Hoof Beats

"A baby is God's opinion that the world should go on."
-Carl SandburgUS biographer & poet (1878 - 1967)

Today we had a pretty interesting morning. We had a camera guy follow us around during most of the morning. It made seeing patients a little awkward. We saw a gentleman that was in a bus that was hit by a car bomb. He had a foreign body in his cornea. The Ophthalmologist thought that it was a piece of glass. He was sent to a different hospital to have surgery.

We had an interesting conversation with the ER doctor which, by the way, was all caught on camera. He was asking about the blue pen light that I gave him the other day. He wanted to know what it was for. I told him that it can be used to identify scratches or ulcers on the cornea. The lesions light up after you add a chemical called fluorescein. He was a little confused because back in his old hospital he would use the blue light as a form of disinfectant. He thought that you could run the UV light over objects to disinfect them. He said that in the OR they had UV lights attached to the ceiling and they would turn them on for a short while so the room could be disinfected. I told him then if that was the case then everyone that used tanning beds in the U.S. should be free of any bacteria. I tried to explain the proper way to disinfect surfaces and rooms. I am not entirely convinced that he believes me. I think that it will take some more reinforcing.

About the same time that we were having the conversation about the UV lights one of the cleaning crew workers came in and started wiping down light switches and door handles with a dry cloth. We asked him what he had on his cloth and he replied nothing. We tried to educate him on the importance of using disinfectants. A lot of the education that we provide is really simple basic stuff that will end up making a big difference in reducing the spread of bacteria in the long run.

We saw a guy who was hit by a car and had right shoulder pain. I asked him what had happened and he said that he was hit by a car and then the driver sped off. I asked how he got here and he told me that he called his brother to pick him up. As we were interviewing the patient the camera man asked me, "So how does this patient differ from one you would see in the states?" I said, "Well for one thing, in the states the driver probably would have stopped to help him and he probably would have been brought here by an ambulance."

I was talking to the Orthopedist and I asked him what happens if a patient needs to be operated on after hours. He told me that an ambulance comes to his house and picks him up. He arrives at the old hospital with sirens blazing. I kind of like that.

We also had another older patient come in with chest pain. The ER doctor was able to get an EKG on his own and was even able to interpret it stating correctly that there was an abnormality. He was correctly able to identify that the patient was having an early heart attack. I felt very proud of him. He both learned how to operate an EKG and learned basic EKG interpretation all in one week. The treatment part was not so simple. Obviously, our treatment options are very limited in Afghanistan. Even so, he knew what the basic meds were that he needed to prescribe and he was able to provide as best care as he could considering the circumstances.

The OB/GYN doctor came to the ER to see me because she had 2 OB patients and she wanted me to teach her how to use the new fetal doppler. It is a little hand held ultrasound that lets you hear a baby's heart beat. When we first showed her the instrument back during the equipment orientation she actually thought that was harmful to use on pregnant women. We had to reassure her that it is safe and commonly used in the U.S. When I went up to the room I was faced with a challenging dilemma. I needed to show her how to use the device but the only problem was I am not allow to see, or heaven forbid, touch another female since I am male. So I had to figure out how I was going to teach her how to use the doppler without using a female patient. I decided to use the male interpreter who happen to be a very good sport about it. We went through all of the typical motions and we were even able to pick up pulsations from his abdominal aorta. I told the OB doc that I would be right outside the door in case she had any questions. With the door cracked open I was able to hear the wonderful sounds of hoof beats which let me know that she was successful.

We still had the problem that both patients had no paperwork, had not had any ultrasounds, and were not on prenatal vitamins. One of them had lab work that was positive for Toxoplasmosis - an infection that can be extremely harmful to the fetus and protein in her urine. The mom said that she had 2 previous miscarriages. I asked the OB doc where she normally did her deliveries and she said that her patients come over to her house. I am not kidding. She asked if she could deliver babies in the new clinic. I told her that it would be better then delivering them in her home. I am now faced with the task of converting a basic exam room into one that is suitable to support a delivery room and even a small nursery.

Since the OB doc did not even have a chart or a medical record on the 2 patients I decided to download a standard OB template that is commonly used in the states. I also downloaded a paper ruler so we can measure the fundal height (the belly). My goal is to have a medical record started on every patient, regular scheduled visits with vital signs and labs, physical exams on every patient, and a half way descent delivery room.

After she identified the baby's heart rate with the small Doppler she asked me if she could use it to tell if the baby was breech or cephalic (head down). I told her that you can only determine a babies heart rate with the device and that you have to feel the abdomen to determine how the baby is lying. I do not think that she quite understood me. When I also suggested that she do a vaginal exam for one of the patients that was 36 weeks she gave me another strange look. I have a feeling that she has never checked for cervical dilation on a patient. This was especially surprising since she says that she has been delivering babies since the 70s.

I would also like for the OB doc to start doing basic ultrasound. I am not very proficient at it myself but I at least am able to check if the head is down and the level of fluid in the amniotic sac.

Take care. Thanks for reading.