One foot in

11 January 2016

The maternal child health project, where MSF will be supporting a district in Sierra Leone, has not begun yet. We are due to commence activities later in January. Currently we are preparing; but as a team of humanitarian workers it is very difficult to be present and not clinically active. We are in an uncomfortable state of limbo, where we are here but without the usual MSF machine in full throttle behind us.

Each morning I go to the hospital to see how the preparations are progressing and check-in with the maternity unit, building important relationships with our future colleagues, and giving technical advice whenever it is needed. On one such morning I wandered in with the project coordinator not long after 7.30am. The hospital was quiet, as it usually is at that time. The twilight time as night shift changes over to day. A nurse must have heard us arrive and appeared at the door, “Can you come? We have serious case”.

Together we walked over to the delivery room. A 20-year-old girl was lying flat on the bed. She had delivered a healthy baby at home the evening before, her firstborn, and then begun bleeding. Luckily she had made it the hospital in time to get help. Drugs were given to make the uterus contract, a urinary catheter was inserted and intravenous lines placed to administer fluids. But somehow she had continued to bleed. Over the course of the night doctors had been called, but could not be reached. Relatives were asked to give blood, but not enough could be found, and then the technician for taking blood could not be found. The nighttime nurses were exhausted and angry, shouting rather than telling us what they had done overnight. But still, this girl lay quietly gasping with her baby sleeping quietly on the bed beside her.

In this time of 'post-Ebola' we must continue taking special precautions. I put the protective clothing on and examined her. She was incredibly pale, not responsive and the blood pressure very low. I turned to the tired team and asked if we could get oxygen, and if we could get blood.

As they began explaining that neither were available I continued to examine her. Large blood clots spilled out as I rubbed her uterus. I turned again and repeated what she needed.

The hospital has oxygen concentrating machines, but they are not kept inside the maternity department. I asked the student nurse to run over and bring it back. Another nurse was sent to collect the waiting relatives and call the blood bank technician again. Incredibly he appeared within minutes, as did the concentrator.

We sent the relatives to give blood, and then began discussing how we could get oxygen for her. There are plugs in maternity but they do not receive any electricity. The project coordinator began working on a solution, generators were found, frantic messages were scrambled on the radio sets to call for back-up. As this was happening I continued to squeeze and massage her uterus to maintain contraction. A Sierra Leonean colleague arrived, and seeing the desperate scene came over to help. He took a careful, studied look at her pale face. “She will not make it.”

“She’s not dead yet, she needs oxygen, she needs blood.”

“I think we have lost her.”

“She is still breathing.”

The plug for the oxygen concentrator did not fit the size of the one on our generator. More frantic talk, there must be a way.

As I continued rubbing her abdomen her gasping stopped, her eyes fixed. Together we began cardiopulmonary resuscitation. The nurses couldn’t find the basic breathing bag we needed so we used one for a new born baby till the adult size arrived. I asked another colleague to run to the blood bank and find out how long it would be till we could get blood. Whilst he was gone we continued, together, fighting though we all knew that we had lost the battle. He returned to tell us that the blood donation had not yet begun. Each of us looked at one another, and together we stopped. Wrapped her body in her colourful shawl, closed her young eyes.

Her baby, hours old, sleeping through the most important event of his life. His chance of surviving past his first birthday was already amongst the worst in the world, it is now dire without his mother to protect and care for him.

There is something called the “third delay”, that is when a patient has gotten to a health facility but then deteriorates because the care they need comes too late, or simply cannot be delivered..

A broken system failed a healthy young woman, her newborn child, her family and a dedicated team of health workers that night. There are many reasons for that failure: social, economic, political, medical and logistical. But there is no excuse.

When I hear people talking about the emergency in Sierra Leone being over I cringe. It may not grab the imagination like Ebola, but it is a true life horror story all the same.

Right now we are one foot in, we are here but not here, we are medics but observers. I don’t know how life will look a month from now, the challenges we are facing are complex and multi-factorial. I hope though, that we will never feel a young mother’s life turn to death in our hands again.