Medical dilemmas

      A beautiful little girl was born at the clinic last night. The mother thought she was 34 weeks along, by ultrasound measurements the baby was 31 weeks. The mom came to the our house in labor just before 3 pm. She said her water broke at 8 am yesterday morning. When we checked her she was definitely dilated and was having some contractions. This was her 4th pregnancy. Now the question is, do we encourage her to go down to a hospital? Do we take her down in the ambulance? Will we find a hospital that will provide care for a preemie? Will the baby live? Only God knows. We decide to take this lady to the clinic and let her deliver there. The baby's heart rate is good, but we have no idea what will happen after the baby is born. Ethically it would not be right to send this lady home to deliver. At the clinic at least we have suction and oxygen if it is needed.  Jay goes to the clinic with her, while Brianna, Amberly and I go to the afternoon service and the girls stay at home with Chancela. We are glad the girls stayed home when we realize how far we have to walk. It is 3 miles one way. We stop in at the clinic on our way home. The first lady hasn't delivered yet but now there is another lady there who is in labor also. The second lady is quite a bit more dramatic about everything than the first one. It is her first baby. Also she has drank ginger tea, which supposedly is to help a laboring mother, but as far as we can tell it just gives them a whole lot of extra pain. It seems that if they have drank ginger tea they aren't in pain only during a contraction, instead they are in pain all the time. I check the second lady and she is not ready to deliver yet. She is dilated to a 7 and everything appears to be advancing normally so we explain this all to her family. Now it is just a matter of time, and she is not yet ready to push. They are satisfied that everything seems to be progressing as it should so they go home. By now the first lady is fully dilated but does not yet feel the urge to push, so we wait. After a couple of hours we start an IV and some Pitocin to try and help speed things along. The baby's head is right there but she still does not feel like she needs to push. After the IV is in, we go home in shifts for supper. A little before 11PM  I check her again. It seems we are ready to go. I encourage her to push with the next contraction. The dad senses that the time is getting close and he disappears out of the room quite rapidly. When she pushes the membranes are visible so we pull the cart with supplies over closer to the delivery table, glove up, and are ready for this baby.  After only pushing a couple of times, the baby is born. The sac is still totally intact around the baby's whole body and the placenta comes right after. I try to tear the sac open with my hands. I get through one layer but with everything wet and slippery I can't get through the second layer. Jay grabs a scissors from the cart and opens the sac. It isn't even 20 seconds later we hear the wonderful sound of this little baby crying. I suction out her mouth and nose and we place her on her mother's abdomen for a few minutes before we take her to weigh her and get her dressed. She weighs 1.57 kg. The dad comes over to look at the baby while we are doing this. Almost right away he notices that his little girl has an extra digit on each hand just like he does. ( That is a very common sight here. Normally it is on both hands and attached by a small piece of skin. Usually the small extra digit does not have any bones but sometimes has a fingernail. ) The dad requests right away that we cut the extra digit off. Jay and I talk about it and give them a randevous appointment for one week. If the baby is still doing well at that time we will tie suture thread around the extra digits so they will fall off. We get her dressed and give her to the female cousin who has been at Mom's side all afternoon.  We try to get the baby to breastfeed before leaving the clinic but she really is not interested. The family is from a long ways away so they will be spending night tonight with someone they know here in Oriani. They all three plus the newborn baby get on the moto and head off into the darkness. We walk home, very happy the baby is alive. I have no idea if she will continue to do well or if she was just born too early to survive without being in a hospital. 

     On Wednesday I saw a 23 month old with severe injuries. I am unsure exactly what happened to this child. He literally had a hole in his neck where it seems like he must have had a large abscess. His neck was continuing to drain some pus but the hole was a very disturbing site. Whenever he would turn his head you could see tendons and things moving around in his neck. He had another wound on the back of his left shoulder that looks like it also had been an abscess that was mostly drained. These wounds both looked like they needed to be packed but it would have been inhumane to pack that one on his neck without some kind of sedation. Plus, this child needed more help than we could give.  His lower back seemed to be swollen and red, but it also had a huge black blister on it. The skin was peeling around these sites and he was swollen, for sure from his abdomen on down. The swelling looked like he was also suffering from malnutrition but it could have been from his other problems, I don't know.  The story is that 2 weeks ago someone was trying to carry this child on their shoulders when he fell. They think he landed on his head. I think he may have landed on his back. I don't know how the boils/ abscesses got there. Probably all of his injuries were exacerbated by "tying". It is a common remedy for any type of pain. Tying is folklore and is supposed to keep pain from spreading to another part of the body. The problem is, often whatever is used to"tie" the wound is put on too tightly and can cause circulation problems etc... Sometimes also, plants or herbs are made into a paste and put on the wound before it is tied. This can lead to huge infections. I suspect that is what led to the abscesses on this child but I don't know for sure. I couldn't tell if the skin on his back was burned or bruised or what exactly was going on there but I suspect an injury inside also, possibly a fracture or sprain of some kind. This child needed x-rays, IV antibiotics, wound care, etc... I didn't want to start treating him when he needed more than I had available.  For instance, I could have given him antibiotics. I could have given him a shot and oral antibiotics but I didn't.  I was afraid if I gave some medicine the family might not take him to the hospital right away, they might try to give the antibiotics for a few days at home to see if he got better but I wanted him to go to the hospital that day. So I simply gave him a dose of tylenol, plus a second dose of tylenol to take in a couple of hours and put small bandages on his wounds to hopefully keep the dust etc... out of them on the ride down to the hospital. I told the family several times they needed to go down that day, not even to wait until the next day. I'm afraid it was too late for this child already.