Sunday, April 24, 2011

#40 Almost

I’ve had five maternal mortalities in my first 4 months of living in Tchad.  It’s somehow harder for me to bear when a young woman here dies of a complication related to pregnancy and childbirth.  Maybe it’s because my specialty is to help women here, and when I don’t or can’t, I feel a sense of failure.  

I wrote about the first 2 already.  The last 3 I didn’t know as well, but they were still my patients.  They all came late and very sick.  We had 2 die just last week.  When you do all you can here, it’s of out of your hands.  

But today....

I kept thinking this was so preventable as I sat by her bedside listening to her struggle to breath.  She was gurgling.  It’s the sound that I’ve heard all too often here.  The sound of death coming.  

What could I have done differently?

I should have pushed the issue of finding someone to donate blood on rounds this morning.  

She came in for agitation after delivering at a local health center 4 days before.  Her baby only weighed 1.7 kg (an all too common weight here).  She wouldn’t breast feed her baby and was acting psychotic.  She got admitted to medicine (Olen’s service).

They said she didn’t lose that much blood at her delivery, but her conjunctiva were quite pale.  She got a unit of blood that was donated from a family member.  She also had malaria and was started on quinine.   

Olen transferred her to maternity.  

Yesterday she looked better but not good.  Her conjunctiva still looked pale, so we ordered another hemoglobin (takes a long time).  I explained to the family that she needed more blood and that someone needed to donate more.  The lab guy came and showed me that he had checked it already before the donation and her hemoglobin had been 2.7!!!  Why didn’t I know this?  Now it was 4.3.  

Please someone donate blood!  Her heart will give out if it works like this for long.  It’s already been too many days!  

She is the rare O negative blood type.  We don’t even have any units of O negative right now in our bank.  

She was eating.  I helped her start to breast feed her tiny dehydrated baby.  Her sister-in-law had been breastfeeding him some, but apparently not enough because his skin was all dried out and he was weak.  

After a long discussion, two family members said they would check their blood types and try to donate blood.  One was her mother, so I thought I had a good chance of getting an O negative.  

Okay good....plan figured out.  More blood, she’ll be better.  I didn’t follow up on it, but Sandrine (the French Midwife volunteer that’s here for 10 days) helped the mother continue to breast feed her baby.  She was producing milk and the baby was eating much better.  I’m happy, this baby may live.  

This morning I quickly did maternity rounds.  Dr. Marc had already done surgery rounds and we were getting ready to start my vaginal hysterectomy.  

She didn’t get any blood yesterday?  Why not?  No one was the right blood type.  Please look for someone else to donate.  

We did a hernia, then removed a lipoma.  Dr. Marc is a great teacher in the OR.  I’m excited about learning.  At noon I ran into Tex (an aviation volunteer, really his name is Jonathan, but he’s from Texas).  I remembered again about needing blood.  He thought he was O negative.  I asked him to donate.  

No luck... he was O positive.  

A couple more surgeries in the afternoon.  Finally at 4pm we wrap things up and are about ready to go home.  A nurse comes to say my anemic patient needs some attention.  

I go to her bed.  Wow, she looks awful.  She is not breathing well.  Her mother was already holding her mouth shut as they often do right before they die here.  

What?  She was eating and drinking this morning.  

We must have waited too long with her anemia.  Now she’s in cardiac failure from her anemia.  

We still have no blood.  It’s probably too late anyways to give blood.  Her heart’s already shot.  She’s probably in end-organ failure.  My mind goes crazy.  I should have pushed the issue harder this morning.  We should have FOUND someone who was O negative.  

I ask the nurse to get an IV and run to the OR to steal some fluids so we can start quickly.  Her breathing is really loud and she’s making gurgling sounds in her mouth.  I try to open her airway.  Not really helpful.  

We push a 1/2 liter of fluid in.  We explain the gravity of the situation to the family again.  I call Olen.  I think it’s too late, but maybe he has an idea.  

He and Dr. Marc came.  What can we do?  I say a silent prayer.  Can you call Noel (the chaplain)?  Simeon (anesthesia nurse) walks by and we ask him if he can bring the oxygen saturation.  

She starts to breath quieter.  No longer gurgling.  She’s probably just tired of breathing.

Olen goes through a list out-loud of things that cause obtundation.  

That’s weird, her oxygen saturation says 99%.  I would think that if she were in cardiac failure from anemia, she’d be hypoxic.  

Olen asks someone to find the lab guy to get a glucose level.  

“The machine won’t work right now because it’s to hot,” the lab guy responds.  

Can we get a hemoglobin?  


Meanwhile the nurse working the guard tonight says that he is O negative.  I beg him to donate blood, and he agrees.  I don’t think she’ll survive long enough to actually get his blood.  

Olen stays with the patient.  I go to the office to finish some gyn ultrasounds fully expecting her to die soon.  Olen says he’s seen too many gyn patients while I was in the OR.  

I start with the first gyn patient.  She’s had 3 pregnancies.  All of her babies died at 7 or 8 months gestation.  Very frequent here.  I can’t figure out if they died before or after delivery.    

Text from Olen: Oh no, I think, she’s died.  “Bring me D50 (glucose).”

I ask the pharmacy to charge it to my account because it’s urgent and run it to Olen.  Then I go back to continue my consult.  

Text: “Bring me another D50.”

I pass off another one to a family member who was outside and continue my consult again.

Text:  “She’s sitting up, eating and drinking now.”

No way.  I’m so excited.  It was hypoglycemia.  I have to go see this.  

She’s sitting up and drinking water out of a bowl.  Praise God!  We say a prayer in thanks with the family.  

Meanwhile her hemoglobin is still 4.1, but she is getting a precious unit of O negative blood now.  Her heart is somehow fine.  Her sugar was too low, which can happen easily while on treatment with quinine.  

Olen gave the husband the empty D50 bottle.  He explained carefully that if this happened again in the night to demand that the nurse give a new one to the patient.  

“I will extol the Lord at all times; his praise will always be on my lips.  My soul will boast in the Lord; let the afflicted hear and rejoice.  Glorify the Lord with me; let us exalt his name together.” Psalm 34: 1-4

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