Tuesday, October 9, 2007

Morbidity and Mortality

I arrive on the wards in the afternoon, and Gerald is in triage with a woman who is lying down, with a unit of blood hanging from an IV pole. She was referred in for severe anemia and fevers six days after a normal delivery, and she was poorly responsive, although normotensive. Because the referring diagnosis was severe anemia, emergent blood was ordered, but a CBC wasn’t drawn because the tube couldn’t be found, and a malaria smear wasn’t done. The woman is agitated but borderline unconscious. She moves her arms around randomly, breathes heavily and looks uncomfortable. She does not make eye contact when prompted. Several worried family members stand around her, looking worried and desperate.

Several minutes later, we go back to check on her; she is having a reaction to the blood. The unit has just finished, and she is covered in hives, her face has become swollen, and she is wheezing. Joseph, the postgraduate, calls for hydrocortisone, but there is none, so Liz, the intern, runs to the medicine ward. All she can get is dexamethasone, so I give it intramuscularly. The woman thrashes and tries to bat away the injections, but her attendants immobilize her. The hives are all over her face, shoulders, arms, abdomen.

When I step outside of triage there is a sick-looking woman in a wheelchair in the hallway. She is twisted in the chair, almost like severe CP, her head turned to one side like torticollis, her eyes rolled upward and a huge gash tearing into the muscles of her right foot. “This woman has been in a motorcycle accident,” someone tells me. But no one can tell me if she was on the motorcycle, or hit by it. And why is she rigid and twisted? Does she have a CNS injury?

We move her quickly into the other bed in triage. She is supposed to be 8 months pregnant, but her belly looks small. Her attendants tell us that she started having fever and convulsions at home, so they put her on a motorbike to come here, but she seized while on it and fell off. I try to get her blood pressure, but I can’t with the rigidity. She seems to still be seizing, so Liz gives her an injection of diazepam. We put in an IV and hang glucose, as she is severely diaphoretic with cold extremities. She softens a little but is still unconscious and twisted. I test her pupils; at first they seem fixed and dilated, but then we manage to elicit a tiny amount of constriction.

I check on the woman with the transfusion reaction again. She is slightly calmer, and the hives on her face have improved a little, but are still present everywhere else. I can’t tell if she is wheezing because she moans a little with each breath. One of her attendants, an old man with a large suit jacket and a fedora, tries to ask me questions in Runyankole, but I can’t understand.

We turn back to the woman from the motorcycle accident. We cannot hear a fetal heartbeat with the fetoscope, nor with a stethoscope (my kingdom for an ultrasound…). We try her blood pressure again, and I get a systolic of 110, but can’t get a diastolic. Joseph and I try several times, but it’s the same reading. It is a hard maneuver, because she is still twisted and trying to flex her arm.

We make plans for both women –labs when possible, antimalarials, ultrasound and monitoring. Liz draws a smear for the motorcycle accident patient. They are both as stable as we can get them right now. We leave the ward for dinner.

When I come back at 9:30p, I head to triage to see both patients. The bed on the left, where the motorcycle accident patient was, is empty. I had just seen Liz and Gerald, and they had no updates, so where could she be? I checked antepartum but no one there looked that sick. The ICU? No, they are reluctant to take patients who are not postoperative. And besides, the interns would have known. I find Sister Judith, one of the nurses, who says “I don’t know of her. There has just been a maternal death. Maybe it is her?” We ask the midwife, who is busy clamping the cord of a baby she has just delivered. They talk in Runyankole. Finally Sister Judith turns to me: “It is her. She has died.” She died at 8:30p.

I check on the other patient, who is still in triage. She is calm now, sleeping soundly. Her hives are almost entirely gone. Her face is smooth, and not swollen. She is not wheezing. Her family is still crowded around her, but slightly less anxious now. At the time, I thought she was close to death, but she has come through.

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