Sepsis

It is Tuesday, my first day on the job in Aweil. The outgoing obgyn is still here, and she is handling the hospital work today while I get my briefings from various people. Katie, the midwife who arrived with me, and I are getting a briefing with the Head of Mission: an abbreviated version of 200 years of Sudanese history. As the briefing wraps up, we get a message from the radio operator that maternity is looking for us.

When we arrive in the Operating Theatre (OT), the patient is under anesthesia, and the outgoing obgyn (whom I am replacing) is attempting to deliver her vaginally. She is 18 years old. It is a full term pregnancy, and the baby is already dead. She has been in labor for 4 days. Since it didn’t come out during labor, we can assume it will be difficult to get out now.

We try the Kiwi vacuum. I like the Kiwi for normal deliveries, because it is easy to use, and doesn’t put too much pressure on the head; if you use too much force, it just pops off. It’s like a safety check. If that happens a few times, it’s time to do a c-section. But in this case, there is no such thing as too much force; the baby is already dead. And the Kiwi keeps popping off.

Next we try to use the forceps, which are metal graspers that are placed on either side of the baby’s head to guide it down. But the head is so wedged into the pelvis, we can’t get them on at all, despite multiple attempts by both of us.

Next we try the stronger vacuum, which has a large silicone suction cup and an external manual suction mechanism. It seems to have more force than the Kiwi. We pull and pull and pull. Slow progress is made. The other obgyn pulls on the suction cup while I hold the patient’s pelvis back to stop her from falling off the table. She is using all her strength. Finally, we deliver the dead fetus.

Because the patient has been in labor so long, there is a risk that she will have tissue necrosis and form an obstetric fistula. From below, her uterus is abnormally displaced upward in her abdomen, near her umbilicus. This is probably because most of the fetus was sitting in her vagina, not in her uterus or cervix, and the lower tissue is stretched out. We examine with a speculum, and the cervix looks relatively normal, although large and floppy. She is not bleeding. We are finished.

The anesthetist comments that the patient was already septic when she came in. This means that she had already developed a uterine infection from prolonged labor that had then spread into her blood stream, and had caused physiologic changes like low blood pressure and high heart rate as a sign of overwhelming infection. The anesthetist had to give the patient dopamine to improve her blood pressure during the procedure. She is not out of the woods yet; she will need strong antibiotics, good care, and a lot of luck.

We send her to the ward, and repeatedly check on her throughout the day. She is stabilizing. She has a fever, but we are giving her antibiotics and Tylenol. She is weak, but able to talk and her family is taking good care of her.

The next day, she looks, so-so. We are treating her infection and giving her IV fluid, but most notably, her oxygen saturation is low at 91% (it should be 95% or higher). In combination with the low blood pressure and tachycardia (high heart rate), I am worried that she is decompensating. We put her on continuous supplemental oxygen. I ask for input from the anesthetist, and she gives me a vial of dopamine and a bag of normal saline, and explains how to give it. The idea is to artificially increase the patient’s blood pressure in order to maintain her organ function until her status improves. The patient’s nurse dutifully counts out the number of drops per minute, to carefully monitor the dopamine dose. Her blood pressure improves soon after starting dopamine. After lunch, we plan to reevaluate and possibly lower the dose gradually.

That afternoon, she looks worse. Her abdomen is swollen and she is complaining of abdominal pain. She is breathing fast and looks uncomfortable. Her oxygen saturation is getting worse. It is very likely that the sepsis is causing pulmonary dysfunction, called Acute Respiratory Distress Syndrome, or ARDS. Her blood pressure is OK on the dopamine, but when we lower the dose, the BP drops quickly.

The anesthetist stops by as I am examining her, and we agree that her bowels probably aren’t functioning well as a result of the infection, and she needs a nasogastric (NG) tube. This tube gets inserted in the nose, goes down the esophagus and into the stomach. It allows us to decompress the stomach and bowels from above, since they are not emptying from below. The nurse races to get an NG tube, and we insert it successfully on the second attempt. We get a little fluid back. I am concerned about her condition and want another opinion, so I call the Hospital Manager, who arrives immediately.

The Hospital Manager (HM) finds a large syringe and is able to aspirate a lot of ugly fluid out of the NG tube. This visibly decompresses her stomach, although doesn’t change her breathing, heart rate or blood pressure. At this point, the dopamine has run out and we need to decide whether to restart it. I am concerned about leaving her overnight with dopamine and no supervision of the nursing staff. The HM, the anesthetist and I discuss the dopamine. The HM points out that the use of dopamine is not sustainable; we don’t have an ICU setting and it is a powerful and dangerous drug that, although sometimes lifesaving, is probably out of our range of care options. It is fine for the acute setting, such as intraoperative resuscitation, but this patient is more than 24 hours out of surgery and we don’t have the ability to provide the intensive care necessary for dopamine. We agree that the patient needs aggressive IV fluid hydration, oxygen and monitoring.

On Wednesday evening, I am in the hospital to do another surgery, and I stop by and look at the patient. She has decompensated. She is unconscious. Her vital signs are still bad. Her oxygen saturation is 83%. For some reason, the oxygen machine has been turned off. I turn it on, and her saturation improves to 90%. There is confusion as to who turned it off and why. Her nurse is frustrated because other staff members came by and turned it off. We speak to everyone we can, and let them know that it should not be turned off.

She is not febrile, but she is now suffering the effects of sepsis. She probably has multiple organ dysfunction, but we don’t have the lab tests needed to find out. Her lungs sound wet. Her blood pressure has improved after fluid hydration, but I realize that her sepsis must have allowed the fluid in her bloodstream to seep out of her blood vessels and into the “third spaces” of the body – in her case, the lungs. I start giving furosemide, a diuretic. We also change her position to have her sit straight up so that her lungs aren’t completely drowning in fluid. After multiple doses of furosemide, she puts out a lot of urine, and her oxygen saturation improves a lot. A few hours later, her lungs are more dry, although her saturation is not perfect – she still has ARDS.

I can’t wake her up. Even after improving her oxygen saturation, giving some concentrated glucose and suctioning her NG tube, she is unconscious. It doesn’t look good. Her blood pressure is very inconsistent. It varies within minutes from very low to normal to borderline elevated. I can’t think of anything else to do. I ask the anesthetist and the HM, but they don’t have any additional suggestions. There is only so much you can do in this setting.

Throughout the next day, I check on her repeatedly, and she looks worse and worse. Her heart rate shoots up to 150s, and her breathing is extremely rapid and she gasps for air with each short breath, even though the saturation on supplemental oxygen is good.

I realize that she is probably going to die. I start preparing her family for this. I tell them, through a Dinka-speaking nurse, that we are doing everything we can, but she is probably going to die. They understand. Her father says “It is in God’s hands now.” Her mother and father both sit on her bed, each holding one of her hands, watching her carefully. They have been so dedicated throughout. When we asked them to hold on to the syringe for the NG tube, they wrapped it up carefully and hid it in the corner under a blanket so it wouldn’t get lost. They help us check her urine, or her oxygen saturation, or adjust her tubes. They are lovingly stoic.

It is only in this moment that I start to process the injustice of this. She is 18 years old. She was having her first baby. That is what is killing her.

It is hard to watch her like this. Although she is unconscious, she looks so uncomfortable. Her breathing is so effortful, so tortured. Her fever spikes again and I change her antibiotics. Now that her lungs are dry, I give a little IV fluid. I have nothing else. Every time I come to her bedside, I check her vital signs, her oxygen saturation, and then I shake my head and walk away. I don’t know what else to do. Eventually, I stop checking the vitals, and just gaze at her from the head of the bed. She is dying, and there is nothing I can do.

That night, I am in the OR late until 2am. I check on her afterward. She is still alive, still heaving. Her family doesn’t even seem to sleep. They sit on her bed, holding her hand and watching her die painfully.

The next morning, I am told that she died at 4am. She and her family were gone from the ward by morning.

In South Sudan, women have a lot of children, and little access to care. Women mostly deliver at home, and when things go sour, they are very far from the nearest health center. A recent survey of a remote area nearby revealed that the nearest health center to that population was six hours away. So, when the baby doesn’t come out, the women just wait and suffer. They wait for days, because to get up and find help would be excruciating, and probably would not be very helpful anyway. That’s how four days go by, and a baby dies inside a vagina. By the time they reach someone that can actually help them, they are so sick that sometimes they are beyond help. We try anyway, and often, miraculously, they make it. Those are the ones that would die if we were not here. Then there are the ones that still die, too many of them, who would not have died if they had given birth in the countries that we come from.

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30 Responses to Sepsis

  1. Lidia says:

    Hi Veronica,
    I woke up in the middle of the night and found your website. My dad passed away few month ago and I watched him dying and his oxygen levels going rapidly down from %85 to %80 then %75 and %71. What did he feel then? Was he suffering?? And then a medical staff came to me to ask wheather they can give something to my dad. I dont remember what was it but something to let him go more easly? What was it? How does it work? I am asking myself all these questions since my dad go. Please can you answer it? My email
    lidia.nightingale@yahoo.co.uk
    Thank you so much,
    Lidia

  2. mohamed says:

    i thanx to u alot nd i read all topics and i nderstood very well we can handle this work as god was helpng us

  3. Enrica says:

    Thank you Veronica for what you are doing.
    I’m a student midwife, God bless you all.

  4. Lisa Thornton says:

    Veronica,

    I am a nursing student who reads MSF blogs with dreams of one day working for the organization. My son Henry is 15 months old and his delivery was similar to the one you describe here, but now we are both fine. I will never forget this story of the girl across the world who did not get to make pancakes with her son for lunch today. Thank you for sharing her story.

  5. Kaush says:

    Hi Veronica, I’m a med student in the UK. I just finished a placement in obstetrics & gynaecology placement & am starting intensive care now, so this post really struck a cord, on so many levels. Thank you for writing – it’s hugely inspirational, both for how we manage patients in better resourced settings & motivating us to make that standard of care a global reality. Much love and thought.

  6. Kari says:

    Hey Veronica-
    Just got I just finished reading 2 or 3 of your posts. You have a truly unique combination of gifts- the ability to use your intelligence and medical knowledge to help those in need and the talent to write stories in a way that places us, the readers, at the bedside. I can’t even imagine how hard it must be- but thank you for sharing!

  7. Khanh K says:

    I’m greatly appreciate your blog of thoughts and daily logs.
    You’re my inspiration for a med student like me :) Please don’t stop. I strive to be like you someday.. soon :)

  8. Gemma says:

    Dear Veronica,

    Thank you for your good work and for doing everything you could.
    I hope to be working where you are in the next six years.

    God bless.

  9. Julie Osenton says:

    Veronica,
    The work you do everyday is a blessing to these people in foreign lands that have no healthcare simply because they were born there. Somehow, someway these stories have to be told so that everyone has access to medical care, food, and shelter. The story is very sad but it should make us all very mad that these conditions even exist in this century. Sepsis is another monster that needs to have a spotlight shined on it so everyone knows the signs and symptoms and seeks help. The SEPSIS ALLIANCE has been established to do just that and your story is going to be posted on their site also. Doctors without Borders is a true calling of caring, kindhearted Doctors who want the world to be better. Thank You Dr Veronica for trying to help the sick in the world and caring about them. May God Bless You and all the Others who fight so hard to save lives.

  10. JEANNIE says:

    WOW!! Thank you for the details of your experience with us. I have the luxury of nursing in Canada where such sensless loss of life due to lack of care isn’t happening. My heart goes out to this young woman’s family and the staff who tried so hard to save her. May your spirit & soul be protected. What can we do to help? Blessings & love to you. Jeannie

  11. DAVID KISH says:

    DR.VERONICA.
    I have exprinced myself with septic uturus one can not do much in these conditions unfortunately , I was practicing medicine in Romania Bucharest late 80′s during old regime and we had have a lot of woman admited to hospital with infected uterus , most of them we have been lossing them even in estern Europe . you did your best , ones condition is septic utrus patents is %80 is not reversible and the best things to do Histerctomy if is posible the sooner beter .
    you did the best God bless you said history ,

  12. DAVID KISH says:

    Dear Doc.
    you are real human you did the best I have practice in Romania during old regime abortion was crime and woman coming sepetic to hostpital and often we could help much anythings they were passing away ,
    I have cried many times seeing very young woman passing away .

    admire your efort remind me 20 years ago my practice in Romania Bucharest , love your dedication . God bless you .
    David Kish

  13. Emese says:

    Dear Veronica,
    thank you for writing about your experiences even if they are sad. The world, our world, is so injustice, just letting this young mother and her baby die like they had less right to live than others. How could you possibly immagine happening this to a pregnant women in the US or in any other developed country?? Take care and wish you all the best for your work!

  14. Emese says:

    Dear Veronica, good to hear about your experiences even if they are sad. The world is so unjustice leaving this young mother and baby die, just liked they had less right to live than others. How could you possibly immagine happening this to someone in a developed country like US or EU??

  15. Christine Nichol says:

    Thank you Veronica.

  16. Zani Prinsloo says:

    Dear Veronica,

    What you are doing is beyond amazing!!!! It is people like YOU that inspired me to join MSF, I start in September and CAN NOT wait!!!!!
    Keep your spirits up, where there is life…. there is always hope!!!

  17. Zani Prinsloo says:

    Dear Veronica,

    I admire what you are doing!!!!!! It is people like YOU that inspired me to join MSF, I will start in September and CAN NOT WAIT!!!!!!
    Where there is life… there is always hope!!!!! Keep your spirits up , what you are doing is beyond AMAZING!!!

  18. Jayalakshmi says:

    Ms. Veronica,
    You, just the mere fact you are there, are a miracle worker.
    Your dedication is commendable.
    Your courage to BE A DOCTOR in Doctor’s w/o Borders says volumes of WHO you are.
    A Human with a HEART to SHARE and CARE beyond what is considered HUMANITARIAN.
    Yes, I too, cried as many after me who read your Story will.

  19. teresa says:

    Thanks for your descriptive words of the circumstances you work. I get excited when i see a blog from you. I want to be part of your team. I have worked with MSF and hope to do so in the future.
    Mind yourselves out there and remember to take time to reflect on your own needs….. Stay strong and keep up the great work.

  20. melanie says:

    Dear Veronica,

    I think of all the women around the world who don’t access to proper care and it breaks my heart, my mind… Your dedication is so unbelievably strong. May this young girl rest in peace. And all the support and love to mothers and their families around the world who don’t have proper care…

  21. Barbara Cordone says:

    Dear Veronica,
    Your story made me cry and probably many more that have read it have cried. But while we cry you are doing something about it. God bless and good luck to you. They are lucky to have you.

  22. Starlie Verastegui says:

    This story touched me so much. In America, we forget how great we really have it. Basic medical care to treat a preventable death. I am thankful for the work you are doing. I wish I was there helping you. I will send an inkind gift.
    God Bless!

  23. Anne Corless says:

    As an ex midwife, now working as a medical artist, I have a particular interest in this. My heart goes out to you all……

    Without you all, where would these poor women be? With you there they have hope…..and the chance of a good outcome with your help.

  24. Shona Kambarami says:

    Veronica, thank you for sharing this story. What a welcome to your new job. I’m a junior doctor doing O&G and I’ve been considering applying for MSF. Your story, though heartbreaking, has encouraged me. This is an amazing skill that we have, an incredible gift that we can give to so many people. It would remiss of us, all of us, to not do what you are doing now. Thank you for going.

  25. Jude says:

    This is utterly tragic, and must be extremely hard for you and your fellow healthcare professionals. Thank you for sharing such a difficult story — as the previous commenter said, it’s so important to get this information out.

    Thank you for your work.

  26. Gale Marie says:

    Dear Veronica,
    I am struck by not only the sadness of this story but the horrific reality of the poor in South Sudan. I am in awe of MSF and the angels such as yourself who selflessly dedicate skills, support, friendship, and your lives for the sole purpose of helping mankind.

    I am in America, and I wish this story was on the front page of every major newspaper across the nation. There are so many in this great country who have so much, yet want so much more. I am speaking medically; as it appears that despite no one has ever been turned away from an ER, the demand for new entitlements continue. Their selfishness sickens me, and I wish they could know about realities for those less fortunate.

    I do not want to make this a political comment, but an illustrative comparison of undescribable hardships that exist in so many other countries. Your gift of self is a treasure to the world. Please give my heartfelt gratitude to those who walk with you across the war and poverty stricken regions of the world. It is not possible to put into words the value of all those in MSF and the difference they have made for so many over the years. Stay well dear one.

  27. YarahJay says:

    I don’t exactly know what to say…
    but maybe God has a reason for this.
    Thank you for doing everything.

  28. Corinna Gallop says:

    How heart-breaking. Thank you for doing what you could. We should now do what we can by supporting your work.

  29. Flavia says:

    Dear Veronica,

    as a lucky mother of two little girls this amazing blog is often painful to read. But yet again, if that was my child in that bed, I would have wanted to have someone like you looking after my daughter. I would feel grateful for everything that you have done, and although it is heartbreaking to face something like this, I would feel that everything earthly possible had been done to save my daughter, and it was done in a caring way too… This would probably help me to find some peace. Your work is priceless! Thank you.

  30. I absolutely have no words. Thank you for sharing the story of this mother. It helps show the urgency of helping more mothers around the world not succumb like this. Thank you for doing everything in your power to keep her alive.