The headaches continue. When I'm doing something I'm fine. Just a little nagging in the background. But when I try to relax, a constriction along the top of my neck, through the base of my skull and encircling it's grasping tentacles around to my throbbing eyes forces me to want to drink a ton of water and sleep.
My eyes are heavy and my throat is sore. I feel almost a desperation to sleep. But there's a lurking fear that when I lie down I won't be able to anyway so I watch a movie, read a book, wander around puttering till the inevitable stop of the generator forces me to hit the sack or attempt my meandering attempts at distraction.
Finally, I lie down. The mattress is soft yet firm. The pillow is perfect. The bed is long enough for my 6'5" frame to stretch out comfortably in any direction even when sharing it with a beautiful Dane. I start off with the illusion of falling to sleep immediately. Something I long and pray for. It doesn't come. Instead come the slow, persistent, building memories from the day's work, strategies, plans, ideas, anything to keep me from sleeping.
Above all, it's the thoughts of what I shoulda, coulda, woulda...and working at a small bush hospital in sub-saharan Africa as the only physician leaves plenty of fuel for that fire.
I should've cut an episiotomy sooner. The baby was already stressed. Sure it's heart beat was fine. But the 14 year old mom had been in labor on that small pelvis for too long. If I'd only got him out a few minutes earlier he might of made it. It was so close. Why did his heart have to beat so long? Why didn't he ever take a breath? Why did I even attempt that tendon release? It wasn't life threatening. He'd lived with it for years already. Sure it was painful and made it hard to walk, but I probably just made it worse. I'm way out of my league.
If I'd recognized that meningitis a day sooner instead of only treating his malaria, maybe that little girl would've lived. She made it a couple of days as it was. I'm sure we did everything: IV fluids, glucose, steroids, appropriate antibiotics...what did we miss?
I should've done a classical incision on that woman with the transverse lie and arm sticking out. If so she wouldn't have torn into both uterine arteries. Sure we managed to control the bleeding, but we almost lost her. What if I'd just done it right the first time?
Did I speak too harshly to the boy who we'd amputated and then had almost healed his wound when he left against medical advice? When he came back with a huge infection needing a higher up amputation I should've spoken gentler. Maybe he would've actually stayed...is he still alive?
How could I have thought it was an ectopic pregnancy? My ultrasound skills suck. An unnecessary operation on a woman with a normal intrauterine pregnancy...I could've saved myself the trouble and her a dangerous procedure.
Is the medical student having a good experience? Should I let him do more? Or less? Is he feeling too overwhelmed with the responsibility? Have I dumped on him or is it just a good experience?
Are Israel and Paul overworked? They are volunteer nurses after all...I want them to have a good time so they'll encourage others to come...am I assigning them too many night shifts? Do they get tired of my calling them to help with all the surgeries?
Will the work at the hospital ever slow down? We seem to just be getting busier and busier as our staff continues to dwindle and I remain the only doc. I can't even begin to count the surgeries I've done since coming back January 10...three to four a day with many minor procedures and the waiting room inside and outside under the mango tree packed. There are no beds available in the hospital. People are sleeping outside, their mosquito nets strung from branches of trees. The nurses can't even walk inside at night. Relatives are sleeping on every available floor space including under the beds.
Images flash through my semi-conscious brain: amniotic fluid squirting onto my face as I cut into the uterus to rescue an infant; my fingers push and pull around a tense hydrocele breaking apart the small fibers attaching it to the scrotum with the sound of tearing cardboard; a hernia bulges in and out with the patients breathing as I grab firm fascia and poke through with
a needle to close that moving masse inside where it belongs; with a small poke, pus bulges out and flows down the back of the throat like a stream of lava as I quickly suction back and forth on the Ketaminized HIV positive wife of the local chief; moans and babbling float across my brainwaves from a million Chadians waking up from a Ketamine nightmare; the baby's head
rolls around despite the firm grasp of Paul as I chase a splinter across his cornea trying to dig it out gently with an 18 gauge needle; gurgles and bad breath roll up to me in my stupor from an alcoholic desperately wishing he had a bowl of rice wine to assuage his pounding head from the beating he got last night while hammered; urine dribbles onto the ground from a foley bag
only partially closed...
Words in Arabic, Nangjere and French wind themselves around my thoughts as I relive my frustration at only being able to communicate on the level of a child...and my deep desire to learn Arabic and Nangjere clashes with feeling so overwhelmed that at any break I just want something to temporarily distract me...
Finally, I fall asleep, and the nightmare begins...until I jolt awake at 3:26 AM. My throat is sore, my lips are dry. I grope for a flashlight and take a drink of water in the bathroom. I turn off the light, roll onto my back, try to sink in...and a flashlight appears outside the window rapidly followed by a rap on the metal door. I unplug my ears, grab my headlamp, pull on some shorts and a t-shirt and go to see Clarice and David.
There is a woman in her 10th pregnancy under oxytocin to augment her labor who has been completely dilated for 3 hours without delivering. I change into scrubs, find my keys, head to the OR, snatch up the oft-used disposable hand-pump vacuum and head to Labor and Delivery.
I put on gloves and examine the woman. The head is high up but there seems to be room. I wet the vacuum and slide it in over the baby's crown. She has a strong contraction. I pump up the vacuum and slowly pull. The head descends and twists to the left as the eyes, nose and mouth pop out slowly over the perineum. I use the bulb suction to clear the airways, release the vacuum and pull the head down to free up the anterior shoulder quickly followed by the squirt of slimy child, arms and legs firmly contracting, already wanting to scream his anger at the world. We quickly dry her off and wrap her up against the cold. The placenta follows quickly. There are no tears and no bleeding. The uterus is firm as a rock. I go home hoping that for at least of few hours of nightmare free sleep...
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