Most days...

03 March 2009 Comments

Most days I love my job but today was not exactly a highlight.

Rounded this morning on antenatal ward, as usual. The first patient took us a long time to discuss: she has severe pre-eclampsia, and intra-uterine growth restriction, and appeared to have some ascites and some dyspnea. She was apparently well in the morning, had breakfast, and had just received her dose of magnesium sulphate. We saw her somnolent and floppy, complaining of being hot.

Unfortunately, it is not common practice here to check and follow patellar reflexes in our re-eclampsia patients. There is a reflex hammer (even this is optional; I am often in the habit of doing it with my stethoscope), so I asked for it. Her patellar reflexes were absent. (Brachial and biceps about 1/4)

Several of my Haitian colleagues did not like my technique for testing patellar reflexes in a supine patient. I said, there are several possible techniques. They said my technique was wrong. I said again,
there are several possibilities. They said, that is not one of them. I said, I suppose the neurologists I studied with at home were wrong?

They said, yes, it seems.

It is not a good way to start the day, being insulted. Actually, there is no time of day when I feel good about being told I am a bad doctor.

Later in the morning, someone came to tell me that there was a cardiac arrest in the delivery room. I arrived to find a resuscitation underway: patient already intubated, gynecologist performing chest
compressions. Shortly thereafter, efforts were discontinued.

The patient had apparently been in labour but well. Her blood pressure was normal. She did not fall into our admission criteria, which have been tightened in order to accept only the sickest patients. (Other patients certainly need care, but can be cared for in other centres). As she was getting into the car to be transferred, she felt the urge to push, and so was brought to the delivery room. There, she had a seizure. Then pushed out a stillborn baby, and a placenta that clearly had abrupted. Then she had a cardiac arrest from which she never awoke.

It is a strange case. My theory – not having yet examined the chart – is normotensive eclampsia, abruptio placenta. The cause of the cardiac arrest: possibly hemorrhage from the abruption, possibly amniotic fluid embolus, possibly something else.

It was so sudden. The staff was shaken. The family, of course, was devastated. The walls shook with their grief. Their screams went on for a long time. I was thankful that the psychosocial team was so near at hand.

And immediately after, one of the gynecologists came to find me. He looked extremely upset. What should we do? he said. There was a patient about to be operated, with severe pre-eclampsia and two
previous caesarians. She is already anemic, with a hemoglobin of 5.4g/dL. They were about to start a transfusion, but, it turns out, she's a Jehovah's Witness and so refused the blood transfusion.

I discussed with the anesthetist and the gynecologist. The patient understands the risk of death without the transfusion. She accepts the surgery. We agreed that it would be good to discuss again with patient and with her family, to know if they all agree, or at least have understood the wishes of the patient. We decided to document the refusal of transfusion separately from the consent for surgery. The doctors asked for the psychosocial team to help with the counselling.

The Brazilian psychologist told me later: everything was arranged. The family agrees: no transfusion. Members of the church came also. The patient would have her operation.

This evening, as I left, I found the anaesthetist, and the surgeon. I asked how the patient was doing. Poorly, they said: she has a systolic blood pressure of 60. They were bringing the husband upstairs to see her.