My First Continuity Patient

I worked the night shift Wednesday. I noticed my continuity patient didn't show up for her prenatal check up Wed morning so I texted her neighbor and asked if she was ok. I wondered because she hasn't missed a check up yet despite her living far away from the clinic. Also, she was 40 weeks pregnant this week so I needed to see how she was doing. She responded and said she didn't make it for her check up because her contractions had started and she was in pain. I've been telling her for weeks to come to the clinic early in her labor since she lives far away and her last labor was quite fast and short. I certainly don't want her to deliver in a jeepny on the way to the clinic. This is her 3rd baby. She's 23 years old. Her name is Emily.

When I asked about her contractions she said they were painful and coming every 5 minutes. I told her to come to the clinic right away and to take a taxi. She said she didn't have fare. I said come anyway, I'll pay for the taxi when she and her husband arrives.

I met Emily at church about 6 weeks ago and noticed she was very pregnant. I asked her where she planned to deliver. She said she didn't know. She was about 34 weeks pregnant at the time. I told her about the clinic. She said she knew about it but that it was too far and she didn't have money for the basic requirements (initial labs). I told her I'd take her on as my patient and that I'd help her with the expenses. Apparently her husband had recently lost his job and she's been quite worried about their situation. Since then she's come to the clinic every week for her prenatal care. So far everything has been normal.

Emily and her husband made it to the clinic at 10:30 Wednesday night. I was so happy that she could possibly deliver during my shift. I thought maybe my Mom would get to see me deliver. She wants to see a birth while she is here and it would just be a bonus if she got to see me catch the baby.

When Emily arrived at the clinic she didn't look like she was in labor. I asked about her contractions and she said they didn't really hurt. I noticed her contractions were very mild and not coming anywhere near every 5 minutes. Upon intake her B/P was 150/100. I gave her some water to drink, encouraged her to relax and had her lie down on her left side to see if her B/P would come down. She said she had rushed to get to the clinic and felt quite stressed so we decided to give it time to see if it would come down - which it did. Within an hour her B/P was 120/80 and remained stable for several hours after. Great, I thought. It was only a temporary rise.

When we did her exam she was only 2 cm dilated and the baby's head was not yet engaged. Also, the baby was in a posterior position (head down, but face up instead of face down). We decided to let her rest and try to get some sleep through the night and hoped the baby would rotate to a more favorable position.

The other staff members and I took shifts doing labor watch. By morning her B/P started rising again. She had progressed to 4 cm and the head was now engaged but she was still only having very mild, infrequent contractions. I wondered if she was really in labor. I left her in the care of the midwives on the day shift so I could go home and shower and get something to eat. I came back about an hour later.

This week, my mom and 2 other trainers are teaching 7 midwives and nurses how to do limited ultrasounds on pregnant women so we took advantage of that and had them scan Emily. We discovered low AFI (amniotic fluid index) and a grade 3 placenta. We also noticed that since the morning she began to have +1 edema in her lower legs. We sent her for a urine analysis to check for infection and also protein in the urine as we suspected pre-eclampsia. The U/A was negative for both.

I texted our OB/GYN and told her about our patient. She advised her for admission at the nearby city hospital and induction right away due to suspected pre-eclampsia. I called the hospital to tell them we were coming, hooked Emily up to dextrose IV and headed to the city hospital.

All week my dad has been saying how he'd love the chance to see the hospitals here. Now was his chance. We got into the clinic vehicle with the driver, my dad, me, a staff nurse, and Emily.
We arrived at the city hospital and it was just before lunch time. I hadn't eaten and was starting to feel shaky. The adrenaline of transporting my patient didn't help.

So we walk into the emergency room at the city hospital. This hospital is one of two public hospitals in the city - one is for city residents, the other is for residents from the province. It's also the place where a lot of our patients get transported to because it is the cheapest. And by cheapest I mean the most basic, antiquated, dirty hospital I've ever seen. In fact a big reason why Glory Reborn exists is to save our moms from having to give birth in this place. We usually do everything we can before we transport to CCMC (Cebu City Medical Center). But in some cases it is necessary.

We walk in and the ER is crowded and chaotic. The first thing we see is a young man lying on a stretcher that must have just come in. He had been intubated but he was dead. His family members were sobbing and wailing around him. It was awful. My poor patient. All I could do was usher her past and tell her not to look. If she was in labor, I would be surprised if it didn't stop in that moment due to anxiety.

We made our way through the crowd to the OB/GYN area which consists of 3 metal beds and a few curtains that only kind-of divided it from the rest of the ER but only one curtain divided the space between two of the beds. The bed they had our patient lie down on was open to the bed next to her where an overweight pregnant woman only wearing a top and with a small blanket barely covering her bottom half lay, on oxygen. On the other bed (if you can call a metal table a bed) there was a woman in very active labor agonizing in pain. There was no obvious person in charge. The OB beds are just across from the toilets. Both doors were open and the stench of urine was overwhelming.

My poor patient lay on the bed and started crying saying she wanted to go home. We tried to comfort her and told her we would stay with her but that going home was not an option. I felt terrible and I just wanted to get out of there myself so I could only imagine how she felt. We gave our information to a doctor that finally showed up and after waiting and watching the craziness around us, she came over to assess Emily. She did an IE (using the sterile gloves that we were required to supply) but made no effort to create any privacy for Emily. I opened Emily's bag and grabbed a small blanket that she could throw over her but the doctor pushed it aside as it was in her way. Emily was wearing a dress so her bottom half was exposed. I knew she was anxious and uncomfortable and exposed and I felt terrible. Finally her husband showed up and we were made to wait for about another 30 minutes while the doctor made phone calls and assessed the other patients.

Meanwhile my father is in the ER just observing everything going on around him. He saw an EKG being done on a patient and my dad said the machine they used was probably from the 1950's. He said the stretchers were like the ones used on the rescue car when my dad started his 22 year career as a paramedic/firefighter with the City of Tampa in 1973. Crazy. He also got some information on the young man who had died. Apparently he committed suicide by hanging himself. I asked my dad how he handled seeing stuff like this and much worse during his time on the rescue car. I still don't know how anyone does it.

Back to Emily. As it turns out, since she is from the next city over they would not accept her and referred us to the other public hospital for people from the province. As much of an inconvenience this was, I was relieved to get Emily out of there as I knew the provincial hospital was so much better - not great but at least cleaner.

We continued to moniter her B/P and it stayed around 130-140 over 90-100 which I was so grateful for. We had a sublingual tablet of Adalat in case it got to 160/110 or above but we didn't have to use it.

So we all piled back into the car, now including Emily's husband and made our way to the other hospital which was also very busy. We took her to the OB receiving ward which no one else is allowed into so we had to wait outside. Once she was received I sent the driver and the nurse back to the clinic. Dad and I stayed because Emily and her husband had absolutely no money and the way it works at the hospitals is you pay for everything as you go. So it wasn't long before they sent us to the pharmacy to buy supplies - soap, laundry soap, shampoo, rubbing alcohol, adult diapers, suction catheters, syringes, gloves, and an OB pack that included a cord clamp, sutures, a bulb suction and I'm not sure what else. After 3 trips to the pharmacy we purchased and provided everything they asked for. Nearly 2 hours went by and she hadn't been assessed by a doctor. I was told the doctors were busy with a C-section. I was asking because I wanted to know what else I needed to buy so that me and my dad could leave. It was about 4 pm at that point and there really was not need for us except to pay for stuff. They told me that didn't know if she'd be induced or what since they were still waiting for the doctor to appraise her. We decided to leave some money with the husband, along with my phone numbers and the number of the clinic and we left. I was exhausted and hungry.

Her husband called and woke me at 6 this morning and told me she delivered at 2:00 am and that she and the baby were healthy. I was so out of it when he called I didn't get to ask him if she was induced or what although I'm not sure he would even know since they don't let the husbands in the delivery room and he wasn't the kind of guy that asked any questions about what was happening - not from me and not from the nurses or doctors that I could tell.

Anyway, I am thankful that she and the baby are apparently doing well. I will go there this afternoon to see her. Everyone at the clinic said to me, "I'm sorry Jen... about your patient being transported" because they all knew I really wanted to get to deliver her baby. And yes I was disappointed about that but not as much as I was that my patient had to go through that experience. It's really awful that those two hospitals are the only options for the poor. If Emily was from the city she would have had no choice but to stay at CCMC and deliver there. The other options are private hospitals that are extremely expensive by comparison and completely out-of-reach for the poor. Many can't even afford the care at the public hospitals and are refused intervention unless they can run across the street to the pharmacy to buy supplies.
To me, this is the picture of how poorly the Philippines government takes care of it's people. It's shameful.

Yesterday was so intense that I needed to process it and wanted to share that experience with you. I never want to go back to CCMC. Never... but I know I'll be back.