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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6 Responses to When it rains

  1. Elizabeth Murphy says:

    Hello Dr.Torres, I really enjoyed reading your post. It helps to imagine a little bit of what it would be like to work in Sierra Leone. I am a midwife in the UK and am very keen to work for MSF in the near future, thanks again,
    Liz

  2. Bev says:

    Bless your hands and the work you do.

  3. Kaush says:

    For what it’s worth, you’ve earned that soapbox with that shift alone. You are totally right about the babies being born with complications of prolonged labour: I spent 2 months in Kenya at a really great DGH where so many of our neonates died from birth asphyxia & many who survive became frequent fliers with aspiration pneumonias because they never gain control of swallowing. All the best with work & have a good 2 days of R’n'R.

  4. Adhar978 says:

    I finished my OB-rotation in Long Island 8 weeks back and reading this article it made me appreciate the intricacies and nuances of your day more. Small things that we take for granted in the states make big impact here. Thanks for the blog and a glimpse in your part of the world over there!

  5. Beatrix says:

    I am a L&D nurse working in a community hospital. Last night we were very busy but nothing compared to the night(s) you had. Thank you for writing your blog and the amazing work you do. It puts things into perspective and inspires me to do better.

  6. paula venn says:

    Very well written and honest and interesting accounts Steve. You really provide insights into your thinking, and how it allows you to cope. All the best, Paula

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