Hemoglobin of 2

17 March 2016

I am so, so tired. The last two nights in a row I have been up all night with C-sections, and during the day I keep getting called for emergencies. I haven’t had more than two or three continuous hours of sleep in three days. I am looking forward to showering, eating dinner and going to bed very early. At around 7pm, I am coming out of the shower, and my phone rings. It is Cecile, the experienced expat midwife.

I answer the phone: “Nooooooo….”

“Yes.”

She explains that a woman on her twelfth (yes, 12) delivery has been 9 centimeters for far too long, she has been trying to push past the last bit of cervix but has been unable. The fetal head is very high, which is extremely suspicious. Cecile has a bad feeling about this. Cecile is an outstanding midwife – if she has a bad feeling, something is wrong. I head to the hospital immediately, stopping only to grab the anesthetist, Eileen, and to shovel a few bites of dinner on my way out.

At the hospital, I confirm Cecile’s impression. Something is stopping this woman from pushing out her twelfth child, and we decide to do a C-section. She wants a tubal ligation. She says, “The ones I have are enough. Although I miss four of them, the ones I have are enough.” Apparently four of the children she delivered died – a common theme in South Sudan.

I am hoping for a quick C-section because I am so damn tired, but I am denied. We deliver the baby successfully, but as I am just getting her uterus closed, the uterus suddenly goes completely limp and turns to mush, or uterine atony.

In order to prevent bleeding, the uterus needs to contract into a solid mass, almost like a rock. Hers was rock-like for about half an hour, but now it is crapping out. She has two risk factors for this – multiple prior deliveries (grand multiparity), and an intrauterine infection (chorioamnionitis). Eileen and I start the protocol for ameliorating the atony. We give her medications – Pitocin, methergine, misoprostol – all at their maximum doses.

Nothing helps. I am constantly massaging her uterus to prevent any blood from pouring out. Finally, I am down to my last option. I perform a B-lynch suture: I take a long thread of suture, anchor at the front of the uterus, loop it over the top of the uterus, stitch across the back of the uterus and anchor in the front again. I tie it tightly so that the uterus squeezes down into a ball, the way it should be if it was contracting on its own. The B-lynch seems to hold. If it doesn’t, my last option is a cesarean hysterectomy – removing the uterus. Luckily, The B-lynch works, and we are able to close and finish the surgery. The patient stays stable and miraculously has not lost much blood, thanks to all the aggressive massage I did when her uterus was so weak.

We come out of the operating theatre (OT) and deliver her directly to the maternity ward. I am extremely relieved to be done with this surgery and really, really looking forward to getting to sleep. As I am writing my operative note, a nurse says that she wants to speak to me when I am finished. She pulls me over to see another patient who is lying in bed on her side.

“The hemoglobin is 2.”

I am annoyed. She is not supposed to be calling me at all – Cecile is on first call. And even if I was on first call, if the patient is this sick, it shouldn’t have waited for me to get out of OT – they should have called Cecile anyway. But now I am here, and even though I am ready to collapse with fatigue, I cannot leave knowing a patient could be very sick.

For reference, a hemoglobin of 2 is insane. In the US, we would not survive that level. A normal hemoglobin is around 13. Here in South Sudan, many women are so chronically anemic from malnutrition, gastrointestinal parasites, and consecutive pregnancies that they can tolerate anemia at levels that you can’t imagine they are still alive. We have seen so many cases of women and children walking in with hemoglobin levels of 2 and 3 that we can’t even count. We don’t even transfuse all of them because we don’t have enough blood for all of them – we only transfuse if they are unstable.

In this case, I need to assess. Is this patient unstable? What is going on? Why did she come? She is lying on her side and she looks calm, but it can be hard to tell anything. Women here tend to be very quiet, but they can be so sick if you don’t look carefully. I turn her onto her back. She is emaciated, as many are, but I can immediately see that she is in respiratory distress, with labored breathing and using accessory muscles.

She tries to speak but she is slurring her words, and her family says that this is not normal for her. This woman is very, very sick. I quickly check her chart. Her heart rate is slightly elevated (111), but not as high as you would expect for a hemoglobin of 2. She has no fever, and her malaria test is negative. There is no fetal heartbeat – the fetus is dead. Her blood pressure is normal – not high, not low.

“Does she have pain?” I ask.

“She has pain all over her body,” the nurse semi-translates. (Not very illuminating.)

“Does she have abdominal pain?”

“She has pain in her abdomen and back.”

“Is she bleeding?”

“No.”

I tell the staff to call Cecile in. Either I will need her help, or she can take over the evaluation. I run through a differential diagnosis in my head. Either this anemia is acute or chronic. If it is chronic, she wouldn’t look so sick and be so short of breath. I have to assume that it is acute. But if she is not bleeding vaginally, where did the blood go? She could be bleeding internally.

She could be having a placental abruption – the placenta could have ripped off her uterus and the blood could be collecting in her uterus, and since her membranes are intact, we would not see the blood coming out yet. Or she could be bleeding into her abdomen – either from an illegal abortion (her uterus does not look full term to me) or from some other organ. Placental abruption would explain the fetal demise, whereas with illegal abortion, she should have vaginal bleeding. Placental abruption is highest on my list.

I ask them to bring over a privacy screen (the beds are one next to the other, and all out in the open), and the ultrasound. I see the fetus, and confirm the lack of a heartbeat. I scan around to look for blood, and at first don’t see much, but as I go higher up toward the fundus, I see what looks like possibly clot and liquid. I need to differentiate where the bottom of the liver ends and where the uterus starts – her liver is slightly enlarged, and this ultrasound does not have very good images. But to me, it looks like both clot and liquid at the top of the uterus.

I suspect she has an abruption. I measure the thighbone and it measures 36 weeks and 6 days. Could she possibly have a full term fetus in that small uterus? It seems unlikely, but I don’t have time to do extensive fetal measurements now.

It would be best to avoid a C-section if possible, because that would only cause more blood loss, and the baby is already dead. No vaginal exam has been done, so I request gloves. Cecile has already arrived, and I brief her on the situation. I perform the vaginal exam – the fetal head is in the pelvis, she is fully dilated and ready to deliver.

Cecile is about to pick her up by herself (Cecile is awesome). I pull her back and tell one of the male nurses to lift her. They move her to the delivery room. The patient is so weak that she cannot keep her legs bent in the position for delivery, so we require multiple people around her to hold her legs up, speak to her, handle her IV, and deal with getting medications and preparation for delivery. It is all hands on deck.

I turn to Cecile. “She really might die.” She doesn’t say anything, but I know she agrees. We both put on gloves and aprons to prepare for delivery.

We break the water, and thick green fluid comes out. But no blood. Where is the blood? If she is having an abruption, we still can’t see the blood. It could be completely trapped behind the placenta, but then it’s hard to imagine that she has lost enough volume to make her this sick.

The patient is very weak, but able to push. We encourage her pushing: “Chol, chol chol!” (“Push, push, push!”) We decide to apply a vacuum to the baby’s head to help expedite the process, since she is so weak and so sick. The vacuum helps, and the head delivers more quickly. I pull the limp, blue fetus out. It is smaller than full term size – later we weigh it, and it is about 2kg. It could be preterm, or it could be full term and growth restricted – it’s hard to tell.

Regardless, I don’t have time to worry about it, because I have to focus on the mother. Her uterus is not contracting – it is completely atonic, and given that she has almost no blood to begin with, we can’t afford for her to bleed from her uterus.

I put one hand inside the vagina and another hand on top of the abdomen, and perform an aggressive bimanual massage. Blood squirts out, but I manage to control the bleeding as long as I massage. The staff injects 10 units of Pitocin into her leg muscle – the standard dose. It doesn’t seem to help. I ask them to inject some methergine, another medicine to cause uterine contraction, and Cecile arranges to hang an IV bag with Pitocin in it. I keep massaging. I am tired, but my fatigue is kept at bay by adrenaline. I will not, I will not, I will not let this woman die.

The uterus does not want to contract. I ask for some misoprostol, and I ask Cecile to put on gloves and take over the massage because my arms are getting tired. I also realize that as the Ob/Gyn, I should be directing the resuscitation and not mired in it.

I place four tablets of misoprostol in her rectum, and step away and let Cecile take over. I take a step backward and look around. The staff has been trying to place a second IV line but has been unable. We have Eileen, the anesthetist, still helping, and now she is offering to place an IV line in her neck because we can’t get anything in her arm. Since we are already running the emergency blood supply in one arm and we need to run Pitocin in the other, I accept Eileen’s offer.

The patient’s mother comes into the delivery room. I have the interpreter help me speak to her. I explain that the baby is dead, and that the patient is very sick.

“She says that she already knew that the baby is dead, she is not worried for the baby, she is only worried for the mother.”

“Tell her that we are also worried for her. She is very sick right now, and we are going to do everything we can. The anemia is very bad, and we are giving her blood to make her better. The uterus is very weak, and it does not want to contract, so we are giving her medicine to make it contract.”

Cecile says that the uterus is still floppy, so I call for a second dose of methergine, since it has been 5 minutes since the last. It is given. The IV in the neck doesn’t work. I will not let this woman die. I look at her legs to see if I can find a vein there. The last time I can remember doing this is residency – this is how sick the patients were at that hospital in New York. I look at the clock. It has been 5 minutes since methergine #2. The uterus is still floppy. I call for a third dose of methergine, the last. I ask Cecile if we have a Bakri balloon, and she directs me to the cabinet where it is kept.

A Bakri balloon is a balloon designed to be inserted into an atonic uterus and inflated to create a tamponade so that it stops bleeding until the uterus can contract. It can then be slowly deflated over 24 hours. It gives you time.

If I took this woman to the operating room, there is not a chance in hell she would survive. She has about seven and a half red blood cells frantically circulating, trying to get oxygen to her brain. If I can compress her uterus long enough (like I did for the last woman with the B-lynch) long enough for her uterine muscle to start working again and then transfuse her, she might be OK.

The methergine is given while we are setting up the Bakri balloon. Cecile needs both hands to prepare the Bakri, so Eileen uses one hand to massage the patient’s abdomen from above. When Cecile attempts to insert the Bakri, miraculously, the cervix has closed and the uterus is too small to receive the Bakri. It has finally, finally started to contract.

“Magic Hands Eileen, where have you been?” I joke. We are so relieved.

We keep the Bakri sterile, just in case, and we observe her bleeding. In the meantime, she still looks terrible. Her breathing is still labored, and she is in pain. During the resuscitation, we had given her Tramadol, so she is a bit calmer, but this whole process is incredibly uncomfortable and there isn’t much we can do about that.

Once the bleeding is settled, we thank Eileen and send her back to base, since she has to be up for cases in the morning. We take a five-minute break so that Cecile can smoke a cigarette and I can eat a Kit Kat.

We come back to the patient. Cecile and I are flummoxed. We may have fixed the bleeding, but we still haven’t figured out what is making this patient so sick. The blood is hanging, and during the atony, we had increased the speed of the blood transfusion because Eileen said it was OK. Now, with the Tramadol on board, the patient is nearly unconscious, and it is making us nervous. Mental status can help evaluate how the patient is doing, and the Tramadol is concealing it. Did she deteriorate or is she just sedated? It mostly seems like mild sedation because she responds to stimulation, but it still makes us uncomfortable.

“Cecile, this patient could really die.” I have said this a few times. I am just so worried, and I can’t figure out what the hell is going on. She is so sick. If she had an infection, I could give her antibiotics. If she had preeclampsia, I could give her magnesium, and having delivered the fetus would help. I’m transfusing her, but the anemia is a symptom, not the cause. If it were something I could treat, then I would treat it. But I have no idea why she’s so sick.

We repeat the ultrasound to check if her bleeding might have been intra-abdominal rather than intrauterine, but I don’t see anything. Her liver is a little enlarged, which is not unusual here, but I don’t see any fluid.

I decide that we need to get the blood into her faster. Cecile notes that she is very cold, probably hypothermic, and that the blood might be making her cold. I have transfused countless patients at home, but it’s usually handled by nurses or anesthesiologists. Our medical referent here is an anesthesiologist – I realize it would be a good idea to call her and let her know this is going on, both to get her input and because she will probably want to be aware of the situation.

I call her and briefly update her. I ask her how fast I can run the blood in. She says I can run it as fast as I can, and she asks if I can warm it somehow. The blood bank technician is standing there, so I ask him.

“Is there somewhere I can warm the blood before transfusing it?”

He points to his armpit. He’s not kidding. Hashtag South Sudan.

The patient’s uterine bleeding is stable. We have her wrapped in the aluminum-foil-like material that marathon runners get after a race, as well as a wool blanket. We need to make her better. I will not let this woman die. Her second unit of blood is here, waiting to be transfused, and her first unit is only half in. I pick up the first unit, stand on a stepping stool, and start squeezing the bag, pushing it through the IV line. I don’t know if it’s helping, but I’m trying. She occasionally thrashes, disinhibited by the Tramadol. Cecile helps me expedite the transfusion of the first unit.

We check her bleeding. The uterus is firm, but there is a steady ooze coming from her vagina. Cecile gets a speculum and tries to examine her cervix, which might have torn during the delivery. She needs my help. I sit down and inspect. The staff has to hold up her legs, because she is both weak and confused. I can see her cervix, it looks OK – there are no lacerations. Why is she oozing? The blood looks liquidy, dark and thin. I have no explanation.

Cecile and I shake our heads. What we mean by that is: What the fuck is going on? We cannot figure out this patient. We have run through every explanation we can think of: preeclampsia, abruption, illegal abortion, HIV, HELLP syndrome, liver capsule rupture, DIC, kala azar, sepsis. Some are possible, others are very unlikely. Nothing really makes sense. We are sending labs to look for kala azar, HIV, and preeclampsia.

Finally, Cecile have done all we can do. There is nothing more we are doing there. The blood is going in. The vaginal bleeding is controlled. The patient is in a Tramadol sleep. Her oxygen saturation is 100%. We instruct the staff to closely monitor her vital signs and vaginal bleeding, and to call us urgently for anything. It’s after 3am, and we head back to base. It’s my third night without sleep. I’m not even sure if I’m tired anymore.

At 5:15, Cecile is knocking on my door.

“Veronica, she is very sick, they are calling me.”

I let her in while I throw on any clothes I can grab.

“Her oxygen is going down. M said ‘she is dying.’ That means she is really dying.”

Shit. We race out the door and over to the car. Her phone rings again as the driver is halfway there.

“Yes? We are in the car. OK thank you.”

“Is she dead?”

“They didn’t say. I just said we are in the car, and they said OK come.”

We are silent. The car arrives, and Cecile bolts out before I can blink. I follow.

She is dead. The staff is crowded around her bed. She is still wrapped in the foil and the wool blanket. The oxygen saturation monitor is still on her finger. The mother is there, with the same look of concern.

“She just died,” Cecile says.

They explain that her oxygen went down suddenly, and they called us, and then she died. I don’t hear much else. I stare for a minute, and I look at her face. I look at her mother’s face.  I think about how hard we tried to save her. I feel myself tearing up, and I quietly leave the room to cry.

I am not a crier. It’s fine to be a crier, and I wish I had a little more access to my emotions because it’s cathartic. It’s just easier for me to cry alone. And as I get older, I find that it’s harder for me to cry at all. But something about this case really gets to me. I find a place in the hallway, and I cry. Cecile appears after a few minutes, and I see that she is crying too. We go out to the courtyard to sit and talk.

I have seen many deaths before, and they all make me sad. I carry them all with me. But when you try this hard to save a patient – when you work so hard, and you throw every bit of energy into it and you try to defy the odds – they sink a hook into your heart. Those deaths knock you down.

Cecile goes back in to evaluate a patient with twins, and I go back in to the delivery room. The patient’s mother and another young male family member are there with the body. The mother’s face has tears pooling on her cheeks. This is striking. It is so incredibly rare to see a South Sudanese woman cry. I have seen them hold their stillborn babies without a single tear. I have seen them go into surgery facing possible death without flinching or crying. This woman is sobbing. She looks at me and speaks. I call over the very sweet local midwife, M, to translate.

“She is saying, she will never blame you, because you did everything. She knows that you did, she could see it.”

I start to cry immediately. Through sobs, I say, “Tell her….tell her….I did everything….everything I could. I tried….so hard. She was just so sick.”

I can’t speak anymore. We both cry.

M is an extraordinarily sensitive and talented local midwife. He is the one who had called Cecile to come in when the patient was dying. His face does not betray much, but he is quiet. Cecile can tell that he is affected by this death. He had tried to get additional labs from the patient before she died and was unable. Cecile and I decide to ask the lab if we could use a preexisting sample to run some tests and figure out what was wrong with her and M wants to come.

On the way, Cecile asks M if he is OK. He is quiet for a second, and then he stomps his foot and he says that he is frustrated that things have to be this way. I understand his frustration. I feel for him, and I am glad to see that he has not become calloused in a place with so much death. He tried as hard as we did to save that woman.

We review with him what happened after we left. He says that with the blood transfusion, she started to improve. Her oxygen saturation was 100% on room air, and she had begun to speak normally, not slurring. She had requested to sit up, but they encouraged her to stay lying down to rest. She said that her chest pain was reducing, and she was more comfortable.

Her heart rate was the same, around 107. Then suddenly, around 5am, her oxygen saturation dropped precipitously to 9%, along with her heart rate. They began resuscitation with the ambu-bag (a mask with a bag attached for forcing air into the lungs), but it didn’t help. They called us immediately, but she died before we arrived. It was completely unexpected and unexplained.

We are perplexed. What could it have been? Two of the lab results come back – her HIV and kala azar tests are negative. We ask the lab to run creatinine, AST and ALT. I suspect that maybe she had an unusual form of preeclampsia, like HELLP syndrome. None of her recorded blood pressures are abnormal, but maybe she was already dropping her pressures at that point because of the low blood count. Cecile also tells me that she did a measurement herself, and although the stethoscope was broken, the first two measurements came back at 110/90, but she thought it was an error, because a repeat was normal.

We return to base. I try to sleep. Every time I wake, I think of her, and of her mother. I know that we did everything we could. I am glad that I stayed with Cecile, that despite my extreme fatigue, I gave everything I had. I am glad that the mother knows that too. Every woman deserves to live, and to have someone try everything they know so that she can live. I will never forget her mother’s face, and how I thought of my own mother.

The next day, we get the labs back. The ALT is normal, so she did not have HELLP syndrome, but her creatinine is 1.87, which is extremely abnormal. We put together the puzzle pieces. I suspect preeclampsia, which is a disease of elevated blood pressures and protein in the urine. Most of her blood pressures were not elevated, but we did have one elevated reading.

In addition, she was so sick when she came in that her blood pressures may have been dropping by that point – if we had seen her earlier, maybe we would have seen her blood pressure elevation. We don’t know if she had protein in the urine. Fetal demise, as she had, is often seen with preeclampsia.

 The elevated creatinine is extremely suspicious for preeclampsia, and I don’t have any other explanation for it. She also may have had hemolysis of her blood as a result of the preeclampsia without the other elements of HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets), explaining the severe anemia and DIC (disseminated intravascular coagulation)-like picture. I have seen patients with severe preeclampsia have a flash pulmonary edema, where fluid from their blood vessels suddenly releases into their lungs, and in a matter of minutes, they can go into respiratory distress and die as she did. I can’t be absolutely certain, but my best guess in this case is that this is what happened to her.

Looking back, my head knows that Cecile and I did everything we could, but my heart will take some time to recognize that. These deaths are really hard to get over. I know I will carry her with me forever.

Sometimes you do everything you can, and it’s just not enough.