Let me tell you about my daily life here in Khost and the one of the MSF staff !
Each of the expats has his or her own “container” bedroom – a truck container that’s been converted into a studio apartment with a window, bed, desk and bathroom. There’s a large volley ball court in the middle of the living quarters as well as a common building that houses the shared kitchen and dining room. To be honest, I don’t even enjoy such luxuries in the US!
The women-only garden ©MSF
My only regret is that, due to security reasons, the walls of the compound (which surround both the hospital and our living quarters) are at least 10-15 feet high, and although I saw mountains on my flight from Kabul to Khost, they are now hidden from view along with the horizon, and we never see a sunrise or sunset. Depending on your mood, the walls can either strike you as prison-like or can contribute to the calming sense that we live and operate in a safe haven, a kind of protected medical sanctuary with birds and flowers that welcomes and cares for all pregnant women who come through our doors.
The entrance to the hospital ©MSF
Today brought me the hardest hysterectomy I’ve ever done. At first I didn’t realize what was wrong. Almost immediately after coming out of the OT soaked in my own sweat after a C-section for twins, a midwife grabbed my arm and pulled me to the delivery room. A 28-year-old woman with a history of 7 prior pregnancies and one prior cesarean section (and only 4 living children) was lying uncomfortably on the delivery table, her abdomen almost resembling a camel’s back – there was the normal expected baby bump, but there was also a smaller bump just above it, ending just below her xiphoid (bottom tip of the breast bone).
Earlier in the morning, she had gone to one of the multitude of private clinics, some of which practice sketchy medicine for profit, and had received an uncertain amount of oxytocin, a medicine that stimulates uterine contractions. After a certain amount of time spent in painful labor, her contractions suddenly stopped. Although her baby had already started to descend into the vaginal canal and is normally delivered shortly afterwards, the baby also stopped moving down, and at some point during this entire process, the baby had actually died.
“What the … ?” I thought to myself. Just as I was asking for the ultrasound machine to figure out what was happening inside of her abdomen, the midwife said, “Uterine rupture!”
Whoa. I have never seen this before, but that would explain the sudden cessation of contractions and the second bump above the normal-shaped baby bump. I quickly confirmed that the baby had died on ultrasound but although I could not fully appreciate the uterine anatomy, I was able to see a lot of blood clots collecting inside of her. We immediately prepped her and moved to the OT.
Once we opened her abdomen, dark, blood-stained peritoneal fluid poured out, and I removed a handful of blood clots from around her uterus. After laboring for an untold amount of time, all of her pelvic anatomy was distorted and swollen. Her bladder was scarred high on the uterus from her prior cesarean section and was twice its size from the edema (swelling of tissue), and a large bloody rent extended from the right lower corner of her uterus down into the cervix.
I was working with Dr. Leila one of the national staff who is experienced in normal cesarean deliveries, but is still learning how to master the hysterectomy. Although I had never seen a uterine rupture before, I knew I couldn’t lose my cool and needed to teach Dr. Leila how to handle such an operative emergency. We extended the already-present uterine tear to deliver the dead baby, then quickly sutured closed the uterus, and started working on identifying the normal from the abnormal structures. After much sweat on our part and blood loss on the patient's part (2.5 liters total – i.e., half a gallon), her uterus was removed, her pelvis was dry, and we were able to close her abdominal wound.
Hardest hysterectomy ever. I can only cross my fingers and hope she does OK over the next few days.