Did I Kill a Girl and Liked it? Part 1/2
By Rick Fischer.
The afternoon was going pretty well for Dr. Sanchez. He had made short work of the outpatient consult and now was on-call for the ER, the day though sunny was not hot. He was entering the last three months of his OSS "Obligatory Social Service". Every physician of his tropical country was sentenced to work for 365 days in a hospital of a rural municipality before receiving their medical license.
1700 Meters high in the Andes mountains was the town of Tizquezoque. With approximately 1000 Inhabitants in its urban town center, and another 5000 spread around its veredas: surrounding ‘villages’ of no more than three or four houses. Almost all of them no closer than a two hour jeep ride through mud-trails.
Tizquezoque itself was pretty far from, well, everything. It was three hours of mud-trail driving away from paved roads. Five hours away from the closest Operation Room. Six hours away from the next Intensive Care Unit. And seven hours away from the closest city in which you could drink tap water without getting dysentery. Yet Dr. Sanchez had managed to survive there nine months, always at the edge of his sanity, but there nontheless.
At four o'clock in the afternoon the painful ringing of the hospital's on-call cell-phone startled him. He was in the ER of his tiny rural hospital; two floor high and staffed by less than a dozen people. And there wasn't anyone there except for him, not even Gloria, the nursing assistant.
"Sanchez here, hello?" he said. "Hello this is Dr. Anzola from Murcia's town hospital" said a female voice with the soft spoken accent of the northwest part of the country. "Tell me, how can I help you? Doctor." replied Sanchez sensing nothing good coming his way. "I have a patient: 24 year old pregnant woman, 22 weeks entering preterm labor, she's in one of the most faraway veredas. It is two hours in ambulance away from me, but just one hour your way. This is an emergency you should send your ambulance to her since she will get to you faster than to me". Essentially she's right, he thought, but he was familiar with the area. "Yes it is an emergency, I know Dr. Anzola, but you have to consider the fact that Murcia is one and a half hour away from the OR in Nuestra Señora and three hours away from the Neonatal Intensive Care Unit in Junta city". I, am five hours away from the next OR, and six hours away from the next NICU. When that patient delivers, a newborn that premature is going to need a NICU an-". "But it is a vital urgency. You must take her and she’s closer to you!" She interrupted. She's just trying to get rid of the patient. Fucking coward... thought Sanchez. Few things he hated more than cowardly physicians. Stuff like this always brought up the macho in him. Little did he know his internal James T. Kirk was about to take the best of him. "Well, if you are sending your patient to me that is your prerogative, Doctor. Unlike you, I am not going to avoid the responsibility so go ahead. I'll take care of your patient..." He said and hung up the phone.
"That bitch is getting rid of her patient on a technicality, this is going to be a mess. A kid so premature is going to fucking die no matter what! There is going to be a fucking witch-hunt after this! Perinatal mortality is a big no-no for the government. She's trying to dodge the bullet by passing the buck, and of course the buck stops at my ass! Fuck it! I'll do it. No one else will!" He was thinking still with the cell-phone in his hand.
He immediately called Don Anselmo the ambulance driver, and told him to pick up the patient. "The patient will be here in two hours... Preparation is the key to success", he thought. He didn't remember where he heard it, and it didn't matter. He got the heads up and he was going to use it to his advantage. He called Gloria and told her to get the delivery room ready. He got the equipment ready. Gauze packs, oxygen tanks, sutures, sterile gloves, monitors, even the other physician who was off-call decided to help. "Check and double check all the equipment please. Let's have everything ready when she arrives!" He said.
He heard the ambulance stopping outside of the ER. The first thing was smell of wet mud from the patient’s boots. God knows how long this girl had to walk to get to the nearest dirt-road the ambulance could get through. Bad news still, the trekking would only speed up labor. He saw her belly, it was way too small to be in labor. Quickly, he greeted the patient while Gloria took the blood samples. He had to rule-out infections and see if it was worth starting antibiotics. "Premature patients like this are normally infected as well" he thought. In the interview the young woman was clueless. Miriam was her name. Unwanted pregnancy. Unknown father. She didn't remember when her last period started. She didn't show up to her ultrasound appointment. No idea of the size of the soon to be newborn. Physical exam: well, first things first, the sound of the baby's heart rate in the Doppler fetal monitor meant he still had two patients to care for. He felt the uterus contracting strongly so she was in labor all right. According to the measured size of her uterus the pregnancy was 23 weeks old. The vaginal exam was far more revealing: the cervix low, opened, and soft, membranes still there, her water hadn't broke yet. He could feel the baby's feet in his gloved fingers. "Podalic as if everything wasn't fucked up enough already" he thought. The baby was coming feet first. That's usually catastrophic and would require a C-section. But a baby this small would still go through the birth canal, he hoped.
"Let's move her" he said, already in his sterile gown. Gloria and the patient's sister helped her to the delivery room. The moment she stood up her water broke. The bleachy smell of amniotic fluid entered his senses. Despite his over 30 babies delivered, his chest was pounding and his stomach turning. The young woman was fixed to the delivery table. It took only one well timed push and no assistance from him for the baby to be in his hands. She was as small as they came, no wonder it was so easy. He couldn't wait until the umbilical cord stopped pulsating. The kid was blue, not crying and completely limp. He clamped the cord, cut it and handed the newborn to Gloria. The Book was clear. In this cases the mother was top priority. The baby’s chances we're pretty low to say the least. If he neglected the mother trying to save a hopeless baby he would end up with two death patients instead of one. Besides Dr. Rodriguez had just arrived and offered to help. She took the child to the incubator. Sanchez helped birth the placenta with no complications. Still after that there was significant bleeding. He checked the birth canal while asking Gloria for a rather vigorous uterine massage. She had been a registered nursing assistant for almost 30 years. The robust 50 year old knew how to do it and was doing it well. "No way a kid this small could rupture the birth canal" he thought while checking. It was intact. The bleeding was coming from the cervix but it didn't seem ruptured. 15 more minutes of uterine massage and 4 ampoules of Oxytocin later the bleeding had finally stopped. And Miriam's vitals were stable.
Sanchez's attention turned now to his other smaller patient. While he was trying to stop the mothers bleeding he overheard the baby girl’s weight: 1100 grams, he had never seen a baby that small. He took of his bloodied latex gloves and put on clean ones as he approached the incubator. He saw the curly black arm-length hair of Dr. Rodriguez crumpled in a surgical cap and her pale white skin as she was ventilating the small baby girl. "Naomi, she's not going to make it regardless of how much you mask-bag her" He said to her. He knew the best neonatology center in the country was in Santa Fé and had a viability of minimum 1200 grams and 23 weeks. "You are only prolonging the inevitable" he added. "Roberto! Don’t say that! I want to give the baby girl a chance!" she cried. Well, he wasn't going to stop her. He just watched the little baby girl. Her almost transparent skin was red, and her chest raised and went down again with each of Naomi's ventilations. He liked touching her little hands with his gloved fingers. "Look it is working. She's breathing on her own!" said Naomi. "Yeah the heat of the incubator and the forced ventilations she had been giving her were working. But for how long?" thought Sanchez. "A kid that premature couldn't be breast fed so she needs a venous access. Who is going to set it? No one here has experience with babies like that. We don't even have a neonatal pulse-oximeter. We can see she isn't blue anymore, yes, but we don't know how much oxygen is she really getting. She's going to need intubation but we don't have tubes for here size here. That is not a transport incubator I can't just load that thing into the ambulance. Soon after I take her out of that incubator her heart will stop" he thought while removing his sterile equipment. But until then she had a pulse and was breathing on her own. He had a patient and a duty to her. “Medicine is a profession of means not of results” he could almost hear in one of his Professor’s voice. He had a duty to give this girl all the means to survive. “The rest is up to God” he guessed.
He called the emergency in. The Urgencies and Emergencies Regulatory Center will tell him the closest place with a NICU bed available. And it will be up to him to make it there with the patient.
There was always a last-ditch attempt strategy for cases like this. The mother's body heat could be used as and incubator. But up there in the Andes mountains this was a rather desperate idea.