Portal de Periódicos da CAPES

Going Global

2018; Lippincott Williams & Wilkins; Volume: 40; Issue: 3B Linguagem: Inglês

10.1097/01.eem.0000531985.94877.aa

1552-3624

Spenser White,

Global Maternal and Child Health

FigureFigureFigureIt was my first night on call in Uganda. I had a reputation and precedent for difficult first nights; my initial intern overnight shift during the weekend of July 4 had been quite hectic, to say the least. Now two years later and halfway across the world, the universe was trying for a repeat. I woke up to the vibration of the vintage cell phone dancing across the cement floor. Still groggy, I looked at my watch and saw that it was only 12:30 a.m. I answered the phone and heard the familiar voice of the hospital midwife. It was difficult to understand her because of her thick Ugandan accent, but I was able to discern that they were having some sort of obstetrics emergency. Obstetrics! Sure, I had seen a few births as a medical student and even completed the 10 uncomplicated deliveries required of an intern, but that was a long time ago and I had never seen a complication. It was a quick stroll down the dirt road to the medical center, and I was greeted as always with smiling faces by the staff. Walking into the room, I saw a young woman in active labor lying on top of a blue tarp on the delivery table. The midwife explained that the woman had ridden in on a boda (the local term for a motorcycle), and the staff noticed that the woman had a C-section scar, but no one knew why. Attempts to discover its origin were futile because the soon-to-be mother spoke one of the 70 languages in the region. Gowned and sterile, I stood in front of the groaning woman as she pushed with encouragement from the midwife. Finally, I could see the baby's head crowning. Continued pushing yielded increasing visibility until finally the head was delivered. Then the head started to retreat, and fear ran through my body as I immediately recognized the complication that was unfolding—shoulder dystocia. I knew it could be fatal if not quickly corrected due to the compression of the umbilical cord in the birth canal. In fact, it was an obstetric emergency I had read about and even practiced on a simulator but never seen in real life. Panicking on the inside, I instructed the patient's grandmother to hold the legs as far back as possible for the McRoberts maneuver. Still no movement. I applied pressure over the lower pelvis. Nothing. I pleaded with the woman to push harder, knowing she did not understand a word I uttered. The midwife handed me a pair of scissors, and asked if I wanted to perform an episiotomy, but the shoulders started to emerge, and the baby was delivered with one final push. The cord was wrapped around the neck at least twice, so we quickly unraveled it and found a lifeless, blue, and apneic newborn. Attempts at stimulation were quickly made, but it was apparent the baby needed help. I asked for pediatric intubation supplies, but by the look on the midwife's face, I knew none existed. With no time to spare, I asked for the smallest mask in the hospital to fit on the ambu bag. For the next 20 minutes, the midwife and I resuscitated the newborn—one bagging, the other holding a stethoscope on the chest (our version of a monitor because one did not exist). Gradually, we saw improvement, and signs of life began to emerge. Eventually, the child was breathing on its own and even let out the long-sought first cry. I sat outside after attending to the second-degree birthing laceration on the mother (another first). Still drenched in sweat, I settled into a moment of reflection, wondering what else laid in store. I wasn't even halfway through my first night. Surgery with No Lights Five nights later I received another memorable call. The mother and baby had already been discharged. This call was for a young man who had been in a motorcycle crash. “Finally,” I thought, “This is something I know well.” When I walked into the room, my first thought was that the patient looked sick. My suspicions were confirmed when I checked the first set of vitals. The patient's blood pressure was low, his heart rate was high, and he appeared confused. My program had equipped me with an ultrasound that plugged into a tablet, so I did a trauma scan first. Blood was seen throughout the patient's abdomen, and it appeared that his spleen was in multiple pieces. The young man needed immediate surgery, or he was going to die. The regular surgeon was not available, so we summoned a surgeon from the neighboring government hospital. As we rolled the man's gurney down the gravel walkway connecting the outpatient hospital to the surgical theater, aggressive fluid resuscitation was started because there was no blood in the facility for transfusion. No intubation. Just ketamine. The patient was placed on the operating table, and the abdomen was prepped with Betadine. The surgeon and I were scrubbed and ready. As we went for the first cut, the room went dark. It wasn't unusual for the electricity to go out in Uganda, but it was the middle of the night and time was precious. Our patient was going to die. The moon was bright enough that night to see the others in the room. We found a camping headlamp and held it at the foot of the bed, which gave us just enough light to view the surgical field. Guided by the surgeon I had just met, I cut the spleen from its vessels. I looked up at the others in the room; none of them seemed as astounded as I was that we had just removed someone's spleen in the middle of the night with a 10-dollar battery-powered lamp. The blood loss was massive, and the patient was unstable. Fluids helped, but he needed blood. Nurses and other faculty called friends at neighboring facilities, and eventually it took taxis to two different facilities over an hour away to get our precious three units. Despite all odds, the young man slowly recovered over the next few days. Ironically, he walked out of the hospital on day five and got on a motorcycle to go home. The next night we received a similar accident, with another spleen laceration requiring removal. This time the lights were on. It wasn't all this crazy. We often cared for similar medical conditions back home, although chronic medical problems were exceedingly rare. In their place were things like malaria, tuberculosis, and what seemed like every tropical disease I vaguely remembered learning about in medical school. Needless to say, the experience was life-changing. Overall, the trip to Uganda continued to be full of first experiences—some I was prepared for; others I discovered along the way. This is the embodiment of emergency medicine. One can never truly be ready for everything that comes through the door. We can only read, learn, and train. Only then can we hope to have the knowledge and skills to help those depending on us.