The CALL Experience

Taking call at Kudjip Hospital has been interesting, to say the least. Each physician on Station covers call about once a week, and since I’m new, a more experienced doc has always been assigned/available for consult whenever needed. (Not bad!) Call begins after Clinic closes in the afternoon, with any leftover or late-comer clinic patients then redirected to the ED. When I’m covering, I start call by making rounds on all 4 wards, checking in with the nurses to answer questions, and set up care plans for any seriously ill patients. Before heading home, I’ll cruise by the ER to see whatever patients the staff have questions about. Many of the patients who come through the ER are seen and managed by the well-experienced nursing staff, but there are always a handful with some form of trauma or critical condition which the Doctor is called to help with. Other times, the case may not be so severe, but the nurses simply need help deciding whether the patient qualifies for admission, or can be discharged home with clinic follow up. I also perform this “end of the day” ER check since there’s a good chance that if I have not, my home phone will ring the moment I put my feet up. What comes next has become one of my favorite Doctor perks – driving Herbie! The On Call vehicle is a rickety little hatchback off-roader (Suzuki SJ-410), which has been adorned with a Herbie-style racing stripe and the number 53. Bouncing around the little gravel roads on Station, the vehicle’s manual transmission, high-grabbing clutch, and failing brake system make me feel like I’m driving “God’s Must Be Crazy” style!

"HERBIE"

Getting home by around 5-6pm, I can usually make it through about half of whatever delicious meal Rachel has prepared before the phone rings. Though my Pidgin is adequate, and the caller will do their best in English, I’ve discovered it’s usually a challenge to find out precisely where the call is coming from, which patient the nurse is calling about, and what exactly the question is. Much of the time, they’ll just ask me to come up, hoping I’ll sweep in and manage whatever problem their facing, but I’ve gotten into the habit of drilling them with questions to ascertain the true nature of the situation. Of course, occasionally they’ll say something startling like “The patient has no pulse or breathing, and we’ve been doing CPR for 10 minutes – please come”, in which case all I ask is the location before flying out the door. But most of the time, it’s not so urgent, so I’ll get the location, age, vitals, and primary concern(s) before providing advice for their next therapy, or decide to come up. There is a fine line between giving the nurses the autonomy they deserve, and being too much of a presence, but unfortunately the line is usually blurred by the quality of information I receive over the phone. In the end, nothing beats putting my eyes and stethoscope on the patient, and once I’m behind Herbie’s wheel, I always feel an immense sense of purpose and joy in being able to help – no matter the hour.

During my first night on call, among many less exciting patients/calls, I spent the better part of 2 hours in the ER suturing bush knife wounds. “Chop chop” as it’s known here, is the nasty result of combining anger or envy, usually alcohol or beetle nut, and the always available bush knife. Both adults and children are rarely seen without such a tool (blade lengths varying from the 5” kitchen knife to the meter-long machete), which are primarily intended for digging gardens and chopping vegetation. For the two gentlemen I sewed up that first night, the bush knife involved was functioning as neither.

Man #1 was drunk, and was carrying a bare 8” blade in his front jeans pocket when he tripped and fell. The result was a deep laceration into his left thigh muscles, which I was glad to find did not pulse arterial blood when I released the tourniquet. He was moaning a little, but it appeared he’d already had a substantial volume of “anesthetic”, so after thoroughly flushing the wound I numbed him up with a little lidocaine and closed the bloody smile – layer by meaty layer.

Man #2, in contrast, had no such pain-killer in his system, but yet he lay quite still; his eyes fixed on the ceiling, his mouth set in determined resolution, and his left arm clutched to his side – a gaping shoulder wound oozing blood, congealing in a dark pool on his bed’s blue plastic sheet. I admired him for keeping cool, but wondered if it was anger that held the pain at bay. This man, Paul, had argued with his wife that night (obvious mistake!), and when his back was turned, she had swung a butcher knife over his left shoulder, aiming for his heart. The result was a deep laceration into his left pectoralis muscle, anterior to the clavicle and shoulder joint, about 5cm wide. The knife had failed to penetrate the chest cavity, as his rib cage had deflected the knife tip down, rather than in. After a quick exploration of the wound with my gloved finger, Paul too received a thorough cleaning (who knows WHAT these knives have been used for!), and I applied a fair amount of lidocaine throughout the ragged muscle tissue to numb against the bite of my suture needle. After approximating tissues as seemed most natural, I used dissolvable sutures to close his internal layers, which I was pleased to find all matched up in the end. Paul handled the whole thing bravely, and we had a little laugh later when my needle wouldn’t drive through his skin. Apparently some of these suture needles are blunt for safety, and short of tearing his skin, I just couldn’t get the needle through. The joke of course was asking if Paul was related to Superman – man of steel! At 1am, with fatigue and nerves setting in, everyone loved it, and we let the laugh go long and hard.

Paul's check-up in Clinic

I have been on call five times since that first night (I am in fact on call right now), and the stories go on and on. I’ll save some of them for future posts, but I have to share the wild fact that I saw a grand total of THREE pig bites in one night during my second night of call. Pigs are vicious little creatures, and most families have them here, so pig bites are not that uncommon – but 3 in one night is fairly rare. What’s even weirder is that two of the three bites were to the groin of young boys. Ouch! I’ll save you from enduring all the juicy details, but you can rest assured both boys are (mostly) ok. 

Another thing I have to mention is the C-sections I have been doing, and LOVING! I think they are very straightforward (as far as surgeries go), and it’s a beautiful reward to hear the first wail of a newborn. In the US, I would never have the opportunity to perform Sections, but it’s practically a requirement for doctors here! Trust me, I’m not complaining. :-) I’ve been accumulating various methods from other docs, assimilating them into my own Sections, and I’m very pleased to report that all the ripping/tearing that I saw all too often in my medical school training is entirely unnecessary! (Unless it’s an emergent situation). My method may take a little longer, but it’s clean, precise, and will produce less scarring down the road. (A big Thank You! goes to Dr Scott Pringle for his excellent teaching and much appreciated encouragement!)

Sadly, not all calls have happy endings. It was 1:40AM, shortly after crawling into bed for the 4th time, hoping for sleep. This time it was D Ward, the nurse reporting they couldn’t find fetal heart sounds on a newly arrived patient. I was at the bedside within two minutes, and I too listened and failed to hear a heartbeat using the nurses' hand monitor. The woman had carried the baby to term without complication, and reported that she had felt good movement earlier that day. Silently praying, I laid my hands on the mother's belly, molding them around her womb, hoping for some flicker of movement to indicate life remained in the unborn child. Again, nothing. I went and retrieved the ultrasound machine from clinic, and swept the probe back and forth across her abdomen, searching the infant's chest for the movement of a beating heart. Nothing... The idea of calling for back-up briefly crossed my mind - someone more experienced to confirm what I already knew to be true, to somehow share in the burden of telling this horrible news. But no. My voice wavered around the lump in my throat, and I told her the baby was no longer alive. She stared at the ceiling through welled tears, her world collapsing. I prayed aloud then, a few nurses solemnly standing by, and I was thankful to see the young mother join with me in earnest. Surely this must be the worst kind of call to attend, and make.

Final story (on a lighter note): The last time I was on call, I saw a man with an awesome forearm fracture (see picture below), obtained in a car accident. The bones were quite displaced, in multiple pieces, and he had a fair amount of soft tissue swelling around the broken bones. Since the hospital is running low on X-rays at the moment, we don’t usually order films on obvious limb fractures, but the nursing staff had already obtained the film by the time I was called at midnight. Obviously, I wasn’t complaining – a picture is worth a thousand words, right?!

I gave the man some medicine to help him sleep, then set to work straightening his arm. In the States, this sort of thing is done by expert Orthopedic docs using fluoroscopy (live x-ray) to ensure everything is aligned properly. All I had were my hands, and to make things more complicated, the medicine wasn’t working very well to keep him still. (His strong friends were very helpful in this respect). I had his arm suspended by the fingers, bent 90 degrees at the elbow, weights hanging from his upper arm to help stretch the forearm. As I squeezed the flesh around his broken bones, I felt the crunch and grating of bone on bone – not normally a satisfying sound, except that now his arm appeared much straighter. I applied layer after layer of plaster, taking care to keep a regular squeeze over the area of broken bone. It felt right, but no way to know – we don’t usually shoot post-casting films either. In the end, the cast was set, but the man didn’t have a ride home, so I approved the ER staff watching over him until the morning. When I arrived the next morning, I was quite pleased to find the morning ER nurse had ordered a film (?maybe thinking he was a new patient?). Anyway, I was able to put the before and after films side by side, and was perfectly relieved to find his bones in good alignment. The patient was also quite impressed, and attempted to buy me a Coke – which I politely declined as I was still working on my morning coffee.

More stories to come!

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