Sunday, July 14, 2019

Work Note

Sheer terror.  That is the only thing I can think of that describes the situation we were in.

Our new doctor Sarah had called me at 1am. Hey Danae, can you please come and help me for a uterine rupture?

Ok, Ill be right there.

So rare in America, uterine ruptures happen here in Chad all the time. Women labor for a long time at home. By the time they get to our hospital, their babies are dead. Surprisingly, they usually arent hemorrhaging badly. The baby typically is compressing the big vessels of the uterus, so the women somehow survive. We cut into the abdomen and repair or take out the uterus.  Its my bread and butter here, or so it seems.

But this is far from that situation. This was something worse.

I walk to the Operating Room (OR) to meet Sarah there. There is a woman on the table already, but Sarah comes racing around the corner with the gurney and another patient. I quickly realize that she was managing multiple patients at one time. She had a patient on the table awaiting Cesarean-section for failure to progress in her labor, but she hadnt gotten to her yet.

The patient on the gurney is the true emergency. I look around at whos going to help us. Five saucer-eyed nursing students stare back at me, clueless as to how bad the situation is.

They somehow switch patients to put the hemorrhaging woman on the OR table. Even doing this is a challenging task for our inexperienced team working tonight.

Has Philippe been called?” I ask.


Sarah calls Philippe. I call Philippe. We need Philippe. We need anesthesia. We need a 16 gauge IV. In fact, we need two. Actually, we probably need three. All we have is a tiny catheter unable to drip fluid into our patient fast enough. Its never going to work.

I quickly assess the situation. The patient has a postpartum hemorrhage. Sarah told me a little of the history. The patient was induced, but then required a vacuum delivery, essentially pulling the baby out with a suction cup on the babys head, a very common and safe procedure. Sadly, but unrelated, the baby had died during labor prior to delivery. Sarah said shed felt inside after the delivery and could tell the patient had a ruptured uterus. She had hemorrhaged out like a bathtub faucet. I try to compress the uterus from below, but it isnt helpful.

Instinct sets in.

Must stop bleeding.

Foley please. Call the other nurses from the other services. We need a good IV! Call Staci to come help. We have nobody here to do anesthesia. Staci can give anesthesia.” Still nothing better for an IV.

A few more nurses show up from the other services. One clearly had been sleeping, rubbing his eyes. Its a major no-no, but I tell myself to address that later.

So many nursing students threatens my sterility, which Im usually absolutely rigid about, but at this point sterility doesnt matter.  I quickly scrub the patients abdomen in 30 seconds. Sarah and I do a half scrub.

Any moment, Philippe should walk through that door and place a good IV, and well be all set. I just have to stop the bleeding right now.

No Philippe, but Staci shows up.

The patient starts making gasping sounds.

I cut into her abdomen with zero anesthetic. She barely flinches. (Not a good sign.) I grab the uterus at its base, stopping the flow of blood into it, and thereby stopping the flow of blood out of it and out of her. Thats all I can do for now. Shes so close to death. It doesnt matter if I do a hysterectomy or not now. Ive stopped the bleeding with my hand, but if we cant get a better IV, we will lose her. I cant do it all at once. I just squeeze.

She has no blood pressure, no response, no sign of life. She needs epinephrine, the pharmaceutical equivalent to a horse hoof to the heart. We give some epi through the barely-functional IV.

Philippe shows up. He tries to get a better IV.  

But its all simply too late. Im trying to run the code, directing traffic to give chest compressions and breathe for the patient and give IV medications. I pass the uterus to Sarah to squeeze while I start chest compressions. Too late. All too late.

Give atropine IV. Give more epi.

Epi. Atropine.

Just keep pumping. She cant die. She labored at our hospital. Sheour patient.

My hands and arms grow tired. The sweat is dripping down my face. Thinking what else to do. We discuss placing a central line, an IV placed closer to the heart, but nobody is really comfortable doing that. I should have told Staci to do one. I should have tried one. Philippe can always get a line. But its too late.

We started CPR minutes after Philippe arrived, but she had already bled too much, too quickly, for too long. She needed blood. She needed blood fast.

After a long time, while shes still being coded, I go out to talk to the family. Her husband is there. I ask how many children they have. Three. I tell them how bad the situation is.

I go back inside. Its too late. Weve coded her for over an hour. We called it. Shes dead.

I give the news to the family.

We wheel her out to the pre-op room and switch patients. The next patient has to be done too. For moral support, I wait in the room as Sarah and Staci perform a C-section on the next patient.

Then I go outside to be with the family of the woman who died. The mother of the patient had been in the maternity ward and hadnt been told her daughter was actively dying. Now, shes actively grieving.

Its 5 am. Were all beat. We debrief some and then go home to sleep a couple of hours. Sheer exhaustion. Thats what happens after a stressful situation. Sheer depression.

The next day at work, I find out the patient had been waiting for a month at the hospital so she could have a safe delivery.  The baby died in labor, and the mother died after a vacuum delivery from a postpartum hemorrhage. A month living at the hospital to ensure she didnt die in labor at home. And she dies here instead.

Deeper depression sets in. We failed. I failed. After a month of being safe.

But theres still work to be done. Still need to round and see all the hospitalized patients. Operations on normal cases. Lots of consults. Sarah had gone home to get some rest because I told her she should take the day off. But shes too depressed to be at home, so she came back to work in the afternoon to help us with the consults. Shes amazing and smart and strong.

She presents a patient to me that had a fistula, an opening between her bladder and her vagina. The patient had lost her medical booklet, but Sarah had copied the operative note I had written in the computer three years earlier. She had been my patient. She had had a large 5 cm vesico-vaginal fistula that I had repaired, including a left ureter anastomosis to her bladder.

This next week is a fistula week at our hospital, but I hadnt made any announcements on the radio yet when this woman came in. So I was surprised that she was here to be operated on again. I was depressed already and now this woman came back who wasnt fixed by my major surgery on her.

She didnt speak any French, only Lele, a language far from Béré with only 26,000 native speakers, none of whom work at my hospital. I bring her into the OR so I can do a proper exam on her with good light. She doesnt smell like urine. Theres no urine leaking from her vagina, and theres none on her clothes. Maybe, just maybe, we misunderstood. I find a nursing student who speaks a neighboring language similar to hers, and we piece it together.

She isnt leaking urine. Shes been dry since I did two surgeries on her back in 2015. I told her to not work until her visit with me. Well, now three years on, shes back for her visit. She hasnt done any major work for three years. She was too nervous about the fistula breaking open. On her exam, everything feels soft and her urethra appears normal. She is cured.

She explains shes been arguing with her husband about whether she should be working or not and came back today to ask if she should. Should she start carrying things on her head and working in the fields this year?

Three years. Three years and she chose today to come back and ask this simple question! With tears in my eyes, I tell her today had been an extremely awful day, and I believe God had sent her for this very moment to tell me she had been cured. He had spoken to her heart so she could encourage me.

I ask her where she lives. She tells me she lives well past Kelo, a town 26 miles away. She got to Kelo and didnt have any more money to continue her journey, so she walked the 26 miles to our hospital just to ask if she should start working again three years after she was healed.

Right then and there, I give her money for her transport back. Actually I stole money from my amazing volunteer nurse, Sonam, so she could ride back to her home, plus a little extra. Which reminds me, I still need to pay Sonam back.