Wednesday, October 8, 2008

The roller coaster continues

I think one of the most difficult things about being here in Swaziland is the day-to-day fluctuations of my emotions. There are times when I am upbeat, positive and truly feel like I am making a difference and then there are days when I am devastating low and feel completely overwhelmed and hopeless. I had one of those days on Tuesday.

I need to tell you about Monday, so you can understand Tuesday.

On Monday I heard that a patient had arrived with an enormous tumour on the side of his neck. I was quite intrigued (in a morbid-doctor type of way). Never in my wildest dreams could I have imagined what I saw. This young man with HIV had a tumour on the side of his neck the size of a soccer ball. I am not exaggerating. It was so huge that it was compressing his trachea (windpipe) to the other side of his neck. He had a marked stridor (a noise that is made when the trachea is partially obstructed) and he was drooling because he couldn’t swallow his saliva properly because his oesophagus (foodpipe) was also partially obstructed. It was horrifying and we all agreed that he needed an urgent tracheostomy (a surgical airway to keep it open). We do not have anaesthetists here at GSH, but rather we have excellent technicians who are able to do various types of anaesthetics very capably. However, I offered to provide a helping hand if it was needed. I had everything set up for a “difficult airway” and I sat for a little while mentally preparing myself as to what steps I would take if one of my airway manoeuvres failed. Unfortunately, it was not communicated to the technicians that I would be in charge of the anaesthetic and this perhaps was the start of one near disaster.
The surgeon wanted to do the tracheostomy under local anaesthetic. I voiced my concerns about this, but being a foreigner and being female, I think my concerns were dismissed. The two surgeons present kept telling me that if we sedated the patient we would lose his airway. I was convinced that this would not happen and that I could titrate the drugs to just make him somewhat calm. Anyway, they started the procedure regardless of my concerns. I was with the patient at his head- I kept talking to him in soothing tones, gently massaging his head and trying my unique way of trying to comfort patients during distressing procedures. It worked really well for a while, but the surgeons were having difficulty accessing his trachea. The patient started to get agitated and I kept saying “We need to sedate him, he’s not coping and this is all going to go really bad”. I was simply ignored and the technicians wouldn’t give me the drugs. Finally the patient got so frightened that he jumped off the bed, retractors and surgical clamps still hanging from his neck. It was a nightmare. People came from everywhere and held him down whilst the technician, without my knowledge, administered a rapidly acting paralysing agent. I was then told to intubate the patient. I was very frightened and nervous. It all happened so quickly and my initial strategic plans were thrown down the toilet. I thought I could see part of the cords. I asked for a bougie and then slid the tube down. During this time and chaos, I think I slipped. One of the technicians listened to the chest and told me he could here breath sounds. I wasn’t convinced I was in the right place. I ended up yelling at the technician to let me have his stethoscope so I could hear for myself. Anyone who knows me knows that I have never raised my voice before in a clinical situation, so it just goes to show how tense I was. As soon as I listened, I knew the tube was not in the lungs. I wanted to try again, but the surgeons insisted on going for a surgical airway and thankfully they succeeded. I then started yelling at the technicians to give the patients some pain relief and they finally allowed me to administer some pethidine. My medical colleagues will be able to read between the lines of this scenario, but I can tell you, I was completely traumatised. The patient was alive and he had an airway, but I felt like a complete failure. I kept ruminating on what the experience was like for the patient and I was physically sick. I had to take valium which I thankfully have easy access to here.
I didn’t sleep. I woke up the next morning and just wanted to die. I had organised to go in early and do my ward round because I was supposed to be taken into Mbabane to get my well overdue visa extended. I did my ward round and went to the administrators office. She told me that I would not be going to Mbabane as some of the documents were incomplete. I can tell you, I almost had a complete meltdown. The visa is not a life or death issue but it’s important because for 6 weeks I have been asking people to get it organised for me. For 6 weeks they have had my documents and nothing has come to fruition. It was the straw that broke the camels back. Chris was with me and she noticed immediately that I was going to explode. Not only had I been through a nightmarish experience the day before, not slept, but I had also got up early to see my patients before my planned trip to Department of Immigration. She pulled me out of the office and we went outside and I started crying. She immediately said “You can’t work today” and we started to walk into Siteki. I cried all the way. I admitted to the helplessness I was feeling. I told her about a patient I had on the ward who has advanced AIDS and lymphoma of the tongue. I told her that my patient is dying of malnutrition because she can’t eat. I told her that on a daily basis I pay witness to people dying the most tragic, agonising deaths that I can’t do a damn thing about. I told her I wanted to go home and that I simply couldn’t cope anymore. She hugged me and told me that she loved me. She told me that I had to keep remembering all the successes I keep having- the ones I tend to forget when they are overshadowed by all the tragedy. I tried to use the internet in Siteki. I wanted to talk to one of my colleagues in Australia and let him know about the incident that had traumatised me so much. Of course, the internet wasn’t working. Chris and I took a taxi back to Good Shepherd. I told her that I would have a coffee and then meet her in outpatients. I had the coffee, but then I went to bed. I desperately needed to feel safe and comforted and my bed was the only place I felt some semblance of peace. I cried and I cried. My tears soaked the pillow and then I fell asleep. I didn’t make it to OPD. Later in the evening I managed to clean myself up as I promised to go to Jenny’s birthday party. I was extraordinarily low, but I honestly think I put on a “good show” and no one was aware of my fragility. The party was a success and Jenny had a good time.
I woke up this morning with a splitting headache, but a good cup of tea and two types of pain killers got me to the ward. Before I even started working, I was told that I would not be working today as Dr Petros was taking me himself to the Department of Immigration. We drove all the way in only to find that more documents were needed from the hospital- I have to go back next week. I knew this would happen. The silver lining was that I suggested that we stop for a cup of coffee. Dr Petros bought me a fantastic cappuccino and a blueberry muffin. It was all I needed to start feeling human again. So I find myself back at the hospital, still unregistered and still trying to alleviate suffering in a country that seems to have no end to suffering. I will stay, I will be strong and I will come out the other side stronger. I hope.
PS. The patient with the tracheostomy is doing well. Despite the ordeal, he smiled at me and gave me a hug. I wish I had the strength of these people.

1 comments: said...

Nice tube, Ms Croft.
You're kickin' ass & taking names...
I'd also like to congratulate you for adding drug use to your seemingly endless litany of personal firsts on this blog. After the extended description of your ass the other week I didn't think it could get any better, but as I've said before you are a constant source of wonder to those of us here back home in Australia.