Please note: all patient names are changed to protect confidentiality.
At 2pm on May 7th, Aimee, age 25 years, arrived at a primary care medical facility here in eastern Chad. She had abdominal pain radiating to her back and she had not had her menstrual cycle since April 18th. The treating medical staff did a basic exam and ordered some lab investigations. The clinical notes for her case are contained in a small notebook cut in half. Half a football player’s face is on the front. This is Aimee’s patient health record. Most of the writing inside is practically illegible and incomplete. As is the case for most Chadians who seek health care in a cost-recovery setting, she was charged 4000 Chadian francs for what can best be considered an inadequate medical assessment.
A later documented medical note revealed Aimee continued with abdominal pain and was very agitated. For reasons that are unclear, she was given a perfusion of intravenous normal saline. Apparently, it was learned later that Aimee’s husband told the treating medical staff that his wife is often anxious around the time of her menstrual cycle. It was later learned that the treating medical staff felt that Aimee was indeed just anxious related to her menstrual cycle. Aimee was given a medication to relax her intestines as well as intravenous diazepam, a benzodiazepine medication used for limiting anxiety and causing sedation.
One of the most critical concepts for me as an emergency physician is “trust no one and believe nothing”. This even applies to information given to me by a well intentioned family members or fellow medical staff. These caregivers and caring people can give you misleading information, clouding your objective medical assessment. “Trust no one and believe nothing” does not mean to not listen to people. It is just a warning to keep an open mind to all possibilities and not fall victim to what we call “premature diagnostic closure”. A critical error by the medical staff that first attended to Aimee was accepting the easiest diagnosis possible and not considering first the most serious or life-threatening diagnosis for abdominal pain in a young woman who was likely pregnant.
Aimee later had a gynecological examination and she was found to have pelvic bleeding. She was still in a lot of pain as well, as the clinical notes revealed. For this reason, the primary care facility referred her to the Amtiman Hospital maternity service – nine hours after her first presentation with severe abdominal pain.
In the Amtiman maternity supported by MSF, the nurses and midwives on duty made a complete medical assessment. A legible, full medical note is written into Aimee’s health notebook. It turned out that this was Aimee’s second pregnancy and her main problem was intense abdominal pain. Vitals signs were completely taken and they indicated Aimee had a fever and was breathing abnormally fast. In my experience, the most neglected and yet revealing vital sign in medicine is the respiratory rate. Pain or shock are key reasons why the respiratory rate is elevated. Normally, it should be around 8-12 breaths per minute, but Aimee’s respiratory rate was 26. Not good at all.
In the maternity, rapid testing for malaria and syphilis were negative. A crucial pregnancy test was found positive. The maternity team on duty suspected Aimee was either having an abortion or ectopic pregnancy. They started an aggressive intravenous fluid bolus, gave paracetamol (Tylenol), and an oral iron pill (the last medication for a reason unknown to me). They decided they needed a doctor and an emergency ultrasound.
At midnight, our expatriate German midwife Sigrid called me. I had been sleeping poorly due to the heat. She asked me to go to the hospital to evaluate Aimee - particularly by ultrasound. I said “no problem” and a few minutes later our driver and I were inside an old, rickety and dusty Land Cruiser on the way to the hospital. The night air was hot. Even though we were driving slowly, the potholes in the road made our bodies slam back and forth into the car doors beside us.
When I got to the hospital at 00:15, I greeted the staff and examined Aimee. I draped her shawl over her legs to protect her modesty. The nurses warned me it was covered with blood, but it was all we had. The nurses offered me gloves, but since I prefer to examine a patient’s abdomen with my bare, human hands – I declined. First however, I listened patiently with a stethoscope to Aimee’s abdomen. It was completely quiet, a bad sign that her intestines had stopped moving. I gently put my hand on her abdomen in different places and she winced in severe pain. There was no question at this point – she needed surgery - tonight. Aimee’s pain was definitely real.
I opened the suitcase I use for carrying the portable ultrasound and asked one of the nurses to hold the machine carefully. I put the ultrasound probe over Aimee’s right kidney on the side of her chest. What immediately appeared was an ominous finding that confirmed that she had an ectopic pregnancy (a pregnancy dangerously outside of the uterus). Not only did Aimee have an ectopic pregnancy – but it had also ruptured and she was bleeding internally. I have attached a photo of Aimee’s ultrasound– you can see her kidney (shaped like a kidney bean) with an abnormal black stripe around it (this black stripe is blood –evidence of intra-abdominal bleeding). The ultrasound exam of her uterus also revealed it was empty – which was further evidence of an ectopic pregnancy.
Ultrasound image of Aimee's intra-abdominal bleeding. The black strip (or sliver) between her kidney and liver is evidence of abnormal intra-abdominal bleeding. © Raghu Venugopal
At 00:30 I called our midwife Sigrid and our surgeon. Sigrid mobilized the MOH head nurse, operating room staff, and laboratory staff. She came herself to the hospital to make sure everyone did their job. Aimee was in the operating theatre at 01:10 and at 02:40 the surgery was finished. The surgeon found a ruptured ectopic pregnancy and was able to remove the abnormal pregnancy and stop the bleeding. A blood transfusion was started at 03:22.
Today is day six after Aimee’s surgery. She is having fever still and is being treated with three antibiotics. She is also being treated with strong pain medications. But she is able to sit up, to shake hands with me, and to smile when I took a photo of her with her consent.
Aimee on day 6 following her surgery. She's able to sit up and smile (photo is with patient consent and the patient's real name is not used). © Raghu Venugopal
Aimee’s pain was definitely real. Her case highlights gaps and problems in the Chadian health care system and why maternal mortality is so high in this country. Qualified medical staff are lacking. Basic and life-saving health care is unaffordable to the rural poor. On a positive note however, the MSF supported medical staff recognized the seriousness of Aimee’s pain and sought timely help. For the future as well, I am teaching the Chadian midwives and nurses how to use ultrasound to answer basic clinical questions. I hope they will use ultrasound, with support from future doctors, after I return home.
Aimee’s pain was definitely real. And she is definitely better now.
Farewell for now from the house-call….to Chad.