Frosting

“Mouaaaaaahhhhhhhh…, Mouuuuuaaaaaaaahhhhhhh.”  The patient laying on the ground in front of me was coming out of yet another hypoglycemic coma.  She arched her back.  Her tongue stuck out.  Her eyes were rolling around doing crazy things.  If I didn’t know anything medical I may have thought she was Devil possessed too.  I do believe in Devil possession.  

But this was not that.  

I’ve seen this many times with the families here.  A patient is sick.  They get worse.  Their family gives up and decides the medical treatment isn’t working and would rather go to the Marabout (witch doctor).  This family was no different.  Already today I had diagnosed her hypoglycemia by listening to her history and looking at her.  

I noticed four small cuts on her forehead.  There were some dried herbs that had been crushed up and mixed with water and sprinkled over the patient’s face and neck.  I’d seen it before.  I wasn’t naive.  This was definitely not God-driven.  This had it’s origins in curses and non-God-centered spirits.  

I got upset.  I yelled.  I told the family they could chose our hospital, which was centered around believing in God, or go to their witch doctor.  Not both.  

After she awoke again with our glucose drip, the family agreed to stay and not do anymore witch doctor stuff.  Still she was very sick.  

I don’t speak Nangere, but I can understand certain words and phrases.  I overheard them saying that they were ready to take her home.  The nurse was also translating certain things to me in french.  

I got really mad.  This girl, Honorine, can live!  She just needs a little TLC.  Her crazy movements were from her actually getting better and coming out of her deeper coma each time I gave her more glucose.  

I spoke to her father. He had his excuses, “Where would we bury her if she died here?  How would I get her home?”

I replied, “You are worried about the dead.  I am worried about the living!”

I told her big sister that if she stole her in the night I would call the police!  She replied with, “Bring me to the police, You are not keeping her here!  She is Devil-possessed!  Look at her!”  This made me even more mad.  No one was respecting me.  They knew her sickness more than me supposedly.  

I kicked out all of the family members.  I told them all to leave.  Several of them weren’t listening, they just stared at me when they clearly understood!  So I started shoving them out of the door.  I called the guard.  He helped me get them out.  I told them they had to leave the hospital compound.  Somehow, though they always find a way of getting back in!  I locked the doors and told the nurse to not let anyone in!  I decided I was going to have to take her to my house.  

This was a full sized 8-month-pregnant woman!  How was I going to get her home?  I was going to have to use the stretcher.  My kids were already in bed and asleep at home with my mom babysitting since Olen was in NDJ.  Maybe this was a bad idea. This girl has gone diarrhea several times on herself.  Where was I going to put her?  Right in the middle of my living room?  I imagined what I was going to do with her.  Watch her drip.  Open it wider when needed.  But if one night of this could make her live, I was going to do it.

I came home to get the OR keys so I could get the stretcher.  I was so exhausted from yelling and kicking everyone out at the hospital.  How was I going to stay up the whole night and work the next day too?  Mom was in the living room and said she would watch the patient if I needed her to.  I went into my bedroom and closed the door.  I needed guidance.  I closed my eyes and prayed, “God, please help me know what is the best thing to do.  Should I bring her home?  Should I let them go?”  

I had left the hospital very annoyed and upset.  How could I care more about Honorine than her own family?  They didn’t seem to care to give her a chance to live.  Clearly she kept getting better with the glucose drip. 

I went back up to the hospital with peace.  This was not my battle.  It was God’s. 

There was a big group still standing around the outside of the maternity area.  The guard was there.  I very calmly asked who was the one person who was responsible for Honorine.  

“I am,” said her father-in law who was a very young-looking man.  He had actually been the reasonable one all along.  

“Thank you,” I said.  “Now can you please pick two other people who you would like to also be responsible.”  He said he would like her father and mother, and his wife.  “Well that’s three, but okay.”  Everyone else has to leave, please.  

I did my best to get the rest to leave, but still, it was extremely difficult.  

Right then and there we sat down and discussed their fears and ideas.  I discussed my fears and ideas.  

Their fears and ideas were that Honorine was sick with a curse.  If they did not get her to the witch doctor in time, she would die.  My fears were that she had hypoglycemia.  If the family took her away, she would die.  I argued my side.  They argued their side.  It was mostly her father speaking.  He clearly cared for her, but he was so concerned that she had a curse.  He even claimed to be a Christian, but he clearly trusted the curse over God.  

The story is that someone stole some money.  They bought some food with it.  Honorine was the first person who ate this food that was bought with stolen money.  That’s why she was sick.  I’ve heard this story multiple times.  It’s a well known fact around here.  If you don’t pay the witch doctor to remove the curse, you will die.  

So I asked the father why was the witch doctor hiding?  Why didn’t he come out here and reveal himself?  Why was I publicly stating my side?  I am not afraid of the witch doctor.  I know my God is more powerful!  If it was a curse, why did my medicine work on her?  All of this was translated into Nangere from French.  

After a long discussion, they agreed to stay.  They agreed to have all of the other family members leave in the morning.  So I agreed to leave her in the delivery room area.  

That morning at 4am I got called in because she wasn’t doing well.  I revived her with D5 and she awoke somewhat.  Still she wasn’t talking.  One of my friends had written and suggested I try something new.  My sweet husband had brought back several small containers of the most yummy frosting you have ever eaten.  So I became a big girl and decided to share some.  

I put some on my finger and shoved it between her lips.  I didn’t want to give too much because she had been vomiting.  I had thought about an NG tube with sugar water, but the vomiting deterred me.  This yummy frosting seemed to do the trick!  She sucked it off of my finger.  She was alert enough to do that!  Still, she was very sick.  She had a very high fever, so we gave her IV Tylenol.  

I told the nurse to give her some often.  

I went home.  I asked God for guidance on whether to do a c-section or not.  Maybe taking away the pregnancy would help her glucose control?  God, please just show me what to do.  

When I came in to do rounds I noticed there was a new young man who was also a family member.  He was mumbling stuff about N’Djamena and leaving.  Suddenly the girl’s father also wanted to leave again.  

“Seriously!  This new young man comes and you want to leave again?  Be a man!”  Why are there so MANY family members still here?  “You promised there would only be you four in the morning,”  

I forced the new young man to leave because he was just stirring up the family to take her to the witch doctor in their village or to another hospital (um, ya).  

Back with the patient, I opened the glucose drip again.  She came to and when I offered frosting, she actually opened her mouth.  She grunted when the family asked if I was the Nasara.  Since there was now a nursing student there, I told him his only orders today were to give my patient frosting every 20 minutes.  He did a great job!  He faithfully wrote down each time he gave her frosting every 20 minutes.  During my day, I kept coming back to check on her, making sure the family did not take her away.  She still was pretty comatose, but awake just enough to suck down some frosting.  She vomited a few times, but kept most of it down.  

That night I put the kids in bed.  Then I went to check on Honorine.  

I walked in the delivery room area and Honorine was SITTING up!  There were several (way too many) family members gathered around her.  She was greeting them.  I was in shock to see her NOT DEAD!  “Wow!  It’s a miracle”, I said!  “Merci à Dieu!  (Thanks be to God!)”  

Her whole family was in awe she was alive and were grateful to God for his healing.  It was clearly not the witch doctor who healed her.  She greeted me and shook my hand.  Then, all I could do was stare at her… in awe of God’s miracle.  

She continued to recover.  The next day she went into preterm labor and delivered very quickly a 2kg (4lb, 7oz) baby boy.  He didn’t cry right away, and, even though he was big enough, he didn’t seem like he was going to live.  We put him on antibiotics with D5 and taught the family how to do skin to skin to keep him warm.  I really didn’t expect him to live.  It seems like in Chad, you can’t have too many happy endings.  There’s always a little sadness.  And it seemed like this little baby boy was going to die.  

But today on postpartum day 1… Both mom and baby are doing well!  He was actually breastfeeding today.  And crying!  And mom is eating!  And hasn’t fallen into a coma for 36 hrs now (since Friday night).  

It’s a miracle from God.  

And… vanilla frosting is not always unhealthy!  

Not What You Think

Who runs on postoperative day two after a laparotomy?  Not many people.  But this young lady was literally running across the room.  She looked so much better, yet she still looked like a skeleton.

My medical student tells me I should write a case report on her, but part of me feels guilty for having to do a laparotomy.  It did work, however.

Bilal is a 17-year-old girl who presented to us last week.  She was a month or so post miscarriage of “4 months” (sex of baby was known).  The family explained that at another hospital she had already had FOUR dilation and curettages (D and C’s) in the month of December.  In her medical booklet, there is nothing written.  Often times people will have surgeries elsewhere, but we can never find an operative note.  It’s like people are scared to write what they did or didn’t do.

Upon arrival she weighed in at 30kg.  She had previously been 54kg… SEVERELY malnourished!  Bilal had no appetite.  She looked like death, like someone with HIV who was about to die.  I put her on triple antibiotics for presumed endometritis and ordered an ultrasound.  She also got a bag of blood for her hemoglobin of 6.  Her HIV test was negative.

Ultrasound done.  Dang.  She had debris in her uterus still.  Really?  After 4 D and C’s?  But here, who really knows what happened previously.  I repeated her ultrasound that showed no clear endometrial line with evidence of debris.

I told her not to eat in the morning and scheduled her D and C for the next day (Friday).  I would start the day with her on Friday, which I would later discover would be bloody Friday since all 3 of my cases bled like stink that day (her, a postpartum hemorrhage, and a ruptured ectopic).

Friday morning I started with her after rounds.  Just obtaining a spinal seemed scary enough since she was so thin it looked like you would poke right through her.

After an excellent spinal, I started her case with dilating her cervix.  It seemed a little infected which wasn’t surprising.  I was able to dilate her and gently put a curette up to her fundus with ultrasound guidance by my husband.  She was a big set up for a perforation so I was extra careful to be slow and intentional.

I could feel debris up in the left side of her fundus.  Some of it was coming off.  Great!  This might be easier than I thought.  I had previously consented her for a hysterectomy just in case things went south.  She was so young, only had had 2 pregnancies, and I hoped it would not come to that, especially since she did not have any children.

I continued.  The rest of the debris was so stuck on!  Some of it came off, but a good part of it would NOT come off!  Then she started to bleed!  A lot.  I tried to curette faster, but it would NOT come off.

Okay, plan aborted.  We are moving towards a hysterectomy.

But while I prepped for this, she was shooting out blood like a water faucet.  And she was so anemic already!  Second line was already in.  Someone was starting blood in a 16 g vein.  We were opening the hysterectomy kit.

I put a foley in her uterus with ultrasound guidance and added 40cc of water to the balloon that compressed the bleeding.  The bleeding stopped.  However, there was still debris in her uterus.  Quite a lot of it.  And it was infected.  It had to come out.

I wondered if I should try to open her uterus and pull the debris out under direct visualization, like a c-section.  No, dumb idea.  Fleeting thought.  She is sick.  She has been sick too long.  Her debris was causing a big infection in her body.  She needs to be healed.  Her family said to do whatever it took to get her health back.  They were at peace with a hysterectomy.  She was a peace with a hysterectomy.

While prepping her, I observed that she was so, so skinny to even undergo such a big surgery.  Her pelvic bones were so prominent.  But she was too weak to bleed or be infected any longer either.  Such hard choices.  But such easy ones too.  Do whatever it takes to give her her health back.

Dad and I scrubbed and opened her belly.

Patricia (medical student) dared to speak out loud and asked if we could just take it out like a c-section.

That’s just what I was thinking, I told her, but it was taking a risk because she could bleed more. Although we did already have the bleeding controlled temporarily with the balloon.

Classical incision into the uterus.  Wow, that debris is really stuck on.  I tried wiping it off with a compress.  I grabbed ring forceps and pulled it out chunk by chunk.  This was much more controlled than from below when I could not get it removed with ring forceps or a curette.  Eventually, it looked like it all had come off.  Hopefully not too much endometrium with it!  It was still bleeding after that, but not extensively like before.  I took some of the water out of the foley so that I could close the uterus back in 4 layers.  Then blew the foley back up to make sure she didn’t hemorrhage.

She may have been in partial DIC, because everything seemed to bleed.  I used a small needle to get the little bleeders left on the uterus, bladder and muscles.

Well, that was weird, but it seemed to work.  Praise God, we didn’t have to do a hysterectomy…yet.

I wrote on the operative note hysterotomy (cutting into the uterus).  One of the nurses interpreted it as hysterectomy (removing the uterus) and told the patient that night that she could no longer have any kids.

When Patricia went to see the patient later that night to check on her bleeding, she told the patient that we saved her uterus.  They both had tears of joy in their eyes.

On post-op day 1, I removed her foley from her uterus.  Very minimal bleeding!

Today, on post-op day 2, our patient is a whole new person!  She wanted to know what she could eat!  She hasn’t wanted to eat in over a month! She had been so skinny, and I told her she was going to stay here for a long time to regain her strength.  I stood her up to walk.  She asked if it was okay to move around.  I said, yes, she could run if she wanted to.  She started fake running across the room!  She was so happy.  Praise God.

The nurses at the other hospital had told her she had HiV and that’s why she was so skinny.  (She was negative here).  Her family told her there was no point going to another hospital because she was just going to die.  She might as well just die of her sickness.

Her sickness was an infection from retained products of conception (debris from her placenta)!

It will be a while before she gains back all of her weight, but she’s off to a good start!  Please continue to pray for her!

Story and photo shared with permission from the patient.

Beeper

My beeper goes off at 4am.  Oh wait, no.  I don’t have a beeper.  Do doctors in America even use beepers anymore with all of their fancy gadgets?  Maybe they just get texts via their smart phones.  I don’t know.  It’s been too long since American medicine. 

Let’s back up. 

I used to wake up with a knock at the door, but the last several months, our husky dog, Sheba, has been quite demanding to sleep outside since it’s uh, um, “cold” season.  From her cool spot in the wet dirt of the flower garden just outside my window (don’t worry, the flowers don’t really grow there), she half barks in a kind of whiney bark that only huskies can do.  She knows to not bark too loud or we will make her stay inside since she’ll wake up the children. 

All this to say that a nurse is at the gate.  They are too scared to come to the door anymore with Sheba sleeping outside. 

But the arrangement works, and I’m awakened. 

Nemadji came to tell me that bed 2 was ‘complicated’ again.  She said that Sabine told her in sign out the patient seized yesterday and…

Wait, back up.  The patient never seized!  We went through this yesterday with different nurses.  I knew this would get messed up in sign out.

“Nemadji, she is hypoglycemic!  Please give her serum glucose 5%, (since we have no 10%, and definitely no 50%). Please come get me if she doesn’t wake up.”   

It’s 4am.  I try to go back to sleep.  Not happening.  I rethink the previous day. 

Honorine had come in on her third pregnancy with a fever of 40 Celsius (104 Fahrenheit)  and a negative malaria test at 34 weeks (by the scan this admission).  She was acting like a normal malaria patient.  She got a day of IV quinine, our best malaria medicine.  Her vomiting stopped.  She started eating.  We switched her to oral quinine.  On her third day of treatment, yesterday, she was still eating some.  But if they don’t look perfectly well, I keep them an extra day because pregnancy makes it harder for the body to recover.  No more fevers, eating… just looked a little weak still. 

Yesterday while I was in the operating room, one of the maternity nurses came in to tell me that bed 2 had seized. 

Since I didn’t remember who she was, I asked if her blood pressure was normal.  They said, yes it was 130/80 and explained she had come in with malaria.  Okay, thank you I said, continue the treatment and give diazepam as needed.  Cerebral malaria.  We see it more often than I would like here. 

Five minutes later, the same nurse came back and said they had taken a manual blood pressure and it was now 150/90.  And that she had seized again. 

Hmmm… I don’t know what to believe now.  But I am scrubbed, so can’t go evaluate her yet.  I’ll tell you one thing, I do not take real vital signs for granted.  Sometimes I feel like they make them up to go along with the diagnosis they think she should have (like eclampsia). 

After I finish in the OR, I go over to evaluate the patient to see if we need to do a cesarean section for eclampsia or not. 

The nurses who had been with her earlier, not 15 minutes prior, were now gone and new ones were on. 

I go to see the patient, who is in a coma.  Post-ictal comas happen after seizures often and she had also received diazepam. 

I have the students retake her blood pressure.  110/70.  140/90.  110/60.  It’s all over the place with the electric blood pressure cuff.  They tell me the manual blood pressure cuff is broken. 

Awesome. 

So I just sit at the foot of her bed and observe her. 

There are about 20 people gathered around her bed in a giant room of 16 beds, all full with patients and their families. 

One of the students spoke their language, so she helped translate for me.  I asked, “So, what did the seizure look like?” 

“She didn’t seize.”

“What? The other nurses told me that she had seized and then went into a coma.”

“No, she came over to her bed, laid down, and said she felt like she was going to die.” 

“Sabine, demandez glycemie, s’il vous plaît! (Sabine, please get a glucose level!)”

I am writing this blog at 5:15 in the morning.  Now my children are waking up.  I am getting interrupted.  Juniper wakes up with a diaper full of poop.  Doesn’t look like she will go back to sleep.  Seriously.  Way too early!

5:30am.  All four children are up.  Olen is asleep.  Hmmm….How did that happen?  Anyone who has kids knows that you never need an alarm clock to wake up either!

To be continued…