Sunday, April 3, 2011

#35 Responsible

Josephine came in the 13th of March with her water broken for 2 days.  She didn’t have any contractions and was 5 centimeters dilated.  I did an ultrasound and her baby had died already.  So I wrote a very careful oxytocin drip protocol for the evening and night nurse.  It got turned off in the night and the next day restarted when she was 8 cm dilated.  After only a few hours the following day I came in to find the oxytocin drip running way to fast (under the supervision of the day nurse).  No notes were written to tell me how often she had increased the drip and she couldn’t tell me for sure.  Again I say oxytocin in dangerous for the uterus if not given properly.  

Though she was fully dilated now, I feared her uterus could be ruptured because she had no more contractions.  I brought her to "the bloc" and was considering forceps, when Samedi touched her belly and said he feared it was ruptured too.  

So....we did a c-section, found a badly ruptured uterus with meconium all over the abdomen, and ended up with a hysterectomy as well. 

A few days later I removed the foley catheter.  The following day I found her in a lot of pain.  I brought her to the "bureau" for an ultrasound.  A huge cystic mass was in her abdomen:  her bladder.  I emptied over a liter of urine.  I should have just left a foley in.  I wrote and gave careful instructions to watch her next void and if it was not much, to put a foley back in.  The next day.  Same thing....huge bladder, no one had put a foley back in.  Okay.  Foley stays in for several days.  

Nine days postoperative.  She started leaking serosanguenous fluid from her abdominal incision.  Oh no!  Dehiscence: when the fascia (the strong stuff that holds the incision together) opens and lets some of the fluid in the abdomen out.  

Back to "the bloc" #2.  She has quite a bit of serosanguenous fluid, but no signs of infection.  I opened her up, then suctioned off the fluid.  It didn’t seem to be accumulating more, so I don’t worry to much more.  I backfilled the bladder and the bladder was intact.  I closed her up (I was the only person scrubbed) and payed careful attention to make sure the sutures did not loosen up on the fascia.  

During all of this she also had malaria (yes, even a positive blood test).  She vomited several times and had a fever, but that can all be attributed to the malaria.  

She started to get better.  She was peeing, eating, walking.  

A few days after I took the foley out, she told me she was leaking something out of her vagina.  Her belly started to look more distended.  

Two days ago I did an "echo" and thought I saw a huge 10cm hematoma.  It was liquid and had movement with it like ascites.  It was definitely not clear urine, one of my biggest fears here.  Great.  I have to take her back to the OR.  Maybe it will go away with time and antibiotics.  I decided to look again the next day.  The next afternoon it looked about the same size.  I stuck a syringe in it and out came clear yellow colored fluid.  Not what I expected.  I put her foley back in.  That also looked pretty much the same color.  Even though the lab was closing I asked them if they could tell me if it was urine or ascites.  They tried but said it was to hard to know.  

Today the urine in her foley looked pretty infected.  I brought her to the OR to look with my makeshift cystoscope.  There are several laparascopes here that have been donated.  There are only bits and pieces, not a full set of anything.  One scope was small enough and actually worked with the light source, but had no apparatus to put irrigation into the bladder.  

I started by looking in her vagina.  Her huge floppy cervix that I had left (supracervical hysterectomy) looked necrotic and dead.  I cut it off.  It looked better.  I hoped that was only the problem.  Maybe the infection spread to her bladder.  

I took my makeshift cystocope (that had been dipped in bleach water as I had no means to sterilize it) and started.  If I could just see both ureteral jets then I would not be worried.  There are many tests I could order in the States to avoid all of this.  But....we are in Tchad.  I prayed long and hard about Josephine last night.  I needed guidance.  I didn’t know what to do with her.  I didn’t want her to have to go through a third operation if it could be avoided.  Maybe I would see the ureteral jets.  Maybe the fluid was just ascites.  There’s no one else to send her to.  I injected sterile saline into the bladder with a foley first, then took it out and put in the cystoscope.  The vision was definitely not clear as I held my eye up the scope.  I flushed her out several times with the same process and looked again.  I  could not visualize the right jet.  We had no indigo carmine (blue dye put into veins that makes you pee blue) to visualize them easily anyways.  All I wanted was a clear jet.  


Uh oh.  All the clear saline is coming out of her vagina!  She has a fistula where the infection had been.  I don’t know why I hadn’t seen that with my vaginal exam.  

Doubts swelled up.  All of this is my fault.  I did the hysterectomy.  I didn’t find a problem with the second operation.  Jesus please help me.  I am NOT qualified for this.  

Laparotomy #3.  All in all it took 5 hours with her in the OR today.  Lots of fluid in her abdomen.  Now there were some pockets of pus also.  Everything was adherent.  Two weeks after any operation will give you a giant mess when you go back in to explore.  Unfortunately it had to be done.  

We found a small hole in what we thought was the bladder that was leaking a jet of urine.  At least it was easier than I thought!  Good.  I sutured several layers over this and proceeded to repair the vesico-vaginal fistula that I somehow caused.  We opened the bladder.  Wow.  There is quite a lot of pus adherent in the bottom next to the vagina.  How did that happen?  On the left I was finally able to visualize the ureteral jet right next to the fistula.  Nothing on the right though.  I decided to leave the fistula open because it would cause too much harm if I closed off the right ureter while trying to close the fistula (about 3 x 1cm).  I would wait until someone else came to help me repair it maybe.  

I put my finger in the bladder again to see if I could feel the depth we had made over the leak.  It was nowhere near the leak.  That hadn’t been the BLADDER that was leaking.  It was the right URETER!  Any GYN’s dreaded fear.  This is what I had been fearing for a few days now.  

I took out the stitches and sure enough was able to dissect down to a nice jet flowing out of the pelvic sidewall.  Everything was adherent around it though. I took a neonatal foley and placed it to verify it was an open tube.  Yes.  Now WHAT?  Call urology of course!  And pray they don’t yell at me as I hide under the OR table or in the corner.  

 Well, maybe now we could repair the hole between the bladder and the vagina.  I remembered seeing ureteral stents here somewhere, but ignored them because I had no tract to put them through my makeshift cystoscope.  But, they would definitely help now!  I put one stent in the left ureter right next to the fistula to know exactly where the ureter was.  Then closed the fistula with several layers after cutting away the dead stuff.  

Then we went to work on the hardest part.  Connecting the right ureter to the bladder.  We poked a hole in the bladder, put the other end of the stent into the bladder, and put the bladder close to the ureter.  I tried to connect the tiny ureter into the bladder and then put another layer on top for reinforcement.  

We were definitely not trying to be heros or supersurgeons.  I think everyone in the OR was definitely ready to be done since I had kept them 4 hours past their quitting time on Friday afternoon.  We were just trying to do the best thing for her.  There was no one else to do it for her here.  I just pray that God would be glorified through this operation.  There are so many things that can go wrong.  

I put her on strong IV antibiotics.  Her infection could definitely come back.  I don’t know how long to leave the foley in for.  I have 2 ureteral stents in her.  Definitely a source of infection.  What if someone doesn’t empty her foley and the urine backs up?  The uretero-vesicopexy (I don’t even know the correct name) will burst and then she’ll have urine in her belly again.  What if the stents accidentally get pulled.  Same thing will probably happen.  What if the infection at her fistula site flares up again?  I don’t know how she got a fistula with a c-hysterectomy anyways.  I don’t think I was that careless.  I know that bladder was intact during the first 2 operations.  So many more things can go wrong with her.  

Oh, and her hemoglobin was very low (5) today, checked during the operation.  She had not lost that much blood with ANY of her operations.  It had been okay after the first operation (even though it was a uterine rupture).  Malaria does damage the blood cells, hard to know if it was just the malaria.  She got 2 units of blood today.  She is a rare O +.  

Please, please pray for Josephine.  She is from N’Djamena.  She wasn’t even supposed to be here.  

Danae Netteburg

1 comment:

  1. How is she doing? Wow. Just: wow. You've got a good head on your shoulders there, girl. *hug*