When doctors need information in the middle of nowhere

PLOS has lots of journal articles...

Biomed Central ditto

via BoingBoing, which discusses using technology so isolated African clinics can have loads of books on their computers...

Fine. Now, you are a doctor, the ONLY doctor at a 100 plus bed hospital...That serves 20 000 people in a rural area...

Problem: Docs are too busy to look the stuff up and read it...Although if it had a friendly search engine and you had a problem case it would come in handy...

What you need are journals like American Family Physician, and basic books such as DePalma's How to set every fracture known to mankind were big helps, as were some surgery and OB books that showed you techniques for procedures when you got into trouble and something weird happened...

and from what I've read of some of the books on the boingboing article, they are really good reference books for isolated third world docs.

But sometimes an emergency problem pops up, and you're not sure where to find the solution quickly... You are too busy to look up what to do.....And in those cases it is sometimes easier just to call someone who knows more than you do...

When I was in Africa, we had a lady whose baby died in utero at 28 weeks...

She had had one caesarian section, so when a careful induction did not expel the fetus, we decided to remove the baby via C section (prolonged carrying a dead fetus can lead to problems...hypofibrinogenemia with bleeding from everything, for example..also infection...).

So we opened her abdomen to remove the dead baby, and....when I went in, as soon as we entered the abdominal cavity we found the baby...not in the uterus but in the Abdomen...

Now, that was a problem not in any textbook...you see, she had had a Caesarian section at another hospital where the doc only did Classical, upper uterine, incisions...We had had two of them rupture during trials of labour, and when we did a CSection electively on another one of his patients, we found that the uterus was held together by an inch wide thin band of scar tissue: The muscle had not healed together...

So the best we can figure what happened for our lady with the baby in the belly was that the pregnancy had started to grow in the uterus, but with stretching, the scar had opened, and the baby popped out, and grew outside the uters...

Alas, so had the placenta: it was attached to the uterus, the intestines, the uterine artery, the abdominal wall etc...

Now, placenta that attach are full of blood vessels, and the place they attach to are also full of blood vessels. In the uterus, when the placenta comes out, the uterus contracts and squeezes all these blood vessels down (and when it doesn't, the mom bleeds to death)...But here, we couldn't remove the placenta without causing uncontrollable bleeding...And the placenta was starting to deteriorate...it was brown and lifeless, meaning that it could cause massive infection/peritonitis and kill the mother...

Now this is not a problem we see often, and it was NOT in my book...so I called the Sister Doc at the next hospital, a locally trained physician who had more local experience than I did...

"WHAT DO I DO?" I asked frantically...

"Oh, no problem", she replied. She had seen a similar case in training, and was blase about the whole thing...

"Just remove as much as you can if it comes out easily, and leave the rest behind...then close her (the abdominal incision) up and give lots of antibiotics and PRAY..."

So we did...and the patient did fine....

They say God watches out for drunks and kids...he also watches out for inexperienced naive docs who see problems not in the textbooks...

And maybe, just maybe, the prayers helped too...