#57 You Gotta be Kidding

I’m surprised my hands aren’t shaking. I cut clean from pubis to sternum, looping around the belly button. I should not be doing this. I cut down through the layer of fat to the muscle. I’m a little off-center, so I rip the muscle up to find center. Then I just keep on going down. Not really how you’re supposed to do it. It risks nicking bowel on your way in through the peritoneum. But I don’t have time. I married Danae so she could do this and not me.

‘Baby, just go. Don’t worry about it. I’ll be fine. What’s the worst that could happen?’ That’s what I told Danae exactly 32 hours earlier. She wanted to go to Moundou with the Parkers. She wanted to do a little shopping and to get out of the house and away from the hospital. She was going to leave at 6am and come back in the evening. Moundou’s only a couple hours away. I was so supportive that I even woke up early and helped her pack a day bag.

‘I think I’ve got an ectopic,’ was what I texted her.

She texted back that she was stuck in the mud. They had driven off the road in the rain and were now trying to get the car back on the road.

‘Should I come back?’

‘No, don’t worry. I’ve still got Samedi here.’ Samedi’s been here like 34 years and has been doing surgery for most of those.

‘Blood pressure’s 70/40. Anemic.’ That was my text a couple hours later.

‘Tire flat. Spare no good.’ That was the text she sent back.

After distributer issues and needing to drain off all the oil (to get the water out), they finally made the two hour trip to Moundou... in about twelve. They decided to spend the night there.

‘Really, Samedi? I think we should take her back. Well, no. I don’t see a for-sure ectopic, but I also don’t see anything in the uterus but her pregnancy test is positive. Her belly is tender and she’s anemic. Well, yes. Her blood pressure did come up to 130/80. Yes, she does have a lot of vaginal bleeding, which is more common in miscarriage than ectopic. I suppose we could do a dilation and curettage.’

Samedi wants to wait. He think with a good blood pressure she’s getting better and will complete her miscarriage without curettage. He doesn’t think it’s an ectopic.

I take Samedi with me to see a patient on the surgery wards. He’s old and he came in for a hernia repair. However, since he arrived he’s started spiking fevers, his belly has become distended and tender, he’s vomiting and he’s stopped pooping and farting. His colon looks really edematous on ultrasound. But his lab tests show Giardia and worms and malaria. He’s getting treated for all that and not getting better. I’m pretty sure he’s got dead bowel. Samedi swears he’s seen this a million times and they just get better with antibiotics.

The next morning at 6am, Samedi goes to N’Djamena. No Danae and no Samedi.

The nurse comes to get me at 8am. A woman just came in. She’s been laboring at home with her first baby since the night before. I wheel over the ultrasound. Baby’s still got a heartbeat. No meconium. Smallest pelvis in the history of pregnant ladies. No way that baby’s coming vaginally. Well, I suppose we’ll let her labor until Danae gets here or until the baby’s heartbeat drops. If mom goes hypotensive, if baby goes bradycardic, come and get me and I’ll do a C-section.

No way those words came out of my mouth. Did I really say I’d do a C-section? I married an obstetrician. There is no good reason in the universe for me to do a C-section.

On surgery rounds, the old guy’s even sicker. He’s obtunded now.

So I have what I believe to be an ectopic, necrotic bowel, arrested labor and no surgeon. Awesome.

I bounce back and forth all day between checking up on my presumed ectopic (who’s got a blood pressure of 130/80, has received two units for her anemia and who’s vaginal bleeding has stopped) and the lady who needs a C-section.

About 1pm, I do another vaginal exam. I can see baby hair, but now the baby’s pooping himself. Meconium everywhere.

I tell the nurse to take her to the OR and set her up for a C-section. Are you kidding me? No way I just said that.

On the way to the OR I glance at the presumed ectopic. Hmm. She doesn’t look so hot. Get her to my office.

I put the probe back on her belly and it’s now full of blood. She just ruptured her ectopic.

Ok, change of plans. Hold that C-section and get this girl in the OR now.

In the OR, her IV’s gone. They finally get a second one and start her third unit of blood. She’s barely breathing at this point. A second IV with a liter of Ringer’s are going. A foley’s in. I’m bagging the patient, since she’s only taking agonal breaths on her own. We even flip on the oxygen concentrator. We can’t get a blood pressure, but the finger oxygen monitor tells me her heart rate is in the 130s and her sat is in the 90s. That’ll do.

I teach Ndilbe how to bag. I tell Abel that this patient doesn’t need anything more than a shot of IM Phenergan for anesthesia. I get Salomon to scrub in with me. Salomon gives a quick prayer. I check the finger monitor again. Heart rate still 130s. Sat 99%. Fourth and fifth units of blood are up. Another Ringer’s is up.

I’m surprised my hands aren’t shaking. I cut clean from pubis to sternum, looping around the belly button. I should not be doing this. I cut down through the layer of fat to the muscle. I’m a little off-center, so I rip the muscle up to find center. Then I just keep on going down. Not really how you’re supposed to do it. It risks nicking bowel on your way in through the peritoneum. But I don’t have time. I married Danae so she could do this and not me.

As soon as I enter the peritoneum, blood is everywhere. Soaked through the surgical drape and my gown and my scrubs and my boxers in seconds. We aspirate out two liters of blood in addition to the pool that I’m standing in. My shoes, everything is covered. I’ve never seen so much blood.

I quickly cut the peritoneum north and south. I hope the bladder got out of the way. I finally aspirate all the blood I can so I can see the ectopic on top of the uterus. I identify all the blood vessels and the Fallopian tubes. I clamp, clamp and cut the bad tube and tie it off. I bluntly dissect the ectopic off the uterus. It looks like it’s matted to the colon too, so I clamp, clamp, tie and repeat a million times. Eventually, there is no blood and no bleeding and no more ectopic left. We irrigate and I close peritoneum/muscle/fascia together in a couple layers. I look at her finger monitor. Pulse 90, sat 90%. It had been as low as 83% when Ndilbe stopped bagging, but now it’s back up.

I scrub out to let Abel (who also scrubbed in when her realized that she was too sick to need anesthesia. I open the fridge. Blood bank only has two bags left and it’s not her type. She’s still pale. She still has no blood pressure.

Abel puts in the last skin suture. I listen for breathing. She’s not taking any spontaneous breaths. How can she have such a good pulse and oxygen sat and be completely unresponsive? Her blood pressure should at least be findable if she’s perfusing that finger monitor.

And then... she loses it. The finger monitor doesn’t pick up anymore. I already had the ultrasound set up in the room and it takes me five seconds to put the probe on the chest. No heartbeat. Simeon and Danae just got into the room from Moundou. Simeon hasn’t even changed into scrubs, but he immediately starts chest compressions. We draw up epinephrine and atropine. I start instructing the nurses to breath, do compressions, give epi and atropine while I dust off the defibrillator and plug it in. I have no clue if she’s in vtach or vfib, but it’s probably her best shot.

She gets three shocks, three atropines and three epinephrines. I’m in no-man’s-land Tchad. What am I doing?

I call in the husband and let him hold his wife’s hand in between the shocks. She had never been pregnant before. In the end, she finally was pregnant. And that was what killed her.

Great. So I correctly performed an ectopic pregnancy surgery on my own. And lost the patient anyway. Most cases that you carry with you in your mind have many ‘if only’s.’ This case has just one. If only I had taken her to the OR earlier.

Before we even get the corpse out of the OR, we bring in the woman who’s been laboring for two days now. We get her on a bed and roll her over to look at the wall (so we can do important medical things, as far as she’s concerned) while they carry out the body of the last patient. You really don’t want to see a dead previously pregnant lady being carried out of the OR when you know you’re the next pregnant lady to go in.

Danae starts the C-section while a nurse grabs me to see a new patient who just came into the ER. Young woman with abdominal pain, vomiting and diarrhea. Cachectic. I palpate a suprapubic mass.

‘Uh, is she pregnant?’

‘No. She had her period within the last month.’

‘Take her to my office.’

By now I’ve got the ultrasound back in the office. I put the probe on the mass. Not only is she pregnant, she’s over 17 weeks pregnant. And the baby is dead. Her blood pressure’s 70/40. I get an IV in her and start a liter of Ringer’s.

I go to the OR to discuss this one with Danae. Danae’s just about to pull out the baby. Danae can’t the baby out. The head is stuck in the pelvis. I put my hand under the surgical drape and into the vagina. I push on the head for all I’m worth. Danae can just barely get her fingers under mine and pull out the baby.

I put the baby girl on the table. She’s hiccuping (or gasping), but not taking in any air. I put one end of a tube into her nose and down into her lungs. I pull it out slowly while sucking on the other end of the tube. Meconium comes out into the trap. After a while, no more comes out. I start breathing for the baby. We get an oxygen monitor on her foot. Oxygen is 80%, pulse 150. With a little help, the oxygen easily comes up to 99%. I stop breathing for her, and it falls to 51%. I breathe for her and it immediately skyrockets again. I show the nurse how to breathe for the girl and I grab a syringe and sugar water. I inject the sugar water in her veins. So many babies here are born hypoglycemic from protracted labor and a malaria-infested mother. This baby fit both criteria.

After three hours, the baby girl will barely take a few halting breaths.

We take her to her mother. We put her skin on her mother’s skin. We put her mother’s hand over the baby. We explain that we don’t expect the baby to survive the night unless she starts breathing better.

We are called to see the old man with necrotic bowel. We tell the family that he needs surgery tonight. They refuse and take him out of the hospital.

We see the woman with the dead baby inside and write orders for her for the night.

We get home about 9pm. I can’t even remember the last time I ate.

The C-section baby dies about 3am.

The other woman delivers her already-dead baby at the same time.

Dead woman of an ectopic. Dead baby after C-section. Dead baby before birth. Guy taken out of hospital certainly dead by now.

Seriously?

What am I doing? Are we helping anybody?

Dear God, give me a sense of purpose and of Your light in this place that can often feel so dark and lonesome and depressing. Help me to understand why all the suffering happens here. And although I live in the midst of all this suffering, please protect me and my family from suffering.

love
olen and danae

missionarydoctors.blogspot.com

danae.netteburg@gmail.com.

Olen phone: +235 62 16 04 93
Danae phone: +235 62 17 04 80

Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Kelo, Tchad
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