A day in an emergency unit cannot be predicted or accurately planned for. Some days the patients come in at reasonable intervals and I feel a sense of calm and control, and other days it feels as though a bus has picked up all the sick patients in Johannesburg and dropped them off in our unit. It’s these kinds of days that we don’t have time to eat or drink anything, and at the end of a 10-hour shift, we feel and look as though we have run the Comrades Marathon, and then some.
On one such chaotic day, we were called outside to the parking lot by a dumbstruck security guard, to assist with a patient who was unable to leave her car. It took some time to figure out what was presenting to us.
There was a woman in the driver’s seat of the 4 x4, her hands and clothes covered in blood, and then there was another woman in the passenger seat, also covered in blood, with a just-delivered baby teetering on the edge of her lap, still attached to the umbilical cord.
The last time I worked in an Obstetrics unit delivering babies was 20 years ago, so it was no surprise that I broke into a cold sweat, feverishly trying to remember the procedures and the relevant drugs and doses required. I felt a huge sense of relief that the baby was already delivered, because I would not have wanted to deal with a complicated delivery, however there was a possibility of a traumatic injury, as the baby was born precipitously in a moving vehicle, and the amount of blood in the car was not a comforting sight. There are also no obstetricians in our hospital, so I knew I had to stay calm and think clearly. At this stage, I was all they had.
We immediately got a trolley, put mom and baby on the trolley, clamped the umbilical cord with artery forceps, which is an improvisation, but it does the job just as well as an umbilical clamp, covered them with clean sheets, and pushed them past the other waiting patients into the emergency room. I never feel comfortable when patients have to wait for me, so it was an added stress to see the expectant faces in the queue of patients. However, I have learned to focus on the present patient, give them my full attention, and work as efficiently as possible.
It was then time for proper introductions. It transpired that the driver, a young, well-groomed Mrs Van Niekerk, had recently employed Mrs Dlamini as a domestic woker. Mrs Dlamini, I noted, was in her late forties, which raised alarm bells, with respect to complications for mom and baby. Mrs Van Niekerk, was on a high, chattering and gushing about the wonderful experience of witnessing a baby’s birth, and hugging the rather reticent and, I thought, sullen Mrs Dlamini. Mrs Van Niekerk was marveling at what a miracle it was, because the baby was only 30 weeks old, but he had a strong pair of lungs and appeared healthy.
We cut the cord, gave the strapping 3.5 kg baby boy his Vit K injection and Chloromycetin to his eyes. He was perfect. Mrs Dlamini was given intramuscular Oxytocin and the placenta was delivered without any complications. She was fine too. I breathed a sigh of relief.
However, it wasn’t over yet.
I was puzzled all this time by Mrs Dlamini’s glum, resigned demeanor and her complete lack of positive emotion. Perhaps she didn’t want the baby. Of course, I was not aware of her personal circumstances. When we were alone, I asked her how far she had been in the pregnancy, and she repeated that she was 30 weeks. I decided to let that go. I knew it to be untrue, but was sure she had her reasons for telling her employer that, and she was probably suspicious of my motives. Not all patients realize that doctors have a strict code of respecting patients’ privacy and it is unethical to disclose any information to anyone else, without the patient’s written consent. I had another thought about her demeanor, and came right out and asked her directly if she was HIV positive. She hesitated, and I thought I saw desperation in her eyes. Perhaps that is what was there all along. I firmly told her that she had no choice but to tell me. I thought of the copious amount of blood all over the car, the employer and baby boy Dlamini.
She was HIV positive. I explained that I had no choice but to inform her employer, and protect her with retrovirals. There was also the question of prophylaxis to protect her baby, as well as advising her not to breastfeed. There are exceptions to written consent.
A sobered Mrs Van Niekerk then became the third patient. She blanched visibly as I discussed the situation and the way forward. She was immediately put onto retrovirals. Baby and Mrs Dlamini were referred to relevant specialists.
And then there was the matter of the queue in the waiting room, which had grown longer. I felt exhausted by what had transpired, and would have loved nothing more than to stop work for the day. However, I took a deep breath, and soldiered on.
I saw Mrs Van Niekerk a few weeks later, when she came in to get her negative HIV result, much to my and her relief. She cheerfully told me that Mrs Dlamini was on maternity leave still, and she was looking forward to her return. I wondered if she was just naive, or whether she understood the risk she was knowingly exposed to by her employee. If so, I would have thought there would be some resentment or disappointment. Or, of the fact Mrs Dlamini also failed to disclose her pregnancy at the job interview, and the breakdown in trust that this inevitably causes. Mrs Dlamini was my patient too, and I could not and would not discuss any of this with Mrs Van Niekerk.
So, it all ended well. Mrs Dlamini kept her job, baby Dlamini was thriving and Mrs Van Niekerk was happy too.
You have to love South Africa and its people. For the most part, despite the fact that we sometimes don’t see or get each other, we muddle along just fine.
Oddly enough, a week later, a Minibus taxi dropped off a woman in advanced labour outside our door, and again, I was in the unfortunate position of being the only doctor available to assist her. However, this time I felt some satisfaction in immediately knowing all the drugs and dosages. We even had a cord clamp in stock.
However, I am well aware that it only went well because there were no complications. I am relieved that there have been no more deliveries, and I pray that I never have to be put in this position again.