are Airway, Breathing, and then Circulation, meaning you don’t even try to help someone do the mechanical work of breathing until you’re sure she has a clear path to the lungs. To manage an airway you might want a little curved tube that ensures that air gets past the tongue to the back of the throat, an “oropharyngeal airway” (OPA). We don’t have those. If someone is having seizures for half an hour (good lord) you might want to intubate them with a tube that goes all the way down the trachea to where the lungs branch off. We don’t have endotracheal tubes. So we went basic and did the occasional jaw-thrust, pushing her mandible out when she started making tongue-sucking snoring noises. Luckily she never vomited. The valium and magnesium hopefully stop the seizures but also, by dulling the central nervous system, suppress the respiratory drive. Despite some episodes of irregular breathing, she didn’t slow her respiratory rate too severely. The only definitive treatment for eclampsia is to deliver the baby, the unwitting cause of this mother-threatening disease. Fadya, the other great attending (from Rhode Island), grabbed a Doppler machine which amplified an appropriately fast and regular fetal heart rate through the filled maternity room, to see if the fetus, should it prove to be developed enough, would be “viable”. I hate that weird, clinical word, but don’t have a better one. After a vaginal exam, which required serious muscular control of the woman’s flailing legs, revealed a closed cervix not ready to deliver even this tiny fetus vaginally, the only option was to take her for a C-section. Unfortunately the one and only surgeon was already in the operating room (theatre) performing another section. So we had to continue trying to control the seizures, keeping the airway open with our basic first aid methods to receive the oxygen we were giving by facemask (borrowed, by the way, from the face of a young woman with her feet up in the air to return blood to her head while her blood pressure hovered around 70/40 and she vomited onto her pillow – a woman who was moved a couple hours later to an isolated room because her expected overnight death would be upsetting to the other seven women in the room), and continuing to guard the IV line from the erratic and occasionally semi-purposeful movements of the seizing mother. Eventually, after maxing out on our medications in a well-communicated dance of safely-handled needles, Kevin and Fadya and I rolled her on a gurney to the surgical building where she had her hopefully-life-saving C-section. We’ll find out tomorrow how her brain, kidneys, and liver survived the trauma of this weird vascular collapse. The baby was a girl who weighed 800g (1 lb 12oz) and, given the futility of resuscitation efforts, was covered with a towel to slip off with hoped-for peace. The girl had not received any prenatal care during which someone would have noticed that her blood pressure was high and that there was protein in her urine. She was from South Africa and living with her grandmother in Lesotho who found out the girl was pregnant as she was being wheeled to the surgical suite. Oof, oof, oof… the solution is in public health, not bedside medicine.

Sixth off, Kevin made a really nice beans, veggies, sausage, and rice mix for diner which tasted awesome with Milk Stout.

Seventh off, I’m going to sleep. xo, Liz