17 years old

A little over week ago we admitted a 17 year old who had been having severe abdominal pain and high fevers for over two weeks. She had been seen by one of the people in her village who had given her native herbs. They hadn’t made her any sicker but neither had she gotten any better. She didn’t live anywhere near a clinic or a hospital so didn’t have access to any other kind of health care.

Her sister finally arranged transportation to bring her to the hospital here when she became very ill. She had a weakly positive pregnancy test and an ultrasound showed a lot of fluid in her abdomen. The pattern on the ultrasound suggested that it wasn’t just plain fluid but more likely blood. Assuming she had a ruptured tubal pregnancy we took her to the OT. What she actually had was the worst pelvic infection I’ve ever seen. Her abdomen was full of pus.

The bowels and the omentum [a large fatty apron-like structure which drapes over the intestines inside the abdomen] had tried to wall off the infection but instead had become part of it. The bowels, inflamed and swollen, were stuck together by thick secretions. Any attempt to pull the areas that were stuck together apart threatened to peel off some of the surface of the bowel. Gradually we were able to free up most of the bowel. I was worried that she might have a ruptured appendicitis but the appendix looked normal, inflamed like the rest of the bowel wall but not enlarged. The source of the infection seemed to be the left tube and ovary. They were stuck against the side of the pelvis but when we got them freed up there was another flood of pus. The uterus looked okay and the other tube and ovary, aside from being inflamed and swollen, appeared fairly normal.

In the end we drained the pus, put drains into her pelvis and abdomen and made punctures through her abdominal wall to externalize the drains, and then closed her abdomen, placing her on broad spectrum antibiotics through her IV. We placed an nasogastric tube through her nose into her stomach, planning to leave it until she started showing signs of normal bowel function. She pulled it out as soon as she was awake and would not let us replace it.

For a day or two she seemed to improve. She ran high fevers, 102 to 103 degrees, but she said she was hurting less. She asked for something to eat but didn’t have bowels sounds so we let her suck on a wet cloth to moisten her mouth but told her to spit out the fluid.

On the third day she said that her belly was hurting again. The drains were still removing a lot of fluid from her abdomen. She still had no bowel sounds. Then she started throwing up bile-colored fluid since she hadn’t had anything on her stomach for several days. She finally agreed to let us replace the NG tube to try to give her some relief from the swelling but it just aggravated her and she pulled it out again.

On the fourth day she started running fevers that were even higher, up to 104 degrees. Her heart was racing and her blood pressures were starting to drop. She was clearly becoming septic and it was apparent by then that the antibiotics alone weren’t working. We took her back to the OT, opened her abdomen again extending the incision all the way to her upper abdomen, and found the same picture we’d found the first time. There were more isolated areas of pus that had been walled off by different parts of the bowel and we were able to drain those. More loops of bowel had become agglutinated together by the infectious process and we were able to free those up again. And after irrigating with normal saline there wasn’t really anything else to do except continue the antibiotics, continue draining her abdomen, and hope she got better.

She didn’t get better.

On the fifth day her fevers became worse. She became semi-conscious and finally unconscious. Her breathing became shallow and labored. The only assistance we could offer her was oxygen through a nasal cannula and cool wet towels to try to bring her fever down. We were giving her extra IV fluids to replace the fluids she was sweating out through her skin and through the drains in her abdomen and stomach but her urine output began to drop. Her kidneys were starting to shut down. Her heart was racing at double the normal speed and her blood pressures were starting to drop again.

I spoke with her older sister. Only 22-years-old herself, she was the sole family member I had seen with the patient during the last week. I explained to her that her sister wasn’t doing well and that it looked like she was going to die. I asked her as gently as I could whether or not we should try to resuscitate her if she quit breathing or if her heart stopped. At first she didn’t understand what I was asking. Through the translator I rephrased it, asking her if we should try to make her heart beat if it stopped or try to make her breathe again if she quit breathing. I almost told her that even if we were able to reestablish her heartbeat or her breathing that I didn’t think it would change the outcome but I bit my tongue, hoping that she could see what was so plain to everybody else. Her sister was dying. And she was only 17 years old.

She didn’t decide right away. She sat with her sister and cried quietly, so differently than the loud and dramatic grief that I’m used to seeing over here. Shortly after midnight the next day, six days after she was admitted, her respirations became erratic. She would quit breathing for 10 seconds and then take a long, gasping breath. Her sister turned to us, told us that she did not want us to try to resuscitate, and then turned back to her sister, speaking in whispers that were not meant for us. When her sister quit breathing a short time later she was still holding her hand and whispering.

I listened for a heartbeat and didn’t hear one. I listened for breathing and heard none. I pronounced her dead and wrote down the time.

All of the beds in the ward are exposed to each other but the nurses had put up barricades to provide a semblance of privacy for the two sisters. Two nurses and the sister washed the body and wrapped her in a shroud. The sister said she would make arrangements for someone to retrieve the body. I got called to labor and delivery shortly after that and when I came back through the ward an hour later the body and the sister were both gone.

Of everything I’ve seen over here I think this one patient has gotten under my skin somehow. It’s been a few days but this is the first time I’ve been able to actually sit down and write about it. I don’t know if it’s that she represents so much of what I’ve seen over here or whether it’s related to the fact that my days here are almost over and this is another one we couldn’t really do anything for. Maybe it was the dignity and strength that her sister showed when faced with choices I hope never to have to make. I just know that I haven’t been able to stop thinking about her.

She was only 17 years old.

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Just another night

I remember my busiest weekend in private practice. It started on a Friday at noon and stretched on until early Monday morning. One patient after another came in either in labor or with some complication that made it necessary to induce labor. At the end of the weekend I had delivered 15 patients, more than double what we considered a busy weekend. The majority of those deliveries were uncomplicated normal deliveries.

In the last 24 hours alone I had 16 deliveries, Seven by C-section, nine vaginally, and only two of those deliveries were uncomplicated. I had three true emergencies. One was a transfer from Kenema, a woman who had delivered two babies previously, neither of which had been born alive. She had been in labor for over 24 hours.

When she arrived the baby’s heartbeat was only 80 beats per minute, well below the healthy range. The nurses, seeing that she had no living children, went into overdrive to get her to the OT for a C-section and we had the baby out in less than 10 minutes but the baby couldn’t be resuscitated. Sometime between the time she left Kenema, where they had a recorded a normal heart rate for the baby, the baby had gotten into trouble. It’s only a two hour drive but for this baby they were a critical two hours.

I had to break the news to the husband and family who had come with her and it was heartbreaking. They all sobbed, grieving openly, and the nurses cried along with them. When I had to tell the patient that the baby had not survived she was stoic and expressionless, in stark contrast to her family. I know that it was a facade, a coping mechanism, but somehow that makes it even more sad.

The day was full of patients like that. A patient came in convulsing with high blood pressures and her baby was also dead. We had to induce her labor while controlling her seizures and managing her blood pressures. A 17-year-old patient whose clinic records identified her as HIV+ stated adamantly that she did not have HIV. When we retested her she refused to believe the results. Needless to say she hadn’t been taking her antiviral medications during pregnancy, increasing her baby’s risks of acquiring the disease. When we encouraged her to take the meds for the sake of the baby she reluctantly agreed but it’s clear that she won’t continue to take them after the baby is born. The best we can hope for is that she will continue the baby’s regimen in the coming weeks.

A 15-year-old came in in labor seven weeks early and the baby was in the wrong position, feet down. She was already seven centimeters dilated so we had to rush her back for another emergency C-section. The fear is that her water will break and the cord will prolapse or the baby will deliver up to the neck but then become trapped as the cervix contracts back down. During the C-section that’s exactly what happened in the incision I made in the uterus. Because of the baby’s position and prematurity the portion of the uterus that is usually wide enough to deliver the baby was instead very narrow. It was wide enough to deliver the baby’s body up to its head but as the uterus contracted the baby’s head became trapped. The only option was to make another incision on the uterus to release the baby’s head.

That’s all well and good for the baby whose head delivered easily after the additional incision, but the 15-year-old mother now has a scar through the thickest part of her uterus that will dramatically increase her risk of a uterine rupture in future pregnancies. I will warn her that she should have a scheduled C-section before she goes in to labor in the future but with the health care system the way it is here there is no guarantee that she will even have that option. That scar makes any pregnancy in her future a potentially life-threatening condition for her.

It was a revolving door in labor and delivery. I would be changing clothes from a C-section when the nurses would say another two patients had arrived. Or I would be finishing the paperwork on a routine delivery and would hear a siren heading up the drive. For the entire 24 hours there was rarely more than 15 minutes when I wasn’t moving from one patient to the next.

On the bright side the day flew by. When I looked at the clock and saw that it was almost midnight I couldn’t believe it. I had noticed it was getting dark so it wasn’t a complete surprise but the previous 16 hours were just a blur. I keep a log in my pocket so I can write down the essentials on each patient; it makes it easier to do the handover to the doctor who comes on call the next day. By midnight I had admitted 10 patients, half of whom had delivered naturally and half by C-section. If you’ve done the math you know that means that six more patients came in during the night and two of them delivered by C-section.

At exactly 4:43 a.m. (I know this because I was writing a note and had just written down the time) an ambulance pulled into the drive. A 35-year-old woman came in by stretcher. She didn’t appear to be in much pain, just looked anxious and a little frightened. Her husband was following behind her. I didn’t actually notice the patient bleeding but I noticed that the husband was leaving bloody footprints behind him. Then I saw the line of blood that followed the stretcher and my adrenaline kicked in. The ultrasound was in the unit so I slathered gel all over the patient’s belly to determine the status of the baby. There was a heartbeat but it was slow, only about 60 beats per minute. And one quick look at the placenta confirmed that it was abrupting, separating prematurely from the lining of the uterus. I wasn’t optimistic that the baby could be saved but it had to be delivered emergently just to get the bleeding to stop. A quick look at the mother’s conjunctivae, the pink lining under the eyeballs, showed them to be almost white. She had lost a lot of blood.

Her blood pressure was very high, 220/120, and she was spilling large amounts of protein in her urine so we knew she was preeclamptic. That explained the abruption, a condition that is much more common in hypertensive disorders. She was 35 years old and had three living children and in the process of getting her consent for the operation I asked her if she wanted her tubes tied. Through a translator she answered that she did but we would have to ask her husband. When we asked him he didn’t hesitate. “No.” And that was the end of that. I pegged him as the type of man who views his wife as his property and had no real consideration for her wellbeing. But she wouldn’t have a tubal ligation without his consent so the discussion ended there.

We were able to get her husband and another family member to go to the blood bank to be screened for blood. We try to get everybody who is with a patient to donate blood since we are usually low on blood products. This patient was going to need several units. Fortunately she had a common blood type.

We got her back to the OT and after the ketamine anesthesia made the incision and quickly got down to the uterus. Her uterus was discolored, black and blue like a giant bruise, from all the blood that had dissected through the muscle wall after the placenta began separating. I made the incision in the uterus and was met by at least a liter of blood clots and blood. I got the baby out quickly and handed it off to the pediatrician I had called and he rushed out of the room to start trying to resuscitate the baby, who did not look good. When I turned around the placenta was floating out of the uterus on another wave of blood and clots. It was running off the table onto the floor, making huge puddles everywhere. The anesthetist was having trouble getting a blood pressure and her pulse was in the 150s. Two units of blood arrived at about that moment and he hung both units and began running them through both IV lines.

We administered drugs to force her uterus to clamp down but they weren’t effective. I massaged the uterus until it my hand was cramping but it still stayed floppy like a big balloon while blood poured out of it. I closed the incision, hoping to control some of the blood loss, and continued to massage the uterus, convincing myself that I felt a little tone coming back into it. That must have gone on for just a minute or two although it seemed like much longer but finally I had to admit that we weren’t gaining any ground and she was losing a lot of blood.

“We need to do a hysterectomy,” I told the anesthetist, a devout Muslim. He looked shocked and said, “But the husband said he didn’t want her to have a tubal ligation.” He knew that the ability to have more children would be gone if we removed her uterus. I knew I couldn’t leave the OT so I asked one of the nurses to go explain to the husband what was happening, that she might die if we didn’t get the bleeding under control and the only way we had left to accomplish that was to remove the uterus. She was gone for about five minutes but when she came back she had a signed consent form.

And then the uterus began to contract. What had been a floppy balloon was now a semi-floppy muscle mass. I continued to massage it and it became downright hard. It seemed pretty miraculous but we were all thrilled at our good fortune. We watched her for another 10 minutes but the uterus stayed firm so finally we closed and moved her back to the recovery area. She had received two units of blood and her hemoglobin was still low at 5.0 but not critically low. Her conjunctivae had some pinkish hue again.

Another patient came in. She’d had two previous C-sections and was in labor. She was only about five-feet-tall and had a huge abdomen. We got her ready for surgery while the OT was cleaned and had an uneventful C-section. We were wheeling her out of the OT when the nurse who was taking care of the lady who had almost had a hysterectomy came running up breathlessly. “Doctor, please come assess,” was all she said. I followed her and my heart sank when I saw the patient in a bed full of blood. I pulled on my long gloves and checked her uterus, not an easy thing to do in someone who is fresh out of surgery. It was as floppy as it had been in the OT.

We opened up her IV fluid, sent out another request for blood as quickly as possible. I saw her husband standing nearby and asked a nurse to come with me to translate. He looked frightened. I suppose anybody would be when seeing a loved one surrounded by that much blood. I asked the nurse to tell him that I had hoped we could save her uterus but that we couldn’t afford to wait, that she was losing too much blood and we needed to stop it now. As she began to translate into Mende, the language the patient spoke, he answered me in english, “I understand. Please save her.” His eyes were moist. I felt like a fool for having so easily characterized him as just a man who saw his wife as property. It’s easy to make everything black and white for convenience when human behavior is infinitely more nuanced.

We got her back to the OT at 6:30 a.m. Maybe it’s just my good fortune but it’s always seemed to me in obstetrics that when you reach that point where you really can’t afford to have another distraction everything just seems to pause. From 6:30 a.m. until 8:00 a.m., the amount of time it took to do the hysterectomy and stabilize the patient, not another patient showed up on labor and delivery. During the previous 24 hours there had not been a 15 minute gap when someone wasn’t coming in or a patient who was already there wasn’t developing a critical condition. For that hour-and-a-half I didn’t have to focus on anything but what I was doing in the OT. The operation went well. She had lots of oozing from various sites but she continued to form blood clots so I knew she wasn’t in full-blown DIC. I left a drain in her abdomen just in case she had bleeding afterwards.

I spoke to the husband after the surgery and he was gracious and thankful. I’m off today since I was on call yesterday but called the hospital earlier to see how the patient was doing. The nurse told me the drain was only putting out small amounts of blood. The husband had called family members to come donate blood and the blood bank received seven units total. Most of them will be used for other patients but my patient received three more units and was now stable with a good blood pressure. Her husband has not left her bedside since the surgery.

8 a.m. arrived and I finished writing my postop orders. My replacement walked in and saw every bed full after we had discharged 15 patients the day before. “Don’t ask,” I said, but then I proceeded to gleefully give her more details than she probably really wanted. Afterwards I made the car ride back to town, back to the house. I walked past the kitchen and straight to my bedroom where I fell into bed fully clothed. When I woke up four hours later I was still in the same position. No electricity. No fan. Drenched with sweat but feeling very rested.

And I think I’ll sleep well tonight too.



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The perfect storm

I was so glad to see the sun come up this morning. It meant there was only about an hour left until I could turn the steering wheel of this out-of-control bus over to someone else.

Every time I have a busy night I think it’s the busiest I’ve ever had but I’m pretty sure that this one, hands down, was truly the busiest night I’ve ever had. Really. Until the next one.

It seems like every week has a special on some complication. Two weeks ago it was ruptured tubal pregnancies, last week it was high blood pressure, and this week it’s abortions. Nobody over here calls them miscarriages. I think in the States the word abortion is so politically loaded that everybody avoids using the word. Even in practice in the States we were always careful to clarify it as a spontaneous abortion in the chart.

Over here when someone says abortion it’s understood that it’s a spontaneous event. Four patients had been admitted with incomplete abortions but the doctor on call before me had been too busy to take them to the OT. There were two patients in labor. One of those patients had had a Cesarean with her first baby and it was pretty clear that this was a big baby and she was going to need another Cesarean. While the nurses were getting her ready for surgery I checked the other patient and I thought she had a pretty good chance of delivering. She was already fully dilated and the head seemed to be coming down.

We took the patient with the previous Cesarean back to surgery and found that she had a ton of scar tissue between the uterus and all the tissues around it. The front of the uterus looked like it had been dipped in glue. It was tough getting through all of that without entering the bladder but we finally got the baby out and then, after checking to make sure all the bleeding we had started was controlled, starting closing the abdomen.

Right then an ambulance pulled up and brought us a patient who was screaming at the top of her lungs. We knew nothing about her, just that she had been found laying on the side of the road, screaming in the same way. The nurses were getting her checked in just as I finished the Cesarean and as I put on gloves to check her she screamed again and the baby’s head started delivering. I got my gloves on and caught (almost literally) the baby, a screaming little girl.

But then the mom started screaming again and there was a gush of water as the bag of waters broke on the second baby she was about to have. She didn’t know she had twins, having never had an ultrasound during her pregnancy. Like most of our patients she hadn’t even had a prenatal visit during her pregnancy. I reached in to feel for the presenting part and felt a pulsating umbilical cord come sliding down, not the sort of thing that is ever welcome, particularly when the patient you just operated on is still on the bed of the only operating room available and that room is still dirty and bloody.

The only option was to get the baby out as quickly as possible. There was still a pulse in the cord but it was slowing down as the baby settled against the bones in the pelvis, putting pressure on the cord. I reached up and felt the baby’s back presenting against the pelvic bones, another thing that you would hope not to find. Ideally you would feel the head and could have the mom push while you put on a vacuum extractor or forceps to speed up the process, knowing that with the cord being compressed you have just a few minutes before the baby starts suffocating. The next best option would be a foot that you could grab on to to help pull the baby out as a breech. But a back doesn’t give you anything and the back sure can’t come out first.

I was able to follow the back bone in one direction and found the baby’s head but the uterus was already starting to contract after the bag of waters broke and I couldn’t get the baby’s head to budge. There was no way to guide it into the pelvis. All this time I could feel the pulse in the umbilical cord; it was still there but it was noticeably slower. So I went the other direction and followed the back to the buttocks, down the legs to the feet. They were so high up in the uterus that I almost couldn’t reach them.

I can’t even imagine what type of pain the mother must have been experiencing while I was doing this but there wasn’t another option and the nurses were great in keeping her focused. I lost my grip for just a second but then grabbed again what I thought was the foot until I realized it had a thumb now. The last thing I needed to do now was to pull out an arm. So I started over, followed the back to the butt and then up to the foot. This time I grabbed it, verified there was no thumb, and started pulling.

There was no movement at first. Maybe it was during the middle of a contraction or maybe I just wasn’t pulling hard enough. I pulled harder and felt what I thought was a small change in the position but it was hard to know for sure. On the third pull, though, there was a definite shift and the foot started to come down. I kept pulling and soon had the foot out of the vagina. I had the nurses push on mom’s belly to keep the baby’s head flexed, chin towards its chest. After delivering the foot the buttocks came out and then I was able to deliver the other leg. And it was about that time that I noticed that this baby was huge compared to its sibling, the female twin who delivered easily.

When you’re delivering twins and the second one is breech, ideally the first one will be the big one, opening the pathway for the second one. That hadn’t happened here. The rest of the delivery is still kind of a blur to me. I know that several minutes had already passed and the pulse in the umbilical cord was slow and weak. I remember that the arms would not come down, I remember that even after finally getting one arm to come down the second arm wouldn’t budge, and I remember that even after finally getting the second arm down the head wouldn’t deliver. I would guess that by now at least 5 or 6 minutes had passed since feeling that umbilical cord come sliding down. I don’t know exactly what finally gave way; I had a finger in the baby’s mouth, trying to flex the chin downwards and suddenly the mother gave an enormous push and the baby’s head delivered up to the eyebrows. One of the nurses gave a strong push on the mom’s belly and the head finally delivered completely.

The baby was a limp rag. I was certain that it had died during the delivery. We took it over to the table and checked for a heart rate but couldn’t find one. We started chest compressions and I starting breathing for the baby. We called for a pediatrician but the nurse came running back and told us they were coding a two-year-old who was in septic shock and had stopped breathing and could not assist. I remember thinking that this was a perfect storm; if anything could go wrong it had. We continued the chest compressions and the bag and mask but I didn’t think the baby was alive. I just couldn’t acknowledge it so we kept up the resuscitation.

Several minutes went by. We would stop every minute to stimulate the baby and check for a heartbeat but felt only a weak, thread pulse. After about three or four minutes we were all ready to stop. And it was right around then that the baby tried to breathe on its own for the first time.

I know this: I will never again underestimate the ability of babies to survive. I had all but written this baby off. It stayed floppy for another five minutes but ten minutes later he (it was a boy) was screaming his lungs out and acting as if nothing unusual had happened. I keep going back and thinking that if we had quit at around the time I had given up hope then the baby might actually have died. He obviously needed all the help he could get to recover from the build up in acid in his bloodstream that had occurred as a result of the long period without enough oxygen. I worry that he still might have experienced some brain damage but it’s a real healthy-sounding cry and he he’s moving all arms and legs and hasn’t had any seizures. I don’t really believe in miracles but if I did I’d be inclined to put this one in that category.

The nurses and I all took off our gowns, double gloves, hat, eye goggles, and rubber apron. We were drenched. We were also a little giddy. Did that really just happen? But you don’t look a gift horse in the mouth, at least not for long. We went through the routine, charting everything that had happened and moving on to the next patient. As it turned out, the girl twin, the first one weighed 5 pounds 2 ounces. the boy twin, the one who took five years off my life and added a lot of gray hair to my head, weighed 8 pounds and 4 ounces, over 3 pounds more than his sister.

And the delivery times show that the second baby delivered 9 minutes after his twin. That’s a long time to go without oxygen. He was probably getting some flow through his umbilical cord, just enough to give him a fighting chance. And he turned out to be a fighter.

It stayed busy from that point on. The other patient who had been in labor ended up delivering shortly after that. I was able to get two of the incomplete abortions taken care of before midnight but the labor ward filled up with patients again and I had to leave the other two to my replacement. All in all last night I had five normal deliveries along with two Cesareans and two incomplete abortions. And, oh yeah, a set of twins that I don’t think I’ll forget for as long as I live.


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A night to remember

The first ambulance came into the parking lot and the evening began. My first patient was covered in sweat, only semi-coherent, and in obvious distress. She was rolling from side to side saying what a lot of the patients here say when they’re in pain, “Why?! Why?! Why?!” as if what they’re suffering through is retribution for some unknown grievance.

According to her history she was three months pregnant but a quick ultrasound showed an empty uterus and lots of free fluid in her abdomen. Her hemoglobin was the lowest I’ve seen here so far, 2.6 (remember, normal is usually around 12 to 15). Her blood pressure was only 60/30, very low, and her heart rate was over 150.

It was obvious that she had lost a great deal of blood which accounted for the abdominal fluid on her ultrasound. Since she had so little blood in her blood vessels her heart was going at double speed trying to pump the little blood volume she had to all the critical organs. Basically she was bleeding to death and was already close to being in shock.

I’ll say this about the OT team: they can move when they need to. Most of the time it seems like nobody here has any sense of urgency. Things will get done when they get done. But in this cases the nurses had her bladder catheter in, her IVs started and fluids running in wide open in record time.

We had her back in the OT in less than 10 minutes and under ketamine anesthesia we had her abdomen open within 15 minutes. The second I made a small opening in the peritoneal lining, the thin layer of saran-wrap like tissue underneath the muscle wall of the abdomen, a geyser of blood shot out. We were prepared and caught most of the initial flood in a bowl and while I started filling a second bowl the scrub tech and the circulating nurse were running the blood through the filter and filling up an IV bag to start the auto-transfusion. We filled up a total of three bowls, gave all of it back to her, and probably lost as much blood as we gave back. We checked her blood counts again during the operation and they were a little better but still low so we also ordered some blood from the blood bank to give her in the Recovery Room.

All the time so far had been geared toward salvaging as much of the blood she had lost as we could but finally I could now try and find the source of her bleeding. She had a lot of adhesions [fibrous bands that form between tissues and organs] in her pelvis, probably reflecting some old infection which would predispose her to exactly what had happened. When there’s infection in the pelvis, usually from a sexually transmitted disease, scar tissue forms around the tubes and ovaries but also inside the tubes. Ordinarily the fertilized egg spends several days making the trip through the tube and into the uterus where it implants and continues to grow. When the Fallopian tube is full of scar tissue the fertilized egg gets held up in its journey and may end up implanting in the Fallopian tube instead of in the lining of the uterus. The lining of the fallopian tube wasn’t designed to support a pregnancy, at least not for very long, and inevitably the tube ruptures open, usually causing heavy internal bleeding.

This patient’s pregnancy had implanted in her left fallopian tube. The tube looked like an inner tube that had been inflated past the point where it could withstand the pressure. It had burst in its middle section but still attached by its umbilical cord and placenta to the lining of the tube was a small fetus, about the size of a thumb. The fetus and placenta were removed and then the portion of the tube that was damaged and bleeding was removed and sutured closed, essentially stopping the bleeding.

The rest of the operation was focused on removing as much of the blood and clots as possible in order to minimize the risk of postoperative complications. After finishing that and closing her abdomen I went back to Labor and Delivery where I’d heard two more ambulances come in while we were operating.

The first of those two patients was a 16 year old girl who was referred from one of the government clinics where she had been in labor for almost two days. She had pushed for over five hours and the midwife had put a suction apparatus on the baby’s head to try to help pull it out but had not been able to get the baby delivered. The mother was running a fever and the baby’s heart rate was very fast. The OT was still 20 to 30 minutes away from being ready for another operation; we still hadn’t even moved the last patient out.

I was able to get the baby out with forceps relatively easy but the baby was not in good shape. We had a heartbeat but not much else. While calling for the pediatrician we started resuscitation on the baby, sucking the thick meconium out of its mouth and nose, breathing for it, stimulating it and right at about the time the pediatrician arrived the baby let out a pitiful little cry.

So those two cases alone would’ve constituted a remarkable evening but the best was yet to come. By now it was about 1am and the nurses took me to the other patient who had been brought in by ambulance. She had labored at home for over 24 hours. Her water had broken and one of the baby’s arms had come out first along with the umbilical cord. The baby was no longer alive. The arm was dark blue and some of the skin was already starting to peel suggesting that it might have actually been dead for a while before she even went into labor.

There was no heartbeat. The ultrasound measurements were consistent with a term pregnancy. The patient was 38 years old. This was her 7th pregnancy and she had delivered six children before this one but only had one living child. I didn’t want to take her to the OT for a Cesarean but it seemed like the only real alternative. It’s not possible to delivery a child with the arm coming first.

There was one other option but I wasn’t very optimistic about it being successful. There wasn’t a significant down side so I decided that once the anesthetist got the spinal block in, before we started the Cesarean, I would try to convert the baby to a breech presentation and delivery it vaginally. This is another one of those things that I had only read about before now but I knew that it had been done for cases such as this when the fetus is not longer alive. It involves reaching up into the mother past the arm that is hanging out and trying to find on of the baby’s feet. Once the mother was relaxed from the spinal I was able to reach up and follow the arm to the shoulder then follow the shoulder to the back, down to the buttocks and finally down the leg which was high in the uterus.

My biggest concern was rupturing the uterus from the pressure I was creating by pushing deeply into the uterus but the mother had no longer been contracting when she came in and if there had been a complication like a uterine rupture I was already set up to open her abdomen without any delay. Once I found the leg I was able to follow it to the foot. Keep in mind that this is all by “feel”. I found myself constantly second-guessing myself, questioning whether that was a hand or a foot, but I was pretty sure that I didn’t feel a thumb so I starting pulling, knowing that I couldn’t hurt the baby.

At first there was no movement at all. I pulled a little harder, thinking to myself that it had been worth a try even though it didn’t look like it was going to work, when all of a sudden there was a massive shift and the baby’s arm just sort of vanished up into the mother just as the foot came out. Once I had one foot out I was able to keep pulling until the hip delivered. Then it was easy to pull the other leg down. The baby delivered to the shoulders easily and both arms came out. The head was the only part that didn’t go as smoothly. The cervix by now had contracted down and was holding the head in its grip but with more traction on the baby’s body and pressure on the abdomen to help push the head from above we finally got the baby out. The baby had obviously been dead for several days. The placenta subsequently delivered easily. And once again I had new respect for the all the skills that were standard for the doctors that practiced long before I was born.

And then it all stopped. It was about 2am by then and for the rest of the night not a single new patient came in. I got to sleep for about five hours and at 8am I turned the reins back over to my replacement. I’m craving a big juicy hamburger with french fries and an ice cold diet Pepsi but I’ll probably have to settle for peanut butter and jelly. But I’ve got a diet Coke that I put in the freezer when I got home this morning. The electricity got turned back on about an hour ago so by the time I get home I’m hoping little ice crystals have formed inside. My eyes are watering and my throat is burning just thinking about it.


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Bottoms up

The day started off busy and stayed that way. My first patient was a 22-year-old woman who had had four pregnancies, delivered three babies and all had died before the age of two. She had delivered this baby at home over 36 hours before. The baby was doing well but she had not delivered the placenta and had started hemorrhaging.

She had to walk an hour and a half to the nearest clinic to get an ambulance to take her to the hospital. When she arrived she was only semi-conscious, covered in blood, and her hemoglobin was only 3.1. I think I’ve mentioned that a low normal hemoglobin for women in the U.S. is at least 12 or 13 so she was dangerously low. We approached her family to donate blood but they all refused and I finally came to understand that they are Jehovah’s Witnesses, who believe that receiving blood products will keep you out of heaven, even though the patient was not.

Fortunately the patient was amenable to receiving blood over the objections of her family (and they were pretty angry at us, convinced that we were condemning her to eternity in hell) and we were able to find blood to give her. I took her to the OT and after a really difficult 45 minutes was able to get the placenta out but during the entire time she continued to lose blood. Her hemoglobin after the procedure, even after the transfusion, was 3.0 and we didn’t have any more blood to give her. We’ll keep looking for blood but in the meantime she’ll need to stay in the hospital until her blood counts have improved. She needs help just to get up to go to the bathroom and now her family is angry at her and refuse to assist her. I can’t help but wonder what life is going to be like for her when she goes home, still ostracized by her family.

That got the day off to a rousing start. It seemed like the door into labor and delivery never closed after that. I’ve started to become desensitized to dead fetuses, it’s so common here. The baby is already dead in easily 1 out of 5 of the patients we see. During a typical month in the U.S. you might see an occasional fetal death but it isn’t common, at least not where I practiced, and most of these babies died before labor started. In contrast almost all of the fetuses that die here occur during labor. It is understandable that in a referral center such as this that there would be a higher rate of complications since any woman who wasn’t complicated would have delivered somewhere else. But I’m beginning to understand why the mothers don’t react with grief they way they do back home. I think they go into the pregnancy understanding that the chances of having a bad outcome are not low so their expectations aren’t high.

Last night after midnight I had a patient come in with severe polyhydramnios – way too much fluid around the baby. As a result she went into labor early and delivered a malformed baby, stillborn. It only weighed 850 grams, about 2 pounds, so even if it had been alive there would have been no attempt to keep it alive. The policy here is no resuscitation on babies weighing less than 1000 grams. That’s what most babies weight at about 28 weeks along in the pregnancy, 12 weeks early. The hospital doesn’t have the resources to keep these babies alive. There are no ventilators, they don’t have the nursing staff they would need, and there is no other place to refer these babies to. When these babies are born alive they are wrapped in blankets and given to the mother to hold until the baby dies. Shortly after she delivered another patient delivered a baby that weighed only 750 grams but that baby is somehow still alive. Perhaps it was further along and just stunted in growth so maybe its lungs are more developed than most 750 gram babies but the likelihood of it living more than a day or two isn’t very high.

I got to bed around 2 a.m. and slept for a couple of hours but then got an urgent phone call from labor and delivery. I still have trouble understanding the nurses sometimes and this was one of those instances so I just got over to labor and delivery as quickly as I could and found a patient who had just arrived by ambulance, pushing, with the baby’s buttocks halfway delivered. This was her first baby and based on the size of the babies buttocks, it wasn’t a small kid. There wasn’t time to get her back for a Cesarean so I got my hat, mask, eyeshields, apron, gown, and double gloves on in record time and prepared for a breech delivery. I felt pretty calm thinking optimistically, “what could go wrong?”. Well, everything apparently.

The baby delivered up to it’s hips pretty easily. Mom pushed again and the baby delivered the umbilical cord. That’s when the clock starts ticking in my head. From that point on the baby’s umbilical cord is being compressed between the baby’s skull and the mom’s pelvic bones, effectively cutting off the delivery of oxygen to the baby. We had mom keep pushing but the baby didn’t budge. I remember Dr. Quirk, a maternal-fetal specialist and the man I learned the most from during my residency, saying of breech deliveries vaginally “Keep your hands off until the baby has delivered up to the scapulas (basically just below the shoulders).” I kept that in mind and tried to avoid trying to help the mom by pulling on the baby until another minute passed and the baby, who had been kicking, started going limp. I could feel the pulse in the umbilical cord and it was very slow. I put some traction on the baby’s hips while having the mom pull her knees as close to her chest as possible to try and give the baby more room but the baby was stuck.

I’ve heard horror stories about babies that deliver up to the head and then get stuck but that’s one of those things you always think will never happen to you. But here it was happening. Out of options I did the only thing I could do and reached up into the mother and found that both arms were trapped above the babies head. Picture someone with their arms over their head getting ready to dive into water and you’ll understand how the baby got stuck. The two arms combined with the head just couldn’t get through the mom’s pelvic bones. I was able to get one finger past the mom’s pelvic bones and hooked around the baby’s right arm near the elbow and tried to pull the arm down, bending it at the elbow but it wouldn’t move. I really don’t know how much time had passed by then. It may have only been a couple of minutes but it seemed like an eternity. Not really giving it much thought but knowing that if something didn’t happen quickly to improve the situation the baby would die, I pulled as hard as I could on that arm. I felt a pop, am pretty sure I broke its arm, but it finally moved and I was able to get it down past the head into the vagina. The other arm came more easily since some of the pressure had been released with the removal of the right arm and after that the baby’s head came out easily. But the baby was as limp as a rag and I could no longer feel a pulse in the umbilical cord.

We moved the baby over to the resuscitation table and started resuscitating the baby. I used the bag and mask to force air into the baby’s lungs while the nurse started chest compressions. Nothing. We rolled the baby to the side and massaged its back, slapped its feet, and then continued bagging and compressing. Still nothing. The mother was wailing, watching us, helpless. And then the baby gasped. It wasn’t much and it didn’t last long but it was enough to give us hope and we kept working, all the while watching the baby’s dusky blue color start to lighten and then turn into a mottled pale and then finally a pinkish color. When the baby opened its eyes and started crying everyone in the room just looked at the person next to them, eyes wide in something like disbelief. I think when you’re used to seeing babies die watching one come back from the dead is especially miraculous. The mother started crying and chanting something, the nurses regained their brusque attitudes, and within a minute or two the baby was screaming its lungs out.

It could’ve gone either way. I hope that I don’t someday have to tell a story like that but with a different ending. I’ve looked back over everything that happened and I just don’t see what could have been differently. Perhaps if she had come in sooner we would have taken her for a Cesarean but around here a breech presentation isn’t necessarily an indication for a C-section. I alerted the pediatrician to keep an eye on the baby’s right arm but even if it’s broken, and I suspect it is, that seems like a reasonable price to pay.

I was so hyped up on adrenaline after that that I never went back to sleep. I’m on call again tonight but wanted to wait until the electricity comes back on at 11:00 a.m (20 minutes ago) and the fan starts working again to try to get some sleep. I’ve been here 3 weeks now and that’s a little hard to believe. In some ways it feels like I just got here but in other ways it feels like I’ve been here a long, long time.

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When it rains

I heard a joke that made me laugh:

Two MSF workers were talking to each other when a third worker came running up and said, “Come quick! Tonya accidently touched an electrical wire and has been electrocuted!” The other two workers looked at each and shouted, “Holy shit! We have electricity?!”

We have electricity from 11am to 5pm today along with the regular 7pm to 7am. That’s when I’m going to go home and take a nap but I’m too wired right now. I got off call last night and it was one of those nights that it’s best not to anticipate, easiest just to roll with it

I mentioned the delivery yesterday morning with the twin breeches. Well, turns out the mother is HIV+ but neglected to mention it to anyone so her babies, who should have received medication when they were born to minimize their risk of becoming infected, didn’t get their meds until today. The mother seems to be in denial about her HIV status but her mother, the twins’ grandmother, has been worried about the babies and informed us of the infection. The HIV rate in Sierra Leone is relatively low, especially compared to some of the other countries in Africa, ranging anywhere up to 4%. There’s a huge public awareness campaign in progress with special attention to mothers and children. All along the highway are billboards that show a pregnant woman swallowing pills with the message “I’m living positively with HIV”. Still, screening can only be done with the consent of the patient so many cases are undoubtedly going undiagnosed. Treatment is provided free of charge by the government but education is the key to breaking the cycle.

Anyway, there was a slow but steady stream of patients through Labor and Delivery yesterday but by 3pm it was quiet. Too quiet. The kind of quiet that comes before a storm (which is easy enough to say in retrospect because sometimes quiet is just quiet). About 7pm, just as I was sitting down to prepare a peanut butter and jelly sandwich, a process I had been anticipating for about two hours, I heard an ambulance coming up the highway. You can always tell when they hit one of the potholes because they siren makes a little burp noise. And I’ve learned the pattern of the potholes and the pattern of the burps they cause. As the first ambulance approached I could hear another ambulance coming behind it. So I screwed the lid onto the peanut butter, stood up and started walking to L&D. I got there just as the first ambulance showed up and started to unload its patient.

It was immediately clear that she was in a bad way. She was very black but also very pale if you can picture the two together. Her eyes fluttered but her speech was incoherent, just mumblings that even the nurses couldn’t understand. We got her into a bed quickly and her blood pressure was about 40 over nothing with a thready pulse. She was 38 years old and this was her ninth pregnancy according to the records. She had had a Cesarean with her last delivery but there were no records of where or how it was done. She had five living children. IV lines were started and opened wide, blood was sent to the lab for crossmatching, a catheter was placed which returned blood and I was pretty sure that I was seeing my second uterine rupture. She had been in labor for days, had shown up at a clinic about an hour away and was immediately transferred here by ambulance. A quick ultrasound confirmed what you would expect, that the baby was dead. Nothing on the ultrasound looked the way it was supposed to and the belly was full of fluid, almost certainly blood. The fact that there was blood in her urine indicated that the rupture had probably torn her bladder as well.

We got a couple of liters of fluid on board and got her blood pressure up a little and then took her to the OR. Sure enough the uterus had ruptured through a vertical scar on the front side. This is called a Classical Cesarean and is done only rarely anymore and for very specific indications. It is a very unstable scar because it cuts through the thickest part of the uterine wall and has a much higher incidence of rupturing open during labor. Back home we always informed the rare patient who needed one of these, usually for prematurity or an abnormal presentation, that she must never go into labor and to get to the hospital immediately if she should start having contractions. That information was apparently never passed on to this patient. The baby and placenta were already out of the uterus, floating in all the blood that had accumulated. While my assistant was scooping up the blood to save and autotranfuse I examined the uterus. The rupture had occurred along the entire length of the old scar and downwards into the area of the uterus that is attached to the bladder. The bladder had a large laceration, about 4 inches (10cm) in length, through which you could see the catheter that had been placed. But the location of the bladder laceration, right in the middle of the back side of the bladder, made it easy to repair without worrying about tying off the ureters, the tubes that lead from the kidneys to the bladder. In a location like this tying off the ureters would probably be a life-ending complication. After closing the bladder I closed the uterus. And then, because she had given us permission, I tied her tubes. Not just tied them but removed as much of them as I could. This lady does not need to get pregnant again. She got her autotransfusion plus an additional two units that were donated by her family. This morning before I left, her urine still had some blood in it but you could also see it starting to clear. She’ll have to wear a catheter for at least a week (and I’m voting for longer). But her blood counts were decent, she’s not running a fever and I’d have to say she dodged a bullet.

After that it was one ambulance after another. By 4am I had done four more Cesareans. In all but one of the patients the babies were born alive. The last patient arrived just as I was starting a C-section for a prolonged labor in a patient with a high fever who had made no progress in the last 24 hours, was stuck at 6cm. That last patient’s baby had a heartbeat when she arrived but by the time we were able to get her to the OT the baby had died. I know it seems cold-hearted but I’m finding myself dealing with that pragmatically, thinking that if the baby were in such bad shape that it died shortly after arriving then it probably would’ve had severe brain damage from prolonged lack of oxygen if it had been born alive. If you don’t learn to think like that I think you’d go a little crazy.

I finally made it to bed about 6am, slept for an hour, and then had two more patients show up by ambulance. I left them with my replacement at 8am. Neither one seemed to have any serious problems. One had had a Cesarean previously but looked like she was going to be able to deliver naturally without too much trouble. The other one is a little more iffy; she’d had heavy bleeding for a couple of hours but it had stopped by the time she got here. I couldn’t see a placenta previa on the ultrasound and I didn’t see any sign that the placenta was trying to separate. If I were still on I would’ve tried to induce her since she was at full term, prepared to go straight to Cesarean if she got into any trouble. But my replacement, Dr. Pathe, may choose to just go ahead and deliver her by Cesarean and I certainly couldn’t fault him for that.

I had this idea before I came here that someone was fudging the statistics, that there was no way uteri could rupture so frequently but I think I get it now. It’s not that they’re more likely to rupture here, it’s that they’re more likely to labor too long over here. The end result would be the same if I were to allow a patient in the United States to labor for three days or more. It’s all about access to health care. That’s the key. It doesn’t require a lot of specialized care, just the opportunity to enter the system before events have already progressed beyond the point of no return.

I’m about to climb on a soapbox so time to call it quits. I’m feeling a little unwound and think that by the time I walk back to the house I might be ready to take that nap. I don’t have to work all day today and tomorrow so I plan to read a book, watch a movie, and sleep any time there’s an opportunity.

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Roughin’ It

Today is another national holiday. We didn’t know about it until yesterday. I’m not sure if it’s just declared by the government at the last minute or whether MSF hides the information from us until the last minute. Either way I’ve got this place to myself for the day. No meetings, no conferences, just cover labor and delivery until tomorrow morning at 8am.

I don’t think I ever appreciated how great we had it in surgery at St. Edward’s. If you drop the electrocautery on the floor you just open a new one. If the suction doesn’t work you get a new unit. If the gloves don’t fit you find a bigger pair. It’s a different ballgame over here. The gloves are one size too small for me and since we have to double glove my fingers are pretty numb by the time the procedure is over. They tell me that they’ve ordered bigger gloves but it could be weeks or longer before they arrive. (My guess is about three months; they’ll probably show up the day before I leave.) The suction is a reusable unit and the vacuum on it isn’t very powerful. If you get into any serious bleeding you can forget about the suction and just start soaking it up with sponges. The drapes, the gowns, the aprons are all reusable. And the instruments are just barely enough to get by with. The pick-ups are all very small, like the kind women pluck their eyebrows with. There are 4 towel clamps, one scalpel, one suture scissor (dull, dull, dull…I think I could cut the suture quicker with my teeth), and one very dull tissue scissors. As a result I’ve started cutting almost everything with disposable scalpels which, thankfully, are always sharp. There is usually just one assistant who helps provide exposure, holds retractors, cuts sutures and passes instruments. One of the labor and delivery nurses (all of whom are also midwives and do most of the routine deliveries themselves) is in the room to open sutures, take the babies when they’re delivered, and generally function as the nursery nurse and the circulating nurse during the whole procedure. For my money she’s the one that works the hardest.

Yesterday we had a ruptured tubal pregnancy that was almost 14 weeks along. The fetus was well-developed and about 8cm or 3 inches from head to toes. The placenta was big enough to fill a large serving spoon. And the mother had about 4 liters of blood in her abdomen. She didn’t have any blood donors available so we auto-transfused her with her own blood. This was a first for me and it was pretty basic, nothing fancy. We used a ladle to scoop blood out of her abdomen and pour it into a container then ran it through something like a cheesecloth to remove the clots and then poured it into some blood transfusion bags and starting running it right back into her veins. Her hemoglobin was 3.2 when we started the case, very low. When we checked it afterwards it was almost 6, still low but double what it was before. I was pretty impressed with the whole process. It’s not an option if the mother has a fever because you don’t want to be putting infected blood straight into her veins but in cases like this one it can literally mean the difference between life and death. Barring any complications she should do well and walk out of here in pretty good shape, anemic still but with iron tablets she’ll build her blood back up to normal levels within a few weeks.

I’m just three hours into my day on call today and the day’s already off to a busy start. Shortly after I got here a 19 year old girl came in by ambulance in labor and with a baby’s foot, a pretty good-sized one, presenting outside of her vagina. A quick ultrasound showed the baby to be about 34 weeks, still alive, and with a second twin, also breech, waiting in line. We got her back to the OT pretty quickly and delivered two healthy baby boys who are still screaming their heads off. I can hear them making a racket in the next room.

It’s not convenient and it’s far from ideal but it’s also kind of satisfying to realize that even without all the fancy accoutrements I always took for granted that it’s still possible to do the things that need to be done and do them pretty well. I do miss skin staples but a well-done subcuticular closing stitch will always be a thing of beauty even though, in my hands at least, it takes about 10 times as long.


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Never say “It sure is quiet”

The first part of my day on call yesterday was mind-numbingly dull. There are quite a few patients in the hospital right now so it took some time to make morning rounds. A couple of patients came in during the day but they were spaced out and neither presented any real problems. I had time to work on some of the statistics that we’re expected to keep so we can track things like infection, Cesarean, and maternal deaths.

And then it all went to hell.

An ambulance showed up around 9pm, just after all the backup help had left for the day. I was getting ready to find something to eat and had just told the ER doctor – who asked me, “Busy today?” – that it had been a quiet day when I got the call from Labor and Delivery that I was needed “stat” and then the phone line went dead. Cell reception around here is the worst so if the phone rings and there’s nobody there I head to Labor and Delivery anyway. They were unloading a patient from the ambulance when I got there a couple of minutes later. She was writhing in agony, sweat pouring down her face, clearly in horrible pain. Her forehead was furrowed, her eyes open so wide that the whites took up more space than the irises and her mouth was wide open in a rictus of pain even though no sound came out. She was clutching her abdomen which stood out like a giant basketball.

We got her into an exam room. She was unable to stand but tried to help us as much as she was able. When I put my hands on her abdomen (after putting on gloves; we’re not supposed to put hands directly on patients because of the Lassa Fever risk and we have to wash our hands after we take off the gloves) it was as hard as a rock. I thought the placenta had probably separated while she was in labor and she was now losing blood into her uterus, making it react by going into a constant, unrelenting contraction. I used the ultrasound to inspect the pregnancy and found, not surprisingly, that the full term baby was no longer alive. There was also a lot of free fluid in her pelvis raising the possibility of a catastrophic uterine rupture.

Her heart rate was way too fast but her blood pressure was maintaining itself at a decent level. Blood work was drawn and I asked the nurse to explain to her that we needed to take her to surgery, that the baby had died and it looked as though she might be bleeding internally. I also told her, through the nurse, that there was a possibility the uterus had ruptured during labor and if it had then we might need to remove it. She was 21 years old and this was her third pregnancy. She had two living children. She started crying, almost screaming, maybe a combination of the pain and the emotion, and then looked at me while she was talking to the nurse. The nurse translated that she wanted to have more children and she asked if I would do everything I could to repair the damage. I told her I would be as conservative as I could but that there was a real possibility that the uterus might have to be removed to save her life and she accepted that with a nod, closing her eyes until she once again grabbed her abdomen and arched her back in pain.

We got her into the OT pretty quickly and under ketamine anesthesia, which is so disconcerting because the patient is staring, tracking with her eyes, occasionally moaning or talking. I opened her abdomen and found about 500cc (2 cups) of blood but no sign that the uterus had ruptured. I opened the uterus and removed the baby but after delivering the shoulders I couldn’t pull it out any further. At first I thought the baby or even the uterus might have some sort of growth that was preventing the baby’s removal but it was obvious soon enough that the uterus had ruptured on the BACK side and the baby’s legs and buttocks were hanging out of the site where the uterus had ruptured. After that the uterus, in a last ditch effort to control the bleeding, had clamped down and the baby was locked in an iron grip by the muscle wall of the back part of the uterus. By pushing the legs and buttocks through the incision with the help of my assistant, and at the same time pulling from the incision I’d made on the front side of the uterus, I was able to get the baby out, deliver the placenta, and finally inspect the damage.

If a small explosive had been placed in the back of the uterus I don’t know that it could have done much more damage to the tissues. They were full of hematomas, blood trapped in tissue like the juice in an orange, but the hematomas were continuing to grow as more blood pumped into them. It is almost impossible to sew through blood filled tissue; it shreds like tissue paper. And unless you stop the source of the bleeding it will just continue to become more and more full of blood. At that point I was thinking I was going to have to take the uterus out but decided to try at least for a few minutes to save it. I trimmed away all of the ragged tissue and hematomas, starting fresh bleeding from the newly exposed blood vessels. I placed clamps along all of the edges to stop the bleeding. The rupture extended vertically down the back of the uterus through the thinnest part down into the cervix but the edges were now clean and easy enough to see. I sutured them closed, restoring the normal anatomy as best I could, and then put another layer of sutures over the first layer pulling the muscle layers back together. And amazingly the bleeding stopped and the uterus looked pretty damned good! After watching it for a few minutes and seeing no fresh bleeding I closed the incision through which I’d removed the baby, inspected the abdomen for evidence of any other bleeding, and three and half hours after opening, we closed.

In so many ways this patient is so so lucky. If she had ruptured out to the side of her uterus instead of towards the back she would’ve torn one of the uterine arteries and the bleeding might have ended her life. As it was her uterus controlled the bleeding that might have been catastrophic and gave us time to repair the damage. And even though we were able to save her uterus she now has a much higher risk of a uterine rupture in future pregnancies. I explained to her that it was important that she get to the hospital as soon as she has contractions in future pregnancies. I gave her a piece of paper that explained what we had done so she could present it to whoever cared for her in the future.

She looked good this morning when I left, making plenty of urine, hemoglobin over 6 which will probably mean she can get by without a transfusion, and was alert and oriented when I went by to see her. The nurses had told her that we had not had to take out her uterus and she told me very emphatically, as if she had been rehearsing the lines (she does not speak English), “thank you”. I’ll tell you, after a night like that those words were enough to bring tears to my eyes. When you’re in the middle of an operation like that, when it’s something you’ve never had to do and there’s nobody to call for help, you feel kind of isolated. I feel confident that I can handle most things but I don’t delude myself that I can handle everything and I know that even when I’m at my best that it’s possible to make errors. So “thank you” meant a lot. She touched my gloveless hand, I grabbed hers and said “you’re welcome”, confident that even though she might not know the words she would catch the sentiment.

And after I was out of her sight I washed my hands because you never know when the infection control police are watching.

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The only American I’ve met so far informed me today today that he has found a store that sells peanut butter! No kidding, that’s about the greatest news I’ve heard in the past two weeks but then it was followed by another little gem: they also sell Diet Coke! Over here they call it Coke Lite but to quote the Bard, “A rose by any other name would smell as sweet.” I’m thinking that if I put one in the refrigerator right at 7pm when the electricity comes on and am in the kitchen in front of the refrigerator at 7am when the electricity goes back off I can drink it while it’s still semi-cold.

I’m drinking huge quantities of water every day (and sweating most of it out) so there’s no way the soft drinks will become the sole source of fluids but it’s going to be a great treat. And I’ll take some bread, some peanut butter and some jelly to work with me when I’m on call tomorrow and will have no worries.

I’ve been meaning to mention the food here. Rice is the staple at almost every meal and lots of it. There’s usually a heavy greasy sauce and a piece of two of meat along with it. There aren’t a lot of fresh vegetables around here but there’s an abundance of cassava, a subsistence crop in many impoverished countries. I’ve seen small fields of it almost every place I’ve gone and it seems to show up in almost every meal. It’s not bad tasting, has kind of a gritty texture in the dishes I’ve had. A lot of meals also have a fried starch including potatoes and bananas. The fried bananas have a nice sweet taste. I mistook them for potatoes the first time I ate them, figuring it might be some kind of sweet potato.

Rather than try to cook for myself during the week I’ve signed on to a meal program with MSF where we pay 10,000 Leones per meal and they are delivered to wherever we’re working from Monday through Friday. (5000 Leones is about $1.16. I’ve got a wad of cash in my pocket that amounts to about $50, must be at least 40 bills. The largest bill I’ve seen is the 10000 Leones bill, about $2.32. 5000s are the most common but there are also 1000 and 2000 bills.)

On the weekends there are local restaurants and now there’s peanut butter and jelly. Breakfast is usually fresh fruit (papaya, pineapple, oranges, mangoes), french bread with butter and preserves, hardboiled eggs, and juice. (I haven’t been going hungry. In fact my pants are starting to feel a little snug. It’s just too hot to go running in the evening and in the morning the sun isn’t up early enough to go running before leaving for the hospital.)

One of the pediatricians just took a week off after being here for six months and went back to Italy, bringing over 20 pounds of parmesan cheese in huge bricks back with her when she returned to Sierra Leone. She became everybody’s new best friend.

Krio is the main language where I’m working even though English is the official language of Sierra Leone. Krio is pretty interesting to listen to. It is a language in its own right with its own grammatical rules but it’s derived from other languages including English, French, Portuguese, and native languages, an amalgamation of the languages spoken by slaves from different countries who returned to their country after they were liberated. Sometimes it’s easy to hear the English origins but most of the time it’s like listening to any language that you don’t understand.

Some of the phrases I’ve learned:

Aw di bodi? (How are you? “how’s the body?”)

Ah glad fo mit yu. (Pleased to meet you.)

A bayg. (I’m sorry. “I beg [your pardon])

Ah no well. (I’m sick.)

And, most important in my line of work: Tu pay! (Push!)

Some of those phrases are easy enough to hear. But there are lots of others that don’t seem to resemble anything I’ve ever heard in English. The nurses at the hospital seem to take an enormous amount of pleasure instructing me how to say a phrase and then laughing their asses off when I repeat it in what sounds like, to me at least, a perfect replication. At least they seem to be warming up to me a little. The first few days I could sense them inspecting me, figuring out if I was worth the effort. I think it must be really hard for them to have doctors come and go, each with their own preferences on how to practice but expecting the nurses to be at their beck and call. I’m taking a more humble approach (called “sucking up”) figuring you catch more flies with honey. It sounds simple enough but there’s a fine line you have to walk between being an authentic-appearing suck-up versus a transparent one.

That’s the end of today’s lesson.

And just for a little follow-up, that rooster seems to have his eye on me, came walking towards me with an attitude I didn’t much care for as I was walking across the hospital grounds. I swear he started walking more quickly when he saw me. I took a route that took me out of his path but shot him a filthy look as I walked more quickly. I’m not afraid of him, mind you, but neither am I looking for trouble.

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Baptized by fire

Today while making morning rounds I stepped on a rooster’s foot. That NEVER happened back home! The screen door hadn’t closed properly when someone came in or went out and the rooster decided he had as much right to be there as anybody. He let out a horrible squawk when I stepped on his claw and then batted his wings angrily at me and started pecking my foot. It was a little unexpected and I may have overreacted just a little but it gave all of the postpartum patients a good laugh. I’m not sure if I should be embarrassed or proud for how far I jumped but I managed to laugh along.

I survived my first 24 hours on call but am just amazed at the types of cases I saw. In an ordinary year of practice you might see a few of these types of cases every year or two but over here it’s a daily occurrence, largely because it’s a referral center for cases just like these. The maternal mortality this past month was about 3% so for every 100 women who presented in labor only 97 would go home. That factors out to 3000 for everyone 100,000 women compared to around 16 per 100,000 in the United States.

I saw a woman yesterday who had been in labor for six days, was diagnosed two days ago as having too big a baby to deliver vaginally, but it took almost 48 hours for her to make the trip from the southern part of the country over rough roads full of potholes. She was exhausted, semi-delirious, running high fevers, and barely conscious. The baby had had a bowel movement and that was draining from the mother but the baby was still alive. It was a true emergency but there is no general anesthesia here so we did the Cesarean under ketamine, an injectable anesthetic that allows the patient to keep breathing on her own. We got the baby out and it still had a heartbeat but its chances of surviving aren’t great. Mom’s uterus initially refused to contract down to control the bleeding but eventually responded and we didn’t have to remove it. But the mom is still running high fevers and has very low urine output, lost a lot of blood and doesn’t have any available blood donors (family members are asked to donate blood if a patient needs blood) and is O negative, a rare type of blood here in Africa. Rh negative patients are few and far between and therefore it’s hard to find matching blood. They make great donors because their blood can be given to patients with most other blood types but they make lousy recipients because they are incompatible with almost all blood types except their own. Her hemoglobin count this morning was 3.1. Yours and mine is usually 12 or 13 or more so she’s operating on about a quarter of what we would consider normal. In her favor is that she’s probably chronically anemic and may be better able to tolerate the anemia. Also in her favor is that there are no insurance companies over here and there is no limit on how long I can keep her in the hospital. If it takes two or three weeks or more in the hospital to help her recover then that’s how long she’ll stay.

And that was only the first of seven cases including a ruptured tubal pregnancy with over a liter of blood in her belly even though she was walking around and denying pain in her abdomen. The only reason she came in was because she was having some discomfort in her shoulder, probably because she had a belly full of blood. There was a complete placenta previa who came in bleeding heavily at eight months. Fortunately she had family with her so we were able to give her two units of blood during and after the surgery. [Placenta previa occurs when a baby's placenta partially or totally covers the mother's cervix. Placenta previa can cause severe bleeding before or during delivery.] All of the cases were like these which is to be expected in a place where the normal labors are referred out. Still, it was a little overwhelming to be confronted with all these complications just one right after the other. (I also found that I felt right back in my element. I had been afraid that not having worked for the past nine months might make me rusty but it’s kind of like riding a bike. It comes back quickly.)

Sierra Leone lost most of its doctors during its protracted civil war. Most of them left for greener pastures and there’s a massive shortage of trained professionals and most of the new doctors that are trained end up leaving the country as well, knowing that they can do better elsewhere. In response to that the government has set up a program to train Community Health Officers (CHO) to fill the gap. These are young men and women who are trained in some of the technical aspects of surgery and management of complicated patients without a large knowledge foundation. I did two Cesareans with a CHO named Amado yesterday and let him do most of the work. He’s very capable and tells me that he would like to go back and become a doctor but for the time being is glad to be employed doing what he is doing. He is in the second class of this project and says that most of his colleagues who have graduated have already found good employment in outlying areas where they are badly needed.

Only four out of five children survive to their fifth birthday in Sierra Leone. That statistic is just astonishing to me but I think it explains the passive reaction of the mother when I tell her that her baby has died. There is no show of emotion, just a resolute stare. I don’t think they grieve any less but they certainly express it differently. I’m told that if a woman has many children it is easier to accept but if she is a first time mother or has no or very few children it is much harder on her.

I think that’s about it for me now. Just writing this stuff down seems to kind of help get rid of some of the pressure you feel in the presence of it all. I have so much more I want to talk about but It’s been over 30+ hours since I slept and I can feel myself fading. I wouldn’t exchange this experience for anything, the heat and the sadness notwithstanding.

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