A little over week ago we admitted a 17 year old who had been having severe abdominal pain and high fevers for over two weeks. She had been seen by one of the people in her village who had given her native herbs. They hadn’t made her any sicker but neither had she gotten any better. She didn’t live anywhere near a clinic or a hospital so didn’t have access to any other kind of health care.
Her sister finally arranged transportation to bring her to the hospital here when she became very ill. She had a weakly positive pregnancy test and an ultrasound showed a lot of fluid in her abdomen. The pattern on the ultrasound suggested that it wasn’t just plain fluid but more likely blood. Assuming she had a ruptured tubal pregnancy we took her to the OT. What she actually had was the worst pelvic infection I’ve ever seen. Her abdomen was full of pus.
The bowels and the omentum [a large fatty apron-like structure which drapes over the intestines inside the abdomen] had tried to wall off the infection but instead had become part of it. The bowels, inflamed and swollen, were stuck together by thick secretions. Any attempt to pull the areas that were stuck together apart threatened to peel off some of the surface of the bowel. Gradually we were able to free up most of the bowel. I was worried that she might have a ruptured appendicitis but the appendix looked normal, inflamed like the rest of the bowel wall but not enlarged. The source of the infection seemed to be the left tube and ovary. They were stuck against the side of the pelvis but when we got them freed up there was another flood of pus. The uterus looked okay and the other tube and ovary, aside from being inflamed and swollen, appeared fairly normal.
In the end we drained the pus, put drains into her pelvis and abdomen and made punctures through her abdominal wall to externalize the drains, and then closed her abdomen, placing her on broad spectrum antibiotics through her IV. We placed an nasogastric tube through her nose into her stomach, planning to leave it until she started showing signs of normal bowel function. She pulled it out as soon as she was awake and would not let us replace it.
For a day or two she seemed to improve. She ran high fevers, 102 to 103 degrees, but she said she was hurting less. She asked for something to eat but didn’t have bowels sounds so we let her suck on a wet cloth to moisten her mouth but told her to spit out the fluid.
On the third day she said that her belly was hurting again. The drains were still removing a lot of fluid from her abdomen. She still had no bowel sounds. Then she started throwing up bile-colored fluid since she hadn’t had anything on her stomach for several days. She finally agreed to let us replace the NG tube to try to give her some relief from the swelling but it just aggravated her and she pulled it out again.
On the fourth day she started running fevers that were even higher, up to 104 degrees. Her heart was racing and her blood pressures were starting to drop. She was clearly becoming septic and it was apparent by then that the antibiotics alone weren’t working. We took her back to the OT, opened her abdomen again extending the incision all the way to her upper abdomen, and found the same picture we’d found the first time. There were more isolated areas of pus that had been walled off by different parts of the bowel and we were able to drain those. More loops of bowel had become agglutinated together by the infectious process and we were able to free those up again. And after irrigating with normal saline there wasn’t really anything else to do except continue the antibiotics, continue draining her abdomen, and hope she got better.
She didn’t get better.
On the fifth day her fevers became worse. She became semi-conscious and finally unconscious. Her breathing became shallow and labored. The only assistance we could offer her was oxygen through a nasal cannula and cool wet towels to try to bring her fever down. We were giving her extra IV fluids to replace the fluids she was sweating out through her skin and through the drains in her abdomen and stomach but her urine output began to drop. Her kidneys were starting to shut down. Her heart was racing at double the normal speed and her blood pressures were starting to drop again.
I spoke with her older sister. Only 22-years-old herself, she was the sole family member I had seen with the patient during the last week. I explained to her that her sister wasn’t doing well and that it looked like she was going to die. I asked her as gently as I could whether or not we should try to resuscitate her if she quit breathing or if her heart stopped. At first she didn’t understand what I was asking. Through the translator I rephrased it, asking her if we should try to make her heart beat if it stopped or try to make her breathe again if she quit breathing. I almost told her that even if we were able to reestablish her heartbeat or her breathing that I didn’t think it would change the outcome but I bit my tongue, hoping that she could see what was so plain to everybody else. Her sister was dying. And she was only 17 years old.
She didn’t decide right away. She sat with her sister and cried quietly, so differently than the loud and dramatic grief that I’m used to seeing over here. Shortly after midnight the next day, six days after she was admitted, her respirations became erratic. She would quit breathing for 10 seconds and then take a long, gasping breath. Her sister turned to us, told us that she did not want us to try to resuscitate, and then turned back to her sister, speaking in whispers that were not meant for us. When her sister quit breathing a short time later she was still holding her hand and whispering.
I listened for a heartbeat and didn’t hear one. I listened for breathing and heard none. I pronounced her dead and wrote down the time.
All of the beds in the ward are exposed to each other but the nurses had put up barricades to provide a semblance of privacy for the two sisters. Two nurses and the sister washed the body and wrapped her in a shroud. The sister said she would make arrangements for someone to retrieve the body. I got called to labor and delivery shortly after that and when I came back through the ward an hour later the body and the sister were both gone.
Of everything I’ve seen over here I think this one patient has gotten under my skin somehow. It’s been a few days but this is the first time I’ve been able to actually sit down and write about it. I don’t know if it’s that she represents so much of what I’ve seen over here or whether it’s related to the fact that my days here are almost over and this is another one we couldn’t really do anything for. Maybe it was the dignity and strength that her sister showed when faced with choices I hope never to have to make. I just know that I haven’t been able to stop thinking about her.
She was only 17 years old.