Three days as a doctor can seem like a lot longer. One World Medical Mission doctor in the post-residency program talks about what three typical days at a hospital in Togo is like.
by Fred Pfenniger, a doctor in the World Medical Mission post-residency program who, along with his wife, is serving at Hospital Babtiste Biblique in Togo.
Sunday, August 18, 2013
7:30 a.m.
I’m grumpy again. My justification is that my wife was supposed to have the day off yesterday. It was her post call day, but I didn’t see her until 3 p.m.
My shift has started. The medicine team from the night before (a doctor and a physician assistant) could not stay long as they had obligations. The doctor rounded on the three pediatrics patients, one who was a premature baby born at 28 weeks admitted two days earlier. The day before, the baby had a double blood transfusion and had been coded but is presently stable.
In Togo, it is especially difficult to keep a baby born at 28 weeks alive because doctors don’t have all the necessary medical equipment.
I, along with the physician assistant, do rounds on the nine medicine patients. All are new to me. It takes us a while. One is a new psychotic break, and three of them are stroke patients with decreasing levels of consciousness. I’m frustrated. I head to the obstetrics floor. I’m more comfortable there. During rounding, we have more admissions, including another stroke patient and a patient with facial trauma from a fall off a motorcycle. For the second patient, we rule out any major injury or fracture and ask the surgeon to do the suturing.
2 p.m.
Home we go. The physician assistant would like to do early rounds tonight as Sunday night worship starts at 6:30. We agree to meet at 4:30 p.m. I eat and talk with my wife. It feels a bit overwhelming. I need control. I decide to write a treatment plan on the patients tonight as we round.
4:30 p.m.
The physician assistant and I start rounding. The stroke patients are hard. What is our end point? We don’t do much for them. We admit them to the hospital and give them symptomatic treatment, but physical healing is up to them.
Rounds take a while, but I now feel more in control. The physician assistant heads home, and I visit the obstetrics floor. All is quiet. I take one last look at the premature baby who has an oxygen level of 50 percent. (The normal level is 92 percent.) I call the nurse and adjust the nasal prongs. The baby perks up, the issue is resolved, and home I go.
8:00 p.m.
I eat and talk with my wife. This is a tough schedule. The phone rings. It’s the physician assistant. She is getting calls about the premature baby. The baby is having apnea spells where it just does not want to breathe. We discuss strategy and medicines to adjust. The physician assistant is comfortable; she knows she can call me if she needs help. We hang up. Minutes later, the phone rings again. It’s the physician assistant. She’s heading to the hospital. The baby’s heart rate and respirations are failing. I also head to the hospital. We code the baby for 15 minutes. We push epinephrine and calcium. I observe that the baby has a good heart but just has no drive to breathe. We adjust her aminophylline to the maximum dose. The baby is now breathing. I tell the family that the situation is grave. If the baby doesn’t want to breathe, there isn’t much we can do. In the U.S. we have ventilators; here we don’t.
Dr. Pfenniger helps the premature baby breathe, but there’s only so much he can do without a ventilator.
The physician assistant heads home. I stop by the obstetrics floor. All is quiet. I’m about to leave when two new patients arrive. The first patient is a 19-year-old boy with newly diagnosed hepatitis B and a bad case of ascites. He had been started on medicine, but this is his third visit in four days. He’s stable, but we’ll admit him for observation because of repeat visits. The second patient is a 70-year-old female with Ludwig angina (a tooth abscess encompassing her right cheeks and left and right neck area). I admit her and call the surgeon. The plan is take her to the operating room where I join him. The case is short.
11 p.m.
I return home. The night is semi-quiet. I get three calls. One is for a newborn baby with a fever. I go over to assess. The baby is active and breast-feeding like a champ. We check a rectal temperature and there’s no fever. We decide to just monitor for now. I head to the intensive care unit and talk to the family of one of the stroke patients. I tell them there isn’t much time left. We discuss CPR, and they decide against it if the patient’s heart stops. It’s a good decision. I discuss this with the nurses, and then home I go.
I am back a few hours later because one of the stroke patients has died. It wasn’t unexpected, but it’s still tough.
Monday, August 19, 2013
6:00 a.m.
I return home. My wife is up and breakfast is on the table. She is on obstetrical and medicine call today. We discuss the patients and a strategy. We have daycare for 1.5 hours today, and there are two new short-term doctors coming today to start tomorrow. Our plan is to round on the intensive care unit patients together. Then I will take care of the obstetrics floor. Rounds go relatively smoothly, but I know my wife will be busy.
9:45 a.m.
I am out, and home I go.
12:00 p.m.
My wife is home for lunch. Rounding is taking a bit of time. She plans to head back. The phone rings. The premature baby doesn’t want to breathe. She heads over. Shortly after, the phone rings again, and the hospital requests my presence. I take our 3-year-old son, Noah, with me. My wife is busy. She is coding the premature baby, trying to treat a 4-year-old kid with malaria who is seizing, and a new patient has come in. I pass Noah off to a nurse with a pathetic plea.
When Fred left the U.S. with his family, he didn’t realize how much God would teach him through his experience.
“Can you watch him for a bit? I need to help my wife.”
I take over the code while my wife focuses on the kid seizing and the new admission. The code isn’t going well. We push epinephrine multiple times and are unable to maintain the heart rate and breathing. We decide to call the code and stop the resuscitation. The child with seizures is not responding to Valium, and my wife asks for phenobarbital. We wait.
A nurse approaches us and tells us that the visiting pediatrician is now in the hospital and wants to know if we needed help.
“Yes,” we say.
In comes Dr. W. We discuss our situation with him. He offers us advice. The situation is under control. The mother of the premature baby is understandably crying. We pray. I am breaking. Where is Noah? Dr. W took him to the guesthouse. Home I go.
My wife’s day does not get better. There are four more admissions. One is another baby who was born at 27 weeks. She gets him stable and squared away for the night.
Tuesday, August 20, 2013
2:00 a.m.
My wife comes home. We talk about a couple of the cases and strategy for the morning, four hours away. I will be on obstetrical call, and Dr. W will be on medicine. The best plan is for my wife to go to rounds as she knows the patients, and I will come over once daycare has arrived.
8:00 a.m.
The morning starts. The phone rings, and it’s my wife. There is a sick patient in the hospital. We are aware of her. She is seven months pregnant and 22 years old. She was admitted two days ago by the surgeons and required a tracheotomy to breath and a gastric feeding tube secondary to a neck mass. She isn’t doing well; she requires oxygen now. We had discussed her already. The surgeons are saying she is getting worse. We need to do a C-section soon. It will fall on my morning.
Day care arrives, and I head over to the hospital. I do the C-section. The baby is limp upon arrival with only a heartbeat. We cannot lose her. Dr. W and my wife are doing the resuscitation—CPR, epinephrine, umbilical venous catheter, and fluid bolus. The baby is really sick. When she leaves the operating room, she’s cold and doesn’t want to breathe. We are committed. We warm the baby and bag her for 3.5 hours. The baby is trying to breathe, but we can’t do this forever. We talk to the family and decide to stop bagging. We do not expect the baby to live. We pray. We stop. The baby is breathing. We have victory for now, but for how long?
Dr. Pfenniger performs a C-section on a patient who would otherwise likely die.
1:30 p.m.
I head home to eat.
2:30 p.m.
I go back to the hospital. I do not want to work. I pass triage. Dr. W and a physician assistant are treating a snake bit victim. She is losing her drive to breathe. I watch. They treat with antivenom and Valium. I help bag.
A nurse comes in. The sick mom who had the C-section this morning is having increasing difficulty breathing. I go to see her in the intensive care room. She looks sick. We treat with more Lasix and salbutamol. My wife is here as the obstetrics floor is calling. There is a woman in triage whose twins are at 35 weeks. She’s contracting, and one of the babies has a low heart rate. I leave and head to the obstetrics floor. A quick assessment shows that her cervix is three centimeters dilated (it needs to be 10 to deliver) and fetal heart tones are strong. There is no action right now. We’ll monitor. I go back to the floor. Minutes later, I am called back to the obstetrics floor for low fetal heart rates with contractions. I assess. We don’t believe the baby can tolerate labor. We decide a C-section is the best route to go and set the wheels in motion.
We do the C-section. The first baby is strong with no problems, but the second baby is limp. Dr. W and the physician assistant resuscitate the baby with CPR, epinephrine, bagging, and fluid bolus. The baby is placed in an isolette and warmed up. He’s alive, but we are concerned. Does he have neurological damage? Should we have resuscitated? We don’t know.
7 p.m.
Home I go. I am tired. I eat and then call the obstetrics floor. There are three laboring patients. I ask if they are stable and if it’s okay if I get some sleep. They say yes.
Wednesday, August 21
After this baby’s mother died, her grandmother and other family members have taken care of her.
4 a.m.
The phone rings, and it is the nurse of the medicine floor. He tells me that the sick mother who had the C-section this morning has passed away. The family doesn’t want CPR done. I tell him I’m not on call, but I ask if he needs me to come over. He says no. I thank him for the call. I hang up. I dress. I go to the hospital. I say goodbye to the mother who has passed.
In all this, I am left to ponder not the existence of God but how one can exist without Him. If I were an atheist, I am not sure what I would hold on to out here. If I were an atheist, I would see only the failure of society, and I would be angry at the world for its failures. How can we call ourselves civilized? But I believe in God, and this isn’t His plan for us. His plan for us was and is the Garden of Eden. Only through Him will we find it.
I must admit I came to Togo for me. I came here to practice medicine, to teach, and to become a true generalist. I love this work. What I didn’t come for was the uncertainty. I didn’t come to be humbled or taught, but I’m receiving both.
Update
The premature baby of the mother who died is currently still alive. She’s about five weeks old. Her condition is still guarded but she is holding her own. Her grandmother sits by her bed daily, and she is being fed through a nasogastric tube. Her weight is gradually increasing after an initial fall (as is expected).
