Ectopy

The morning started similar to other mornings.  Roosters were crowing long before the 530 sunrise, workers were preparing for the days duties, and I turn over and smash a pillow over my head.  Typical.  I spend more time in bed trying to figure out the mapping procedure for this project than normal.  My translator isn't due to show up until 9 am so I can see help with the unofficial clinic from 8 till 9.

I finally break open the front door to my converted bedroom.  The building Angie and I are living in will eventually be a school building.  My room at one point housed 5 beds when all of the volunteers were here.  Now it is solely my domain.  My front door opens into the dirt and gravel yard that I have grown accustomed to seeing in this somewhat barren place.  My back door opens to a magnificent view of a mountain range flanked by some of the bluest water you can ever imagine.  This more than makes up for the fact that when i cast my flashlight throughout my hollow, concrete chamber I feel like I'm a character in one of the Saw movies.

As the sun and heat remind me that I'm still not in Iowa, Angie let's me know that breakfast is ready and we have about 5 patients to see before I go about my business conducting surveys and she starts her community health worker class.  Usual morning greeting.  Usual breakfast.  Usual day.  Until I walk to the treatment room.

The community health workers' first patient is a little boy whom we've been following for a nasty 2nd degree burn to his left leg.  But, he's playing enough to where his dressings are a light brown on the surface when we change them.  The female trainees have a ball cleaning, wrapping and then taping the same boy that sent many of them on a three-hour search through Arcahaie.  Next up is a young, healthy woman with a little crampy abdominal pain, possible dysuria, and discharge.  It's Haiti and she's a female.  I'm not surprised because that is the most common complaint I've received from women.  Urine sample, please.  I'm also told that our first patient, a woman seen before I finished breakfast, is off providing a urine sample as well.  Gonna be a discharge clinic.  Again, what else is new?

She came back and immediately I got the sense that something wasn't right.  Not that I have super-doctor-powers or anything because it was pretty obvious.  Her movements were slow and labored.  She didn't have a lot of postural support.  And her facial expressions screamed 'FML'.  Plus, it helped when Angie prefaced clinic with, "One of them may be actually sick."

I get a brief history as she returns with her urine.  No period since mid-November.  Been having daily bleeding since December 31 and now her lower abdomen is hurting.  "Any chance you could be pregnant?"  "No."  "When was the last time you had sex?"  "In November."  "Do you take any measures to prevent conception, pills, shots, condoms?"  "No."... So you could be pregnant...  And she was.  Mathematically it would likely be about two months.  But who knows.  Maybe she didn't really have her period in November and it's been a lot longer.  We certainly can't tell.  Still, any pregnant lady with pain and bleeding immediately moves up on the "scary diagnosis" list.

Angie and I take turns with an exam. Her abdomen is tender over the left, lower quadrant and suprapubic region.  I question whether or not there is a mass on her left inguinal region.  On spec exam the os is closed but there is blood coming from it.  I don't guess she has aborted her fetus, but at the very least it is threatened.  On bi-manual exam she is tender on the left worse than right and I think I sense something on the left side when compared to the right, but I can't quite put my finger on it.  Angie confirms my findings and says that she's pretty certain that there is a "fullness" on the left side.  Damn.  She needs and ultrasound and a scalpel.

We wrap clinic.  Nothing else is quite as interesting.  Little tyke with an ear infection.  Perfed his TM, but we offer some antibiotics anyways. My mind is with the potentially fatal case in the front room, waiting for a "tap tap" to show up.  It finally does half an hour after it was called.  We place the patient in the front seat with the driver.  I sit in the back with my translator, the patient's sister, the little boy with the burn and his mother.  For those that don't know, an ectopic pregnancy is a life-threatening condition.  It is a non-viable pregnancy stuck in the tube or elsewhere in the abdomen/pelvis.  It invades tissues and tries to set up the same blood supply that a normal fetus would require from the placenta.  That's a lot of blood.  And when the ectopic ruptures, that blood will poor into the patient's pelvis as if you had sliced through her aorta.  Notice I said 'when' as opposed to if.

#Anxiety.  I sit in the back of the pickup truck.  Holding on as we bump along the dirt roads.  I check my phone every couple minutes.  This woman needed to go under the knife an hour ago.  I can't even reassess her as she's in the cab.  The truck stops.  We are two minutes away from the compound.  A gentleman walks up to the driver-side window, just for a chat.  He laughs.  The driver laughs.  The woman in the passenger seat moves closer towards catastrophe.  #Frustration.  What the hell is going on?  He leaves.  We move forward, slowly.

We stop again.  The sister stands up and starts yelling and I see a gentleman come running towards the truck.  Partner?  Brother?  Who knows, but he hops in next to me.  We start again.  We drive past the intersection and head toward Arcahaie proper.  I haven't ventured this far south yet.  Still looks the same.  And we stop...  I ask Wesley what's going on.  We have to get a gallon of gas.  The 'attendant' talks over with a plastic canola oil bottle filled with a clear, pink liquid in one hand and a homemade funnel in the other. He dumps it into our gas tank and the male who had just jumped in the truck pays the attendant.  Curious.  Pay for the ride and then pay for gas when the driver needs it?  Sheesh.  #RawDeal.

The truck continues at its painfully slow pace until we reach the clinic in Arcahaie.  People are spilling outside the courtyard.  Not a good sign.  Wesley signals for me to follow him.  The family attends to the patient.  We weave through the crowd.  I put my stethoscope around my neck hoping that I can buy a little extra credibility.  Wesley finds a nurse while our patient finds a seat in the outdoor 'waiting room'.

I convey a sense of urgency to the nurse.  I drop the words ectopic pregnancy and say that she might need an emergent surgery.  She walks off, presumably to find a doctor for me, right?  She comes back a few minutes later with a stack of files.  She starts calling out names.  Not ours.  Not our patient's.  In fact, she's standing right in front of me but looking past me trying to locate the bodies moving towards her desk.  She calls another name, and another.  Not helpful.  Wesley notices my irritation and again motions to follow him. He knocks on a door with "Konsultayson" written on the frame.  Is that German?  Two physicians are inside surrounded by nurses and patients.  I have no idea how they get anything done.

They each rise to shake my hand and introduce themselves.  I'm a med student guys (#DirtUndertheTotemPole), no need to be polite to me.  I'm not used to it.  They are Cuban doctors working here in a deal between the two nations.  And from what I can tell they work their asses off.  One speaks Spanish.  The other tries his hands at English.  I explain the concern that we have a patient with a possible ectopic.  He goes to find the Ob/Gyn, immediately.  #Thankful.  Finally, a sense of urgency I'm used to seeing regarding medical emergencies.  He disappears into the main hospital while I wait outside with Wesley.  A female doctor emerges a few minutes later and comes straight to me.  Ob/Gyn, no doubt.

I work through Wesley, who works through a Haitian nurse, who communicates in Spanish to the doctor a very brief patient report.  #Doubt.  I worry that what I said wasn't enough to convey my concern for the patient because two of the doctors engage in a lengthy discussion in Spanish.  Finally, they tell me that they are going to take the patient to 'sonografi'.  #Success.  We'll know soon enough whether or not she has an ectopic.

She did.  The ultrasound room was crammed with patients and technicians, so I didn't follow the two physicians and my patient in.  But after about 10 minutes the Ob/Gyn came out and said in broken English that my patient did have an ectopic.  They plan to admit her right now and presumably she will go to surgery as soon as there is a surgeon and an OR room.

#Relief.  My patient is going to receive the treatment that we could't offer and the treatment that will save her life.  I ask how much we need to pay for her stay and surgery.  Then Wesley gives it a shot in the Spanish that he knows.  Nothing.  Free admission and surgery for our patient because she is Haitian.  Damn.  #Awesomeness.