Week eight: no good choices

This blog post contains content which you may find distressing.

This blog post contains content which you may find distressing.

One week from today I’ll be in Juba, the capital of South Sudan, packing my bags and getting ready for the long trip home. I leave Aweil for Juba on Thursday next week. Saturday afternoon I’ll leave Juba for Dubai and then, after a three hour layover, from Dubai to Amsterdam, then Amsterdam to Atlanta and then finally to Fort Smith. I should get back, knock on wood, Sunday in the late afternoon.

This week has been filled with its usual share of disasters. I had one patient who showed up hemorrhaging with a placenta previa [placenta covers the cervix] and almost died. She had no blood pressure when we got her to the operating room (OR). The baby was dead but the patient survived. Her hemoglobin (normal is around 12-13) was 1.8 after she received her first unit of blood. She got a second unit before she left the recovery room but is still severely anemic.

The blood bank is down to 12 units of blood so we can’t afford to give her any more unless her family steps up and donates. Two of them have given blood so far but we need at least two more.

Today a patient showed up in labor with a baby that had severe hydrocephalus. The measurements of the head were off of the ultrasound charts. She had previously delivered two children so we followed her in labor, hoping that she would have enough room in her pelvis to deliver the baby but her labor arrested at about five centimeters.

She was still having hard, regular contractions but the baby’s head couldn’t descend any more because it was so large. I’ve run into this a couple of times before and have felt comfortable putting a needle into the chambers of the fetus’s brain and draining off the extra fluid to allow it to fit through the pelvic bones but always before the fetus was already dead. This fetus was alive with a normal heart rate.

The brain was full of fluid, so much fluid that it was hard to find any normal brain tissue. It had all been pressed close to the bone by the fluid volume. When I first looked at the fetus with the ultrasound shortly after the patient was admitted the heart rate was only about half normal so I was thinking (and hoping) that it would die during labor. But as the labor progressed the fetal heart rate returned to the normal range. When the mother reached five centimeters it was pretty obvious that she wasn’t going to progress any further unless we intervened.

I really struggled with this one. There were no good choices, only choices that were less bad.

If I had taken her to the OR and done a C-section it would almost certainly have been a classical C-section, the type where the incision on the uterus is made vertically, going through the thickest part of the uterine muscle. This is the type of C-section that is most likely to rupture in the future. The other option was to try to drain some of the fluid off of the baby’s brain to reduce the head size to deliver naturally. The baby’s prognosis was close to zero; even in a developed country a baby like this would probably have only rudimentary brain function if it survived. In a country like South Sudan it would just go home to die.

But the baby was still alive. It had a heart rate and that’s how we define life. There really weren’t any good choices, just choices that weren’t as bad as some of the others. I discussed it with some of my colleagues. Even though it wasn’t unanimous the group consensus was the logical thing to do, the least bad thing to do, was to drain the fluid from the baby’s brain even though it still had a heart rate. And that’s what I did.

I won’t say it’s the hardest thing I’ve ever done in medicine but it was right up there at the top. I’ll spare you the details except to say that it worked and the baby was stillborn, for which I’m grateful. We weren’t monitoring the heart rate so I don’t know when it died but I’d like to believe it was early on in the process. I felt pretty much emotionless during the procedure and the delivery (which occurred almost immediately after draining the fluid) but as I was washing my hands off afterwards I felt myself choking up and had to leave the room for a bit.

That part took me by surprise. I thought I hid it pretty well but the nurses and midwives gave me extra space and were much nicer than usual afterwards.

I think it’s easier sometimes to be tough in a situation like this, to compartmentalize your emotions, than it is to be vulnerable. I’m kind of relieved that something like this mom and her baby can still affect me in this way. I guess it means I’m not too far gone.

The mother was still holding her baby when I left the hospital. It was the right decision to help her deliver the baby normally, I have no doubt about that. But just knowing that doesn’t make what we had to do to help her do that any more palatable.

I know that the stuff I’ve written to you all about is mostly morbid and depressing but I think the good experiences, while maybe not as interesting, have been just as frequent. I’ve made some friends that I know I’ll stay in touch with and hopefully work with again.

I’ve learned how to say “push as hard as you can” in another language. I’ve learned that when you ask for patient’s chart here you will most likely just get a blank look but when you ask for the patient’s file or the patient’s form you’ll have much better luck. And I’ve learned that when you tell a French-speaking person that you’re tied up right now they will more than likely misunderstand completely.

I think I’ll sleep for a week when I get home but within a few weeks I will have forgotten all the bad stuff and I’ll be ready to do it all again. 

Because tomorrow needs her: womens' health
Stephen finished working in South Sudan in April 2015