Carlsberg don't do on-calls...

But if they did, I don't think last night would be one of theirs.
I can confidently say that the last 36 hours have been my most harrowing work experience to date in my career. I've cried more than I thought possible and drunk more strong sugary tea than my dentist would approve of.

The day started badly when, before lunch, I'd told a woman that the twins that she was 16 weeks pregnant with didn't have heart beats on the scan. And then promptly delivered one of them on the USS couch, before taking her to theatre to have the other one removed.
It was a busy afternoon, and then at 5pm as I was finishing up the OPD patients I had an emergency call from the Paeds ward. I arrived to an 11 week old girl that had been admitted with a LRTI an hour previously, who had now stopped breathing. Despite going further in Paediatric resuscitation than I ever have before (if there's no one else there to intubate, you might as well try) we weren't able to get a cardiac or respiratory output back and agreed to stop. I was distraught. Paediatric resuscitations are always upsetting but in this setting I can't but help feel that we just can't do enough. We have no way of checking gases or urgent electrolytes or even cardiac monitoring. And whilst we all try hard, we're not experienced or knowledgeable enough to be single-handedly resuscitating children (which is very much the situation you find yourself in). I couldn't recall doses of drugs but couldn't look them up in the critical first 5 minutes as I was bagging and doing chest compressions.
Explaining to a mother that her child is dead when you feel like ultimately we have let her down through lack of resources and skill is heartbreaking.
I found it especially hard as the other staff involved are more used to these situations and were able to carry on with their work as soon as we stopped. When I've been involved in these situations in the UK, you rely on support from your colleagues and try to take time to debrief, something that isn't seen as necessary here. I've also never been the person who has been ultimaltely responsible for the decision to stop nor for telling the parents and then bringing their child to them to hold. I've often wondered how appropriate it is to cry in front of relatives in this setting but last night it wasn't a concious or controllable decision.

There followed a night of hourly calls (anaphylaxsis to traditional zulu medicines, rape of a 4 months pregnant lady, a 1.5kg baby born at home and brought in) only one of which (not one of the listed ones you'll be pleased to hear) I managed to deflect to allow me two consecutive hours in bed. One of the things I find hardest about the on calls is that I've always favoured bouncing my thoughts about diagnosis and management off another person (even if only to ignore their advice) but at night here, you are the only doctor around (unless you urgently require the second on) and the nursing staff are of very variable quality, so in addition to being physically exhausted, I feel the strain of having to make all the decisions single-handedly without anyone even to say 'I agree'.
By morning I was mentally, emotionally and physically exhausted.
Then at 6am I was called to a lady who was 26 weeks pregnant and having PV bleeding and abdominal pain. Examination revealed her to be fully dilated with bulging membranes. Due to poor equipment here, our cut off for resuscitation of neonates is 28 weeks (as opposed to about 25 in the UK) but as many women are unsure of dates and don't have reliable (if any) USS I wasn't willing to put this lady on the female ward to deliver. So, much to the annoyance of the midwives, I took her to the labour ward. And I was glad that I did as the 850g baby that she delivered cried at birth, and I felt relieved to have some resuscitation equipment to hand. However, after spending an hour and a half resuscitating the boy with fluids, antibiotics and the available respiratory support, his breathing failed and he died shortly before 9am.

Sadly my day was not over there and I still had my ward round to do and a couple of further hours in OPD where my final case was a 15 year old girl requesting termination of her 8 week fetus, fathered by her own brother.

The thing is that any one of these things would have upset me tremendously at home, but being here and facing all of them in one shift, without my usual support networks is almost more than I can bear. The way I feel now, I don't know if I am strong enough to manage the year.

Time for another sugary tea I think.