Highs, lows, and what if?

It’s been a good week overall. The heat backed off a little, although I suspect it’s going to come back with a vengeance later. They say that March and April are supposed to be the hottest months so I guess I’ll find out soon enough.

It’s been a good week overall. The heat backed off a little, although I suspect it’s going to come back with a vengeance later. They say that March and April are supposed to be the hottest months so I guess I’ll find out soon enough. Some days this past week there have been breezes that make the walk to and from the hospital almost pleasant.

We see so many moms here who come in with fetuses who have died. We see a huge number of twins. And just this week there were three babies born with major birth defects.

The first was a baby with anencephaly, basically a failure of the brain to form. Where there should be a head is just an open defect starting above the eyes and ending at the back of the neck. The second was a baby with a huge tumor on its lower back, a sacroccygeal teratoma. The tumor was larger than the baby’s head. In every other way the baby was completely normal. It had full movement of its legs, no signs of paralysis. There is no place in South Sudan to try to repair a defect like that. Even back home it would be a major surgery. There is a place in Sudan that might operate on the baby but only if the parents, who have four other children, could come up with the money to travel there and pay the doctors and the hospital.

Instead the parents will probably take the baby home and care for it as best they can but ultimately it will die. The third defect was a baby with a huge hydrocephalus, water in the brain. The mother was able to deliver it but only because it was premature. Again, this is a baby that will probably just go home since the parents can’t afford to travel to a specialized center where the baby might be a candidate for a shunt.

I lost a patient last night. She was 28 years old and came in with a dead fetus. We induced her labor and she delivered the baby but afterwards had a large hemorrhage that we couldn’t control. We were finally able to get the bleeding to stop with medication and massage of the uterus but by then her blood wasn’t clotting correctly. We were giving her whole blood trying to replace what she had lost when she just quit breathing. All of our efforts to resuscitate her were unsuccessful. Her family was with her through all of this and thanked us for our efforts.

I spent the rest of the night second-guessing everything I’d done. What if we had taken her to surgery and removed her uterus before she lost so much blood? What if we had started transfusing her sooner? It’s enough to drive you crazy. As unstable as she was I think there’s a good chance she might have died during surgery or afterwards and then I’d be asking myself the same questions about what might have happened if I hadn’t taken her to surgery. The bottom line is you make the best decisions you can with the information you have at the time and if the outcome is not a good one then hopefully you learned something that you can use next time you’re faced with a similar situation.

That was the low point of the week. But there were some high points. Lots of twins, healthy and crying. A couple of emergency C-sections with good outcomes. Lots of sick patients who have gotten better. I had a patient with severe malaria who came in unconscious and completely unresponsive. We started her on IV antimalarial medications but she didn’t show improvement over the first 24 hours.

She did, however, go into labor. When she was fully dilated she didn’t have any urge to push so we had to pull the baby out with forceps but got a healthy baby. After three days on the antimalarial meds the patient started to show some signs of awareness and today, six days after admission, she is able to walk with assistance and able to hold a cup of porridge as long as someone helps her. She will probably make a full recovery but it will take time. She’s already been lucky. She had a 20% chance of not surviving the severe malaria. So I’m counting her as a high point of the week.

I also saw a 23-year-old woman this week who is three months pregnant and was picking up something in her garden when she was bitten on the hand by a poisonous snake. She didn’t come in for two days. By the time she arrived the hand and forearm were about four times normal size. We started antibiotics and steroids to treat the inflammatory response but she wasn’t yet a candidate for the antivenom we keep. We have a very small supply and it’s very expensive and the criteria for using it are pretty stringent.

But she met the criteria on the third day after her snake bite when the swelling progressed to the next joint, her shoulder. We gave her the antivenom through an IV infusion and within about six hours she was already having less pain. Her arm is still swollen and it will probably take a week or more for it to go back to normal but she still has good sensation in her fingers and is able to move them. She should make a full recovery.

The anesthetist was telling me about a similar patient who was seen before I arrived. She had also been bitten on the arm by a snake but instead of going to the hospital had gone to her tribal witch doctor who proceeded to use a sharp object to make punctures around the snake bite, presumably to drain the venom. Instead she ended up coming to the hospital with infected skin from all the infection that ensued after his punctures along with the trauma from the snake bite. She is still having dressing changes twice weekly in the OR and will likely lose much of the skin on her arm. Skin grafts, if they can find someone to do them, are probably in her future.

It may not sound like the makings of a good time but I’m enjoying myself here. In spite of the heat and the dust and the poverty and the sadness it feels good to be pitching in. We have a good group of people and I’m enjoying working with them. It’s already been two weeks, a quarter of the time I’ll be here. The time is flying by. 

Because Tomorrow Needs Her