Fieldset
A Strange Sense of Dread

On this latest trip to Chaman, I travelled with a strange sense of dread, for no reason in particular. There was nothing I could put a finger on. I could reflect that we have been lucky so far; no mass casualties, disasters, horrible deaths or incidents.

On this latest trip to Chaman, I travelled with a strange sense of dread, for no reason in particular. There was nothing I could put a finger on. I could reflect that we have been lucky so far; no mass casualties, disasters, horrible deaths or incidents. Human resources is human resources – a daily frustration but nothing to dread. And as always, I enjoy seeing the patients. Their stories are interesting and miraculous, unfortunately often with a tinge of sadness. I am always excited to return to clinical field work, just to see the patients. So as my journey to Chaman earlier this week filled me with a strange sensation, I was nervous. I knew that I had had great luck so far. All the team were safe, despite the constant security warnings. Yes, I had had some bad clinical cases, but nothing that has made me worry that I will never be the same person again. Still, I can’t forget exactly where I am working. This is the border of Afghanistan and Pakistan, and for some reason, this is resting on me heavier than usual.

 

A few days into the visit, it is Eid. I am busy working at my computer, and can hear the noise outside throughout the day. Celebrations, crowds cheering, vehicles in the street. The ever-present farm smells that I always find strange in a hospital context. Barbeque smells also travel on the breeze, as today is a day for prayer, sacrifice, family and feasting. But it is the constant sound of firecrackers, gunshots, and explosions that deliver a steady dose of adrenaline to my system. Were they celebration gunshots or real gunshots? Was that only a very close, loud firecracker, or an explosion? I repeatedly walk into the courtyard to check the skyline. Surely I would see a mushroom cloud if it were something serious? Nothing eventuates, but I still feel uncomfortable with the adrenaline. I’m not exactly stressed, but I can’t relax either. The work at my computer is just mundane enough to allow my fingers to work and my brain to wander. Was that one finally a gunshot? My ER colleague has left for holidays, so I am also officially the ER doctor on-call. I can handle this, but I am not in my comfort zone. The ER protocols and guidelines aren’t in the forefront of my mind as the obstetrics ones are. Instead of instinctive moves on handling babies and placentas, I have to retrieve information from the storage facility in the back of my mind. What if I can’t remember what to do at a critical time? But the ER cases are clear-cut today, and I even manage to teach the national staff a few tips.

 

I came to MSF and Pakistan knowing that I would be working in challenging situations with challenging patients. I knew there was a very good chance that I would encounter a maternal death on my watch. Back home in Australia, a maternal death is so rare that some near-retirement colleagues have never experienced one. Here, everyone knows someone who died in childbirth. It’s either your neighbour, your cousin, your aunty or your wife. It doesn’t happen to someone else, it happens to you. Now, it has also happened to me.

 

I have spent the past hour-and-a-half analysing all that we did, all that we could or should have done, all that we didn’t do. What could have made a difference? What wouldn’t have helped? There is so little that I do know. As with most patients here, the mother had had no antenatal care. Her previous eight deliveries had been at home. I struggled to collect a history from the patient’s family via translation. It is such a painstaking process, I have to rephrase my questions many times before I get the answer I need. We run through the motions of obstetric emergency management so well that I am relaxed. I’m even giving bedside teaching to the staff, once things are a little calmer. With the baby delivered in dramatic fashion, I return to the staff quarters as all seems normal with the patient. But I am called again two hours later. The mother is in a “critical condition.” I give directions over the phone as I wrap my head in a scarf and hurry out the door. But it is genuinely bizarre; vital signs are normal and the obstetric complications which I am hyper-attuned to manage are not present. She is agitated, but fully cognitive. She responds to commands, but continues to writhe around on the bed. The clinical picture is strange; I see things I do not expect and what I do expect is not there. I test everything I can, but I crave the instruments and facilities available back home. Would they give me more clues? Suddenly, out of nowhere, her eyes roll back and immediately we all see that she is gone. Within seconds, her skin is grey and her eyes sallow. We attempt resuscitation, but it is futile. I knew from the moment we started what her body was telling me. She is gone.

 

I’m left running through clinical cases in my head. Signs, symptoms, classic presentations and rare disorders. Things that I would never think of at home, such as undiagnosed cardiac disease. Surely not. Wouldn’t she have had symptoms? The usual obstetric conditions did not occur, so I am left with the unknown. An autopsy is out of the question, even though it could give me answers. Answers that I desperately crave. I’m fitting the symptoms into some clinical cases that can be defined as ‘likely’ and ‘unlikely’. But unfortunately there are quite a few likely causes. What can I learn from this and how should I do things differently so that this never happens again? Here is the crux of my problem: I can’t find anything to do differently. There was no gaping hole in patient management. We all did the right things. The most likely condition – amniotic fluid embolism – is deadly in any setting. One of my textbooks states that on average, 34 units of blood are required to counteract the destructive mechanisms that are occurring in the bloodstream. Thirty-four units. Here in Chaman, I’m lucky to get three for one patient. As the family say, it was God’s will. Sometimes people simply die, and there is nothing we can do about it. Here the odds are stacked against us. But even with all the resources in the world, people still die. Human nature has the uncanny ability to remind us that we do not have complete control. I have learnt that I am human and so is she. I will never forget this case. If I ever see this type of presentation again, I have a much higher chance of recognising it early. Another woman, some day in the future, may have a better chance of survival, because of the misfortune of this woman today. But did I miss something? I will never really know.

 

This is why I joined MSF, to experience things that I could never experience at home. But I am left feeling empty. Stunned. I think of her eight children at home. What conditions do they live in? Does her husband have another wife to care for them all? I don’t know what to think, I don’t know what to say, and I don’t know what to feel. I also think of the silence in the birthing unit. I expected tears; wailing, angry family members and a shouting husband. Instead it is silence. Everyone gets down to business. The patient is wrapped and taken away. The family are tearless, asking very normal questions. There is not one raised voice. Usually, as I leave the maternity unit gates, there is a crowd of men waiting for their wives. But this is Eid and only the most serious of cases present to the hospital. So my walk back to the staff quarters is deserted and eerie. The patient and her family have already left, only half an hour after her death. I could mistake it for a bad dream; were it not for the lump in my throat and the stunned faces of my colleagues.