Unqualified!

Most days practicing medicine in Malawi I feel like I don’t know very much.  I am trained in Family and Preventive Medicine – they are specialties, but very broad.  I was trained mostly in outpatient medicine, but work mostly in the hospital.  I was trained to use an advanced set of diagnostic services, and here there are few.  Put into a tropical context the depth of understanding and experience I have regarding what I do on a daily basis is quite limited, and I feel incompetent every day.

A few nights ago I was called around midnight by the clinical officer, “Doctor, I think there might be two babies, will you come and do an ultrasound?”  As a diagnostic tool ultrasound is very practical here.  We have a small portable unit, and it is invaluable – if you know how to use it.  I had very limited training in residency with ultrasound – I could measure the fluid around a baby, tell if its heart was beating, and whether its head was down or not.  I could also probably tell whether somebody had a liver or not…

It seems like it should be pretty easy to tell whether there is one or two babies in a women’s belly.  I always pictured it as a black and white matter, but at 1:00 am this morning it didn’t seem so easy to me.  I looked around in the very round abdomen (which was definitely larger than the 33 week gestational age reported by mom) for about 30 minutes, and was pretty sure that I saw one head down, and one head up.  I was also pretty sure that I saw two different hearts with different heart beats.  It had taken a while, but I felt pretty sure of my diagnosis – “Twins!” 

Now if that were the end it would be a nice story, but there were a couple other questions: the patient had a gush of fluid 6 hours ago, and the midwife had felt a pulsating cord next to the presenting part when she did a vaginal exam.  I checked the cervix myself – it was 3 cm dilated, the head was not engaged, and I did feel a pulsation on the left side deeper in the pelvis.  Now, at this point I should put a bit of a disclaimer here – I am a Family Physician – not an obstetrician.  I have never delivered twins, seen a cord prolapse, and have always transferred patients with preterm rupture of membranes to the nearest obstetrician on call.  So there was a bit of perplexity that found its way into my diagnostic algorithm because tonight I was THE doctor on call. 

After a little discussion with the clinical team and patient we decided that we should pray and give her some steroids (to help the baby’s lungs mature), antibiotics(to prevent an infection since her membranes had ruptured), and salbutamol (to try to slow down her contractions). 

I headed back up the hill to get a little sleep.  About an hour and a half later my phone rang again, “Dr, the cord has prolapsed. See you in the Theatre (OR)”.   I was afraid that would happen.  I hurried back down the hill.  When I entered the Operating Theatre, sure enough there was the umbilical cord.  It had a strong rapid pulse.  I had once read a story about a missionary doctor who had held a baby’s head off of a prolapsed umbilical cord for several hours while they drove to a surgical facility.  It made sense to me, so I put on some gloves and pushed the baby up off the prolapsed cord while the clinical officer prepared to do a caesarian section.  The anesthetist placed the spinal anesthesia, and the surgery commenced.  I was impressed with the surgical skills of the clinical officer.  I thought about his training – he has three years of training after high school, but he handles any emergency in the hospital whether pediatric, adult, obstetric, or trauma.  The Malawi health system depends on clinical officers – they are the clinician of Malawi, and at least ours do a great job for the training they have had. 

He finally opened the uterus.  I had been pushing the baby up for about 30 minutes, and the pulse was unreliably present by this time.  With a little trouble he extracted the first baby which was the one I was pushing on.  The baby was clearly asphyxiated – blue, breathless, floppy, but had a heartbeat.  We took Baby 1 over to the resuscitation table where we dried and stimulated the baby, but with no response.  We started to bag the baby with oxygen.  The color was starting to improve when the nurse brought another little blue baby and set it down.  Baby 2 was also floppy, but was at least breathing intermittently.  We started to do a bit of a unique resuscitation – two babies, one bag mask – hyperventilate a little here, then there, dry, stimulate, suction, etc.  I was feeling pretty bad right about now, as it looked like both babies were in a bad way.  I was working on the babies with the anesthetist when he said, “Go get the other one”.  Other one?  

Then the nurse handed me a tiny Baby 3.  This one was almost half the size of the others, but she was breathing, had good color, and normal tone.  She joined her two brothers on the table, and we just settled in for a cozy resuscitation.  After about twenty minutes Baby 1 started to breathe on his own – thank goodness!  Baby 2 by this time was pink and moving, but still with rapid shallow breathing.  Baby 3 was just chilling – eyes open taking in the newness of life, looking for her first meal. A few minutes later Baby 1 started to holler, and didn’t stop until I left.

Baby 1: 1.6 kg  (3 lbs 8 oz)

Baby 2: 1.5 kg  (3 lbs 5 oz)

Baby 3, Girl, with Grandma

Baby 3: 950 gm (2 lbs 1 oz)

I looked at the three babies with their hand-knit hats bundled up in their sheets, and I was grateful.  I was the least qualified to help them come into the world, but here they were.  In Malawi, 25% of children die by the age of five.  Unfortunately, these three have a much steeper mountain to climb.  They are small, premature, and had a bumpy start, but at least today they are alive.

“The Lord has done this and it is marvelous in our eyes.” Psalm 118:23.  Despite my limitations, God made something beautiful.

In medicine it is easy to feel that our success is dependent on our experience, knowledge,  and qualifications.  If you are getting  bogged down in that kind of thinking, come visit us in Malawi where there is a different kind of medicine – the kind where God doesn’t depend on our qualifications.  We need a qualified obstetrician.

--jamie