Hemotoxic

I hate snakes.  I hate snakes.  I hate snakes.  

I hate them even more after this story.  

We have some neurotoxic snakes.  Their venom attacks the nervous system.  There are other types of snakes here that are hemotoxic.  Meaning once you get bit, the venom binds to your blood’s clot-making system, causing it to quit working properly and your blood can no longer coagulate and make clots and stop bleeding.  In our worst cases, our patients slowly ooze from their IV sites, from their ears, from their nose, from their gums, even from their eyes.  They cough up blood, they vomit blood, they poop blood and they almost always pee blood.  Slowly.  No big gushing fountains of blood.  Just mere oozes.  Oozes that never stop oozing.  And despite the slowness of the oozing, you eventually outstrip your body’s ability to make new blood.  Your marrow can’t keep up with the slow oozing.  And you eventually hemorrhage to death, or “bleed out”.  

Scary, right?  Remember the Ebola epidemic?  Caused you to bleed out.  Same thing.  Only if you get bit by a snake you aren’t contagious like with Ebola.  

I once had a pregnant patient come in with a nose bleed after getting bit.  It stopped eventually and she did fine.  I’ve had another pregnant patient come in after getting bit, lost her baby, delivered, stayed in a coma for a day or so, but eventually recovered. 

I’ve had some real disasters this month.  This was one of them.  But somehow I had a bit of hope for the patient who came in last week.

She was a young village girl coming in with vaginal hemorrhaging at six months pregnant.  I mean, she was really pouring out blood, not oozing.  Vaginal bleeding, we know how to treat.  The only thing is she had been bitten by a snake four days prior with no antivenin (“anti-snake-venom”) given.  And… our hospital was out of antivenin.  Sigh.  

With uncooperative blood like this, it’s never a good idea to do a c-section.  I’d rather get her delivered vaginally.  However, she was bleeding too much.  And we weren’t certain that her blood wouldn’t coagulate, just speculating since we have no labs to test that here, except for cutting the patient and sitting around and watching to see how long it will take the blood to create an effective clot, if ever.    

So c-section here we come.  

Mom was completely alert and talking as we wheeled her into the OR.  I don’t like to scare people, nor do I ask everyone if they know God before surgery, but this one just was a setup for disaster.  You see it over and over here.  You can see death has a higher possibility of occurring in this patient, but not in that one.  You think about it later and wonder if it would have changed their eternal outcome if you would have said something and told them it was easy, just accept grace, unmerited favor.  No point in wondering anymore. 

Like most of my patients, she didn’t speak French.  I asked her through an OR nurse if she knew God.  She said she did, but seemed shy and not real clear with her response.  I told her it was never too late to decide you wanted to be on God’s side.  The thief on the cross decided right before his death. We prayed and started the c-section.

Cut through skin, fascia & uterus.  Got tiny little baby out.  Only about 1 pound.  Looked dead already, but had a heart beat.  Lived only a couple minutes.  

Closed uterus.  Uterus wouldn’t contract well.  Put stitches around uterus to help it stay contracted.  Seemed to work.  

One problem.  Her muscle.  Her abdominal muscle would NOT stop bleeding.  And her uterus then started to bleed from the suture points.  A few more sutures put in.  Sutured up the muscle as best as I could.  Next her subcutaneous tissue (her fat) kept bleeding.  I kept suturing, closing off all of the tiny vessels that wanted to bleed out.  They were begging for a way to let her blood drain.  Skin sutured.  Done.  She wasn’t hemorrhaging vaginally.  Her conjunctiva looked pink.  Sigh of relief.  

Five units of blood were given during her surgery.  She was blood type O positive and we only had six more units in the fridge of O+.  I put a very pressurized dressing on her lower abdomen and prayed for the best.  Sometimes that’s about all you can do here.  

Two hours later Ndilbe told me she did not look well and looked really anemic again.  

Oh boy.  This wasn’t going to end well.  I knew it.  Mason knew it.

But as a doctor, it’s hard to sit by and watch someone slowly ooze to death without trying everything you can do.  So we try.  We try despite our knowledge this is unlikely to work.  But you think there’s a chance.  You give the patient that slim chance.  And then you leave the rest to God.  

We urgently brought her back to the operating room.  She was not the same young girl, alert and talking.  She was in a bad state.  Anemic and out of it.  

I reopened her and found a belly full of blood.  The abdominal wall muscles simply would NOT stop bleeding.  Now bleeding seemed to come from everywhere.  I wanted to try to block off all of the big vessels that might be causing her hemorrhage.  I did an emergent hysterectomy.  There was no more pelvic bleeding.  I ligated her bleeding abdominal muscles again.  I closed her again.  

We tried.  Mason poured more blood into her.  Yet five more units for a total of ten bags of blood.  When I finished the surgery, he held up his last unit of O+ blood, and we agreed reluctantly, hesitantly, somberly, that we couldn’t give it to her.  We needed to leave something for the inevitable pediatric patient with a hemoglobin of 1 or 2 or maybe 3 who would certainly come in that night, like they do most nights this time of year.   We did everything, except give an eleventh bag of blood.  

She lived another eight hours.  And then she died.  She died of a snake bite.  One that we don’t have the antivenin for.  And one that the family refused to go to Lai (18 km away) to get the available antivenin.  It costs 38 dollars there.  And we hadn’t charged her anything for the care we gave her.  Honestly, it probably wouldn’t have made a whole lot of difference.  It was already so late in the game.  

We won’t know the real outcome, her eternal destiny, until Heaven.  Only God knows.  Until then, we keep trying.