Friday, February 26, 2010

"Why Did She Do This"

The midwives have a few patients they would like me to review, and one of them, they say, “has a retained placenta.” After a delivery, the placenta should detach within about 30 minutes. On occasion, it does not, and this can lead to infection and excessive bleeding. In the hospital, we actually reach in and pull the placenta out manually, and if that doesn’t work, then we do a D&C. But when women deliver at home and this happens, they have to come to a health center, but often in countries like this, they die at home.

The midwife points out the patient. She does not look like she recently delivered a full term infant. She is skinny as a rail, wearing a tight, fashionable ankle-length skirt with a cute fitted top and I can see no bulge on her abdomen. There are 2 male family members accompanying the patient.

“They are saying that the fetus came out, but the placenta didn’t come. They say she was three months pregnant.”

Now the picture is a little clearer. She had a miscarriage, not a delivery. That would explain the lack of a visible bulge. But something doesn’t make sense.

“If she was three months pregnant, they shouldn’t have seen much of a fetus. How do they know the fetus came out?”

At three months, the products of conception usually look like a big mush after a miscarriage. The midwife agrees that this is strange, and re-interviews them.

“They are saying they saw it,” she says.

“How big was it?” I say. Maybe she thought she was three months, but she was really in second trimester. In second trimester, you do see a fetus separate from the placenta, and can identify each. The midwife translates.

“They don’t know how big it was, but they say they saw it and the placenta is still inside.”

OK, whatever. I go to examine the patient. Her face shows a mix of fear and something else. Sadness? Apprehension? But the women are often intimidated when they come to the hospital. Luckily, she speaks English. I ask her about the bleeding, which sounds like it was quite heavy.

I notice there is blood on the bottom of her feet. In residency, one of my attendings taught me the blood-on-the-bottom-of-the-feet sign. Women often come and say bleeding was “heavy,” but many women have never seen truly heavy bleeding, and think that a normal period is “heavy.” But when you see blood on the bottom of their feet, that’s when you know it was a serious hemorrhage.

I want to look for her chart, so I ask for her name. The two men tell me her given name. We ask for her family name. They look at each other confusedly, then, stuttering, give us a family name. Why is this so difficult? The midwives ask their relationship to her. One is the husband. Why would a husband not know his wife's name?

I go back to the patient to try to elicit the story from her, because I am guessing that she will be a better historian than the men, who are probably just freaked out. She doesn’t fully answer my questions, though. I am trying to ask when the bleeding started in relation to the pain, when the bleeding became excessively heavy, and when it became lighter. Her answers are vague non-answers. This is weird, because typically women are acutely aware of the onset of pain and bleeding in these situations.

The medical student and the nurse are trying to help me elicit the information. I know I need to get the ultrasound to see what is inside her uterus, but it would be helpful to have a history first. Then, suddenly, she tells us the truth.

“A woman came to the house. She removed it. But the bleeding was there.”

“Who was the woman?” I ask.

“A nurse,” she says.

“When did she come?”

“Last night.”

“When did the bleeding start?”


“You have been bleeding since then?”


Now I understand why the husband’s story didn’t make any sense, why the girl was being vague, and why she has that look on her face. I want to reassure her that it’s ok, that I don’t care, and that she doesn’t have to fear what she has just told me. I don’t want to be totally open about it in front of the midwife (just in case), but I know I should say something.

“It is ok. I am glad you told me the truth. You don’t have to worry. We are going to help you, and it will be fine.”

Her expression doesn’t change much, but she nods. Illegal abortions are done by all kinds of random people. Some are medically trained, some are completely non-medical, and some are people who work in hospitals and maybe have observed a D&C and so they think they know what they are doing. They stick instruments, sharp sticks, cassava stems or whatever they can find into the cervix. They don’t know the anatomy of the pelvis, and have no idea what to actually do and what not to do. Women can end up with life-threatening infections, or hemorrhage, and often have a perforated uterus – a puncture in the uterine wall from an instrument or stick jammed in with force. A small perforation might be inconsequential, but these are rarely small, and rarely sterile. Bowel can be injured if the stick goes too far. The more advanced the pregnancy, the thinner the uterine wall, and the higher likelihood and danger of a perforation.

It’s hard to know why this girl is bleeding so much. It could be that the procedure was incomplete, but it also could be that she has a perforation. I check her vital signs. Her blood pressure and temperature are normal, and her pulse is on the higher side of normal, which is ok since she is probably terrified and has been bleeding. She doesn’t seem to be septic. Her abdomen is not particularly tender. I do a pelvic exam, and find blood clots and an open cervix with more blood inside. She will probably need a D&C, but I need to make sure first that she doesn’t have a perforation.

As I am listening to her heart with a stethoscope, I hear the medical student asking her something. I take the stethoscope off and ask what he said.

“She says she is married, so I asked her why did she do this if she is married.”

“We don’t ask that,” I say, tersely. He picks up on my tone, and complies.

Later, I explain to him – with the midwife listening – why I cut him off. I tell him that women are desperate, and many will risk their lives to have an abortion. Once they come in having had one, there is no point in asking why, or making her feel bad. We are here to treat and help. I see the midwife nodding next to me. The medical student understands what I am saying, and agrees. I tell them that abortion is legal in the US, and women who are considering it can openly discuss it with a doctor, and receive counseling. Sometimes they choose to do it, sometimes they choose not to. But the abortion rate is much lower in the US, and it’s not a coincidence.

“That is good, the women can discuss” says the midwife. “And also women in your country are allowed to choose family planning?”

That too – American women don’t need their husband’s permission to use contraception. (There is no rule in Uganda that women need their husbands permission, but it is a cultural norm – so much so that a woman requesting contraception is nearly always asked what her husband wants. A woman who wants a tubal ligation is prompted to have her husband sign the consent form, but it doesn’t seem to matter if she signs. I always insist that she sign.)

I bring the ultrasound from the clinic. I see that her uterus is hugely filled with clotted blood, but there is no fluid in the abdomen or pelvis, and the uterus looks intact. A perforation seems unlikely.

So now she needs a D&C, but there is a problem: no power. Without hospital power, we can’t do the D&C. Another alternative is Misoprostol, the wonder drug. It’s the same drug that is used for induction, and it is also great for postpartum hemorrhage and as an alternative to D&C. She doesn’t seem infected, so we have time for the Misoprostol to work.

I haven’t been using Miso as a D&C alternative, because the patients have to buy it, and they are wildly overcharged. The medicine itself should cost pennies, but at one pharmacy, they pay USh 10,000 ($5) per pill. For this indication, I would need 3-4 pills, which is a huge amount of money for most patients here. I recently found out that there is another pharmacy that charges only USh 3000 ($1.50). This is more reasonable, although still many times the actual cost. In this situation, we have no choice because we can’t do the D&C. This patient is lucky that she is here with male family members. Men usually have the money, and can go and buy the medicine. When women come with other women as attendants (more typical), they usually have little or no money.

We send the men to the pharmacy. When I return to Labor Ward, the medical student is putting the pills in vaginally. Misoprostol is a versatile drug – the same pill can be taken orally (swallowed), buccally (sucked on until it dissolves), dissolved in water for drinking, vaginally or rectally. In this situation, I would have preferred that she take it buccally, since she is bleeding vaginally and this can make the pills come out. But what is done is done, so hopefully it will work out fine.

The next day, the patient is dressed in another cute outfit – she has style that would fly in New York. She looks calmer and relieved. She had some increased bleeding overnight after the pills were inserted, but now it has completely stopped and there is no pain. I bring over the ultrasound, and see that the uterus is now empty.

I ask the midwife to send her home, and she handles the paperwork for me while I dash to see other patients. Before I go, I tell the patient where to go for family planning and problems “like this” in the future, just in case. I hope she doesn’t need another abortion, but if she does, I hope she listens to me and chooses a safer place.

Thursday, February 25, 2010

Kidney Failure, Update

An update on the little boy with kidney failure.

It turned out that the hospital did not have IV steroids available, and I knew the mother would not be able to buy any, so I got some steroid pills (prednosolone) from our clinic and gave it to her. I told her to give two pills in the morning and two pills at night. When we have the family member administer the medication, it is much more reliable than the overtaxed nurses who have too many patients to care for.

I went back to see the boy every day. He stopped crying when I arrived, and it worried me because I thought it indicated he was weaker. He was looking more and more swollen – his head was now hugely swollen with fluid, his eyes so puffy they were almost swollen shut. The urine continued to drain well, and the scrotum actually became much smaller, to about the size of an orange.

One of the ongoing problems was the mother’s poverty. She had no money for food. She had no change of clothing for herself or the boy. She didn’t even have clean sheets – the two she was using were dirty, and she had nothing to use while she cleaned them. She had no family with her, and no one had come to check on her from her village.

Then two days ago, I went to visit him, expecting a frown or a whimper on my arrival. The mother was sitting nearby with some other ward patients, who were generously sharing their food with her. I walked up to the boy’s bed, and to my surprise, he looked at me and smiled. It was possibly the best smile I had ever seen. I held out my hand, and he shook it. I couldn’t believe it – he was finally used to me. I pulled out my stethoscope, and he reached up and pulled his sheet off his chest, knowing I would be listening to his heart. I was so moved by that, it was nearly overwhelming.

His heartbeat was no longer fast, and apart from the swelling, he looked ok. But the swelling was so bad and made me very sad for this poor little boy. A man who was among the people sharing food with the mother came over to help translate. I explained the situation. The mother repeated her sorrows – no money, no food, she wants to go home to raise money. I explained again – the man translated – that her son could die if he goes home. I had bought her a large sheet that I cut in half to make two sheets. I gave them to her, and had the man tell her that they were donated from some nice people in our clinic. (I don’t want to create the image of mzungus throwing around money, but I couldn’t bear to see the little boy lying in dirty sheets). She was very grateful for the sheets. I reminded the nurses to give him the Lasix, and confirmed that he was getting the steroids.

His labs finally came back, and they were surprisingly uninteresting. He was moderately anemic, but everyone is here. His creatinine was just slightly elevated for his age. His blood urea nitrogen was also a little elevated, but not remarkably so. I took some urine from his urine bag, and had it analyzed. It had a lot of protein in it, and some triple phosphate crystals.

I started putting together a differential diagnosis. It seemed very likely that he had a nephrotic syndrome that is not uncommon in children. The kidneys themselves are functioning, but they allow protein to spill abundantly into the urine. That protein is sifted from the bloodstream into the urine. Because of the lack of protein in the blood, the water component in the blood filters through the capillaries, and causes anasarca (fluid in the skin) and ascites (fluid in the abdomen). It is treated with steroids, and with adequate care, children usually make a full recovery. The question is, what kind of “adequate” care does he need to survive this?

The next day, the boy was lying in bed, between the sheets I had bought. He shook my hand and exposed his chest and belly helpfully when I needed to examine him. His swelling was still severe. A woman on the ward translated for the mother, who again described her situation. She begged to be able to go home. I asked if she could go and come in one day – and possibly leave the boy behind in someone else’s care? No – she lived far away, and would need several days at home to raise money to be able to come back. I explained that I felt badly, but I couldn’t tell her to take him home, because he could die. The woman translating understood the gravity of the situation, and explained it to the mother.

Every day that I saw the boy, I held my breath, hoping that that day, the steroids had started working. Today, I went to the ward to see him, and his bed was empty. Other mothers told me that they had seen the mother take him home a few minutes earlier – she left on a motorcycle.

I don’t know what will happen to him. I don’t know if he will survive the time at home, and whether she will ever bring him back. I have had other patients in Antenatal clinic who were very sick, and they left for “a few days” and never came back.

Sunday, February 21, 2010

Cesar No Power

I arrive on the Labor Ward one day and there is a lady I recognize. She is light-skinned for a Ugandan, and she is tiny; she looks like she’s 12 years old, minus the hugely pregnant belly and the developed breasts. I remember that I had promised to do her cesar.

She hands me her card, and I remember more detail. I had seen her a month or two ago, and confirmed her gestational age. She had three deliveries before, and two were cesareans. Only one of the children is still alive. Because of the two cesareans, she needs another one in this pregnancy. I had scheduled her to come back at full term.

By my calculation, she is between 38 and 39 weeks. Typically, we do elective cesareans at 39 weeks, but given the haziness of the dating here, the difficulty that most patients have reaching the hospital, and the likelihood of disaster if she goes into labor at home, better to do it when we can. Unfortunately, we can’t do it today. It’s Tuesday, and the power has been off since Sunday. The power was cut off because the hospital couldn’t pay the power bill, and we don’t know when it will come back. I tell the midwives to admit her, and we will wait until we can do the cesar.

I plan to meet with the hospital administrator. I call him to see if he is around.
“How are you?” I say. (It’s a required exchange at the beginning of a call, even before you know who you are talking to. The universal answer is “fine.”)
“Not very well,” he says, “The power has been cut for nonpayment. The situation is very bad.”
I sympathize. He tells me that they are worried about the vaccines that need refrigeration, and was hoping to ask the various study centers in the hospital (there are 2 others, and all have generators) if the hospital can store some materials with them. I assure him that we will make some room for the hospital vaccines. I ask him to take an inventory of what he needs, and I will look for space.

I meet with the head of our lab, and he makes space in our fridge. Later as I am on Labor Ward again, I get a call that the hospital administrator has come to the clinic looking for me. I rush back, and he tells me that the most urgent thing right now is the blood for transfusion. I tell him we are happy to store it. The head of the hospital lab brings over 2 coolers filled with packs of blood, and they all fit. We also find room in the pharmacy fridge for hospital vaccines.

We discuss the power issue, and it is not sounding good. The hospital has a generator, but there is no fuel for it because of the money problem. And the generator would not last long even if there was fuel. I tell him that I have a cesar patient who is stable, but who will need the cesar urgently if she goes into labor, and she is too poor to refer. He is very concerned, and tells me that if I need, he will find some way to get fuel for the generator. I thank him and assure him that we are ok for now.

The next day, there is power in the morning, by some miracle. It seems that the hospital was able to obtain some money to pay half the bill, and the power company agreed to give the hospital power for 24 hours while the money came through.

I am passing through the Antenatal Ward, and I see my cesar patient. I wave and she smiles and waves back. She looks well, and I will come and check on her in a few minutes. I spend 10 minutes on Peds Ward seeing the child with kidney problems, and then I pass back through Antenatal Ward. Suddenly, the patient looks terrible. She is very pale, sweating, moaning, keeping her eyes closed and only minimally responding to me. The other women on the ward are starting to close around her. What is going on?? Is she rupturing her uterus?

One woman tells me that the patient is having contractions, but another woman insists it is chest pain. The patient doesn’t speak English, and only opens her eyes when I force her to respond to me. She looks terrible. Her pulse seems a little high, but not remarkably so. I palpate her uterus, but it doesn’t seem tender, which you would expect if she were rupturing the uterine scar. She seems to moan in 2-3 minute intervals. Seems like labor. I call a midwife over, and ask her to resuscitate. If she is going into labor, we need to do the cesar NOW. The nurse goes to get IV fluid, and I dash over to theatre to get them to do the cesar, since we have power. They need 1 hour to prepare and sterilize everything. An hour is about as urgent as it gets here, so I agree.

Ten minutes later, the power goes out. NOOO! I must do the cesar. I can use a head lamp if necessary, but I have to do it. I race to the administrator’s office. He greets me warmly and tells me that things are still not good. I explain the situation and he is very concerned. He tells me that he has obtained some fuel for the generator since we spoke, and he asks how much time I need. I have a headlamp, so I can use that for the easy parts of the surgery, but it would be good to have adequate lighting for the harder parts – getting in, getting the baby out, and closing the uterus. I tell him I need an hour at most. “That is fine. Let us help this poor patient,” he says.

We decide that I will call the person in charge of the generator immediately before we need it, in order to have it switched on. I dash over to theatre to tell them to prepare the OR. I have heard rumors from the midwives that there might be no sterile instruments or no sterile drapes. When I arrive, the theatre nurse says that there are instruments, and that she will look for drapes.

I race back to the Labor Ward, where the midwife tells me that the anesthetist has just arrived, and has said that we can’t do the surgery for lack of drapes. He recommended referral. I don’t understand – it seemed like the theatre nurse could find some.

I race back to theatre to try to find the anesthetist. He is not there, and neither is the theatre nurse, but I fine the theatre tech, a young man. He says the instruments are sterile, but that just before the sterilizing machine for the drapes was to be turned on, the power went out. There are no sterile drapes or gauze.

For crying out loud. Is this for real? Am I going to have to send away a poor, contracting, possibly rupturing patient because there are no freaking sterile drapes? I have an anesthetist, I have a headlamp, I am a surgeon, I have instruments, I have everything. Drapes?

I rack my brain to think of ways to adapt. I grill the theatre tech about whether there might be sterile drapes hidden anywhere. He opens all of the sterile drums and they are empty. Do I really need drapes? Can I do it without the drapes? But that would mean no gown – that’s really dangerous for me. Also, no gauze to wipe with. How could I see anything through the blood?

Ugh. Think, think, think. There has to be a way. The overriding theme in residency was “Make it Happen.” No matter what the task was, you had to get it done. It took a lot of effort, with uncooperative and surly ancillary staff, satanic ER attendings, and sometimes less than ideal availability of resources. If you didn’t push hard, you would never get adequate care for your patients. Here, the people are a lot nicer and more cooperative, but there are no resources.

Finally, I am at a loss. I can’t believe it, but I might have to admit failure. That feeling comes back to me – the one I had when I allowed them to refer the bleeding placenta previa. A pit in my stomach full of guilt, rage, sorrow, horror, injustice.

I trudge back to Labor Ward, hoping for some kind of inspiration or deus ex machina. When I approach the patient, I notice immediately that she looks much better. Her eyes are open, she is calm, not sweaty, and appears to be in no pain. She has a bottle of IV fluid hanging. I ask how she feels, and she says the pain has gone aside from some slight backache. Using her neighbor as a translator, I tell her that if she is in labor, we need to refer her to St. Anthony, because she will need a cesar. “She says she has no money, and the pain is gone. She will stay.”

I am surprised to find she is so much better, but I also know that IV fluid can do that. I tell the patient that she should not eat this afternoon, in case the power comes back and we can do the cesar. The neighbor translates “She says she has not eaten or had any drink in two days. She is very hungry.” I almost laugh out loud. No wonder she was so dehydrated. She must have starved herself in anticipation of the cesar, even though we told her there was no power. When a pregnant woman is very dehydrated, a hormone is released that mimics oxytocin – the hormone that causes contractions. This can cause a very believable false labor, but usually the patient’s cervix does not open. That’s probably what happened.

I tell her not to eat until 6pm, just in case. If we haven’t done the cesar by then, she can eat, but she should fast after midnight. Power comes back at 4, but the theatre staff has already gone, so I let her eat and we decide to do it tomorrow. She wants her tubes tied, and her husband has finally arrived, so I have the midwife help me consent them for the cesarean and tubal ligation. Even though this will only be their second living child, they both feel strongly that she should not have any more cesars.

The next day, I plan to do the cesar at 9am, which is the earliest I can agree to get anyone to arrive. At 9am, I can’t find anyone. I keep hearing the theatre staff is around, but they are not in theatre. The night midwives have not yet been relieved by the day shift. It takes until 10am to get everything together. I am holding my breath, hoping the power won’t go out before we get to do the cesar. I confirm that there are instruments and drapes. I will use my headlamp if I need to, but I will do this cesar.

When I see the patient, I see that she is contracting for real. It doesn’t stop with IV fluid. She cries out in pain with every contraction. We move her to the OR, and we reaffirm the tubal ligation. The cesar is tough. She has a prior vertical skin incision, which I hate, but I use it because it’s better to use the old scar. There are many adhesions everywhere. My assistant is a very inexperienced and overconfident Ugandan medical student, who has never done an OB rotation before and cannot do an adequate pelvic exam, but frequently professes to know what he is doing. (This is atypical from my experiencee – in Mbarara, I was very impressed with the knowledge and competence of the medical students. Their exams were extremely challenging, and they were expected to know information on a resident level, and to work independently, for better or worse.)

When I get to the uterus, it is largely covered by the bladder and scarring. I can’t differentiate bladder from adhesion, and I need to move the bladder away so I can incise the uterus. The medical student keeps pointing at the scarred mess and insisting it’s bladder. He doesn’t seem to appreciate the significance of that being bladder (ie. you can’t cut it), nor does he consider that it might be more complicated than he thinks if I am not sure. At first, I ignore him, then I chastise him. There are few things more dangerous than an overconfident medical student.

I identify the bladder, and am able to dissect some of it off. Eventually, the uterus opens up, and I am forced to enlarge the opening and deliver the baby. It’s tough, but the baby comes out and is fine. Now I have the problem of closing the uterus when the bladder is nearby. The overconfident medical student keeps pointing out bleeding areas and wanting to clamp them. Unfortunately, they are on the bladder, and can’t be clamped willy-nilly. I keep trying to explain that to him, and I ask him to hold the uterus or assist me (as he is supposed to) but he keeps dropping what he should be holding to point out bleeding that I already know about and insist on clamping the bladder. I want to smack him. I let my voice get just annoyed enough to shut him up. It works for about 15 seconds.

I close the uterus, and do the tubal ligation. I have to physically restrain the medical student from poking the engorged blood vessels around the tube with idiotic abandon. “I wasn’t poking,” he says. I consider throwing him out of the OR, but I need someone to retract, and he is wearing the only other gown.

I finish the cesarean, but the blood loss has been high. She looks pale, and I ask the anesthetist to give her a lot of IV fluid (they usually give way too little). Her heart rate and blood pressure are ok. I will check on her later to see if she needs a transfusion.

In the evening, she seems to be doing well. Still pale, but I will check the level in the morning. Power in the hospital is still on, and this lady is lucky it came back when it did.

Friday, February 19, 2010

Abdominal Pregnancy

A midwife asks me to review a patient.

“She had ultrasound scan, and it shows abdominal pregnancy,” she tells me.
“Abdominal pregnancy? But that is so rare. It can’t be,” I say.
“That is what they have said. But I want you to review.”

An abdominal pregnancy is a type of ectopic pregnancy, but rather than implanting in the fallopian tube or the ovary, the pregnancy implants somewhere in the abdomen. Because the pregnancy size is not limited by a tube or capsule, it can grow quite large before it is diagnosed, into second or even third trimester. However, the blood flow to the placenta is poor, and most untreated abdominal pregnancies end in a fetal demise.

I see the patient. She looks calm and healthy. There is a bulge in her thin abdomen that looks like a second-trimester pregnancy, and it is somewhat tender. I learn that she is 37 years old, and has 5 children. She has been having pain for a while, maybe weeks. I see the ultrasound report, and it does indicate abdominal pregnancy. But could this really be one? They are so, so rare. There was one such case during my residency, and I didn’t manage the patient, but I heard about it.

I go and get the ultrasound from the clinic and repeat the scan. Immediately, I see her uterus, and it is empty. I scan higher in her abdomen, and I find a huge mass. It is dense, solid, and varies between white and grey color. It looks more like an abdominal mass than a pregnancy. I see a small area that has a glow of white that could be bone, but no definitive pregnancy.

I ask if she had a pregnancy test. A midwife helps me to translate, but before I get an answer to my question, she wants to tell me that she has pain, and all about her other complaints. I make a mental note of the symptoms she has told me, and then I ask again about the urine pregnancy test.

I am curious about the pregnancy test because it is possible that she could have a certain kind of ovarian tumor (dermoid cyst) that can be dense, large, and can have pieces of bone, teeth or hair inside. It could be confused with a pregnancy if the ultrasonographer is inexperienced. I also wonder if she has some kind of embryonic tumor or sarcoma that could look like a pregnancy, because I am really seeing a big solid mass.

She says that she did have a urine pregnancy test yesterday, and it was positive. While some tumors can secrete HCG (the hormone that is tested in the urine to detect pregnancy), they are rare. Then again, so is abdominal pregnancy.

I keep scanning, and I go even higher on the mass. Then I see a glimmer of what might be a pregnancy. I focus on it, and I see what looks like a fetal skull. It’s hard to see, but it does look quite distinctively like a skull. It measures to a 17-week size. I also see some sort of long bone, maybe a femur. Because it is surrounded by dense material and not fluid, it is much harder to tell what I am looking at.

I re-read the prior ultrasound report. They report a fetal skull, and fetal spine. They interpret it as a degenerating abdominal pregnancy. There is not fetal heartbeat. I can’t find a spine anywhere. My best guess is that this is a degenerating abdominal pregnancy surrounded by a large amount of clotted blood, but I also keep ovarian tumor within my differential diagnosis.

Now, what to do? The management of abdominal pregnancy is clear – surgical removal. However, it can be extremely difficult and extremely dangerous. The placenta could have implanted anywhere – on intestine, on liver, on blood vessels, on uterus, on any intraabdominal organ. If it implants on the uterus, that’s easy – you do a hysterectomy. But if it implants on a vital organ, it can be very dangerous, and if it implants on a blood vessel, then removing it could cause major hemorrhage. Oy vey.

When we had that abdominal pregnancy in residency, it was a big hullaballoo. The patient was transferred to our larger hospital, the entire Gynecologic Oncology team was involved, there were multiple people (attendings, residents, fellows, anesthesiologists) in the room. The patient had invasive monitoring, large-bore IVs placed, blood and blood products available in case of hemorrhage, cautery and all kinds of intensive care. She might have even had preoperative embolization of the pregnancy in order to reduce the intraoperative bleeding. I have me. Ta-da.

At the moment, the hospital doesn’t even have power. The power bill hasn’t been paid in a while, and the power company shut it off. There was an emergency action taken, and the hospital administration managed to get 24 hours of power while scrounging up money for the bill, and there was power in the morning. But then, the power went out for the whole neighborhood (a regular occurrence here for load shedding). Sigh.

Luckily, the patient is stable. She is somewhat tender, but doesn’t seem to be actively bleeding. One option is to transfer her. We could send her to Mbale (where there is a regional hospital) or Kampala. But “transfer” means “tell her to go” – which means she has to pay to get herself there. Once there, who knows what will happen. She might have to pay for all her medications, or other supplies. She might encounter someone who will require a bribe to admit her or treat her or perform surgery. I ask the Ugandan medical students working with me whether this is the case, and they say “Well, this is Uganda. These things happen. Yes, probably this will happen.” I can’t say my own country’s system is a whole lot better - we treat you, but then you go bankrupt. I suppose it’s like a bribe after the fact. But at least you will get emergency care.

I discuss the options with the patient. She can be referred, or she can be admitted here and wait for the power to come on. I tell her that her care will be free, but there is less supply here – like available blood and intensive care - that she might need in an emergency. She very firmly states that she will not be referred. She will stay and wait for the power. “She cannot afford to go,” says the medical student who is translating.

I am nervous about this. There is a good chance that this could be surgically very complicated and very, very dangerous. I have never operated on anyone with an abdominal pregnancy. I could probably adapt some of what I have learned, but what if I get into real trouble in the OR? Who would I call? There is no one in Tororo with specialist training. Many of the medical officers have had to operate, so I suppose I could call them. I don’t even know if the cautery in the OR works, and cautery is essential. She could bleed like stink. What if I need blood? I will have to cross match at least 4 units. What if she dies on the table? That would be horrible, horrible. But then….what are my other options? I could force her to go to Mbale – but that’s no better. I’d be sending her to be operated on by someone with probably a 1-year internship, not a specialist. And she might not even get the care if she doesn’t have the money. I would have no certainty that she would be operated on. How could I sleep knowing that I had abandoned the patient like that?

I take a deep breath, and think for a while. I decide to do the case. I will tread lightly. If I get into hot water, I will stop the bleeding and close. I will read up on surgical management of abdominal pregnancy. What else can I do? She could die in the OR, but if I don’t do this, she will die.

We admit her to the Female Surgical ward. I have another operation I need to do as well, so I do a lot of running around to the hospital administrator to see if and when the power will be switched back on, and what my options are. It sounds like there will be power tomorrow.

I check on her in the evening, and she is doing OK. I realize, however, that she is very pale. She has already been cross-matched for blood, so I go to the lab and ask my friend in the lab to check a hemoglobin level. It is 5.3. In the US, this would be insanely low. We would freak out, and transfuse the patient in double time. Here, it is not low enough to warrant transfusion. The hemoglobin needs to be less than 5 (or sometimes even lower) for a transfusion to be indicated. Her heart rate is not elevated, and she is asymptomatic. Of course, we are about to do a huge surgery, so she will likely need blood. At home, sometimes we will preoperatively transfuse the patient, but here blood is so scarce (in fact, it is taken from schoolchildren because of the high risk of HIV in adults, and when school is out, there is no blood to be found). In addition, who knows if the operation will actually happen tomorrow. There might be no power, of who knows what might happen. And lastly, I imagine I would have to argue hard with the lab and the nurses to even get a preoperative transfusion. I decide not to transfuse preoperatively, but I do confirm the cross-match. Luckily, there happens to be a lot of blood in her type available, so even if I need more units, they are there.

The next day, the patient is still doing fine. Since she can’t speak English, I need a nurse to help me translate the consent. She has already given “consent” by signing the form, but I doubt anyone told her the procedure I would be doing, much less that we might remove her uterus and/or tubes and/or ovaries, and that there is a high risk of death.

I go to Female Surgical Ward three times over the course of the morning, but never find a nurse. It gets very frustrating. The patient’s attendant claims to speak English, but when I ask her to translate, she has no idea what I’m saying. I give up.

We schedule the case for 2pm. When the patient is in the waiting area, I bring over a medical student who can translate. Before I can speak, she says something. “She wants a tubal ligation,” translates the medical student. That makes me chuckle a little, since I am about to tell her she might lose all her pelvic organs.

I am very forthright with her. I tell her that I might remove the uterus/tubes/ovaries, I might damage the intestine, other organs. I tell her that there is a risk she could die in the surgery. When I say this, the medical student stops before translating. “I should tell her that?” he asks, stunned. “Yes, she needs to know,” I tell him. He translates, and then I go on to say that I will take every precaution to save her life, including transfusion and anything else we need to do. “She says thank you,” says the medical student. The patient is smiling and takes my hand.

I go to make preparations for the surgery. I pull out all the sutures I might want. I ask the medical student to put in a second IV line. I confirm that the blood is in the OR for transfusion if needed.

A few months ago, a visiting resident bought 2 c-section kits with donated money. I have never seen these nice instruments – I haven’t bothered to fight for them to be used. But now, I will need them. The anesthetist shows me where they are hidden, and they are a glittering treasure trove in my eyes. “We don’t take them out because they will have legs,” he says. But what’s the difference if someone steals them or you never use them? You still have no new instruments.

I pull out all the clamps and forceps and retractors a girl could ever want. I am in heaven. I give them to the OR tech for autoclaving.

Dr. W, one of the hospital doctors, has volunteered to scrub with me and assist in the surgery. I am glad to have a second set of eyes, although cautious because I have never met him. I hope he doesn’t give me flack for being young or female, or that he doesn’t assume I don’t know anything about medicine. As it turns out, I was glad he scrubbed with me. I told him my intraoperative plan as we waited for the OR to be ready – 2 large-bore IVs, blood available, vertical skin incision, remove what is possible, remove pelvic organs if needed, and leave placenta if it is implanted on something vascular or vital. He agrees.

We start the case. I make a vertical incision, but we end up extending it more generously to the side of the umbilicus. It looks like there is blood beneath the peritoneum, and as we open it, old dark blood gushes out. We suction that up (no wonder her hemoglobin was so low – it was all in her abdomen). We can’t see much, so I reach my hand in. I feel a couple of globular structures in the pelvis that I can’t identify. Higher up, I feel fetal parts. I pull out the fetus. It’s dead, and looks about 17 weeks in size.

Then we see a gleaming white structure in the pelvis. “What is that?” we ask each other. We decide it’s uterus. I try to pull it up, but it seems stuck. Dr. W tries to pull it up, and it frees a bit and comes toward the surface. Suddenly, we realize it is placenta. Whoa. I realize that there is something around it – some kind of membrane or tissue. It’s uterus! Whoa. It’s hard to see, but it looks like the uterus probably ruptured posteriorly or in the fundus, and the placenta is coming through. Maybe she had an illegal abortion, and the person perforated the uterus? Whoa.

If the uterus is ruptured (and it seems like a big hole), we need to do a hysterectomy. I reach in to pull the whole uterus up, and I pull it out. To our surprise, the whole thing is placenta – it comes out, and one portion of it is still attached. We can see an intact uterus below it. Now we realize that the uterus is not ruptured or perforated – what we thought was uterine muscle was actually membrane and adnexal tissue on the right side. We delineate the attachment and realize that the placenta has implanted on the outer side of the adnexa (which is the ovary and the tube, plus the mesosalpinx, a membranous tissue attaches the two). WHOA.

I am still marveling over the insanity of this case when Dr. W breaks me out of my shock. “We are finished. We remove the whole thing, and we are done.” True. We can remove the entire adnexa. She will still have the ovary on the left side. If we detach the placenta but leave the adnexa, then the placental attachment site could bleed. After carefully assessing our location and surrounding structures, we clamp off the adnexa, cut and tie it so that it does bleed. Easy as pie.

Then we evaluate the other side. She wants a tubal ligation, so we could take just a piece of tube. But the tube has some adhesions and is already looking oozy. Taking just a piece could allow the rest of it to continue bleeding. We remove it, and leave only the ovary. The uterus is fine, and we leave it in place.

There is still a lot of blood in the abdomen. Dr. W seems ready to close, but I insist on suctioning it out, and irrigating. Blood in the abdomen can be very irritating, increase postoperative pain, and sometimes temporarily paralyze the gut so the patient has trouble eating for a few days. We get it all out, and I check all of our operative sites.

As we close, Dr. W lets me use the sutures and the technique I like. I insist on my subcuticular closure, and make jokes about how the incision is the only part that the patient sees. He laughs and agrees; he says he doesn’t mind doing the subcuticular.

After the procedure, I take the specimen to evaluate it. I still can’t figure out what happened. Where was the implantation? Was the pregnancy in the tube? It couldn’t have been – the fetus was floating in the upper abdomen, and a tubal pregnancy would never have grown that big. Did a tubal pregnancy rupture and then re-implant on the outside of the adnexa? Or did the pregnancy implant there from the beginning? I’m still not sure. I find an intact segment of tube, but not the fimbriated end. I also find the ovary, which is intact. The placenta seems to have implanted on the mesosalpinx, below the ovary. Most of it has abrupted off, but there is still a small portion attached. I have a medical student take pictures of the specimen while I display it so that the different elements are visible. Probably too gross for this blog, but pretty amazing.

The patient is in recovery now. She got 1 unit of blood in the OR, but she didn’t lose much. Most of what she lost was already in her abdomen. I write her for some pain medication, and I explain to her family what happened, and that she will be fine. She is a very, very lucky woman. That surgery could have been much worse, could have been fatal. I am incredibly relieved. I know I never would have forgiven myself if she had died on the table, even if I felt like I had no other option.

Wednesday, February 17, 2010

Where is the Pregnancy?

One of the study doctors says to me “There is a mother here I would like you to see. I have told her to wait for you.”

The “mother” is the mother of a child in one of our pediatric studies. According to the study doctor, she had complaints of pain with bleeding, and another of our study doctors had given her some antibiotics (a common theme – antibiotics are like candy here) but she didn’t improve, so they thought she should see me, and that perhaps I should do an ultrasound. No other details are known.

We invite the woman into the room, and although she speaks some English, she doesn’t feel it is strong enough, so the study doctor translates for me.

I ask for a description of the problem.
Her period started two weeks ago, and hasn’t stopped. She is also having a lot of pain, and she doesn’t usually have pain with her periods, so she was concerned.

When was her last period?
She isn’t sure, but they are regular and she hasn’t missed one.

So she had one last month?
Yes, she did.

In which part of the month do her periods usually come?
Toward the end of the month.

So the period that came two weeks ago was at the right time?
Yes, it was, but it hasn’t stopped.

Is she using family planning?
No, she isn’t.

Is she pregnant?
No, she isn’t. She hasn’t missed a period.

When was her last child born?
Two years ago.

Is the bleeding heavy?
No, it is light. Lighter than a usual period, in fact.

Is the pain strong? Which side?
Yes it is strong, but she is able to do her usual activities. It is in the middle.

I decide to do an ultrasound, but while I am getting the machine, I ask the patient to give a urine sample for a pregnancy test.

When I return with the ultrasound machine, the study doctor says, “Her urine pregnancy test is positive.”


“She is surprised, because she doesn’t think she missed a period.”

Lesson number one that all Ob/Gyn interns learn: Always get a pregnancy test.

I palpate her abdomen. She is mildly tender in the center of her lower abdomen, but it is not very impressive. The bleeding could suggest that she is having a miscarriage. But it could also be present in case of an ectopic pregnancy. The classic teaching is that if the bleeding is out of proportion to the pain, then be highly suspicious for ectopic.

I start the ultrasound. Right away, I see her uterus. The uterine lining is thin, and there is no blood or pregnancy inside. Ding. I look around the uterus, and immediately I see a thick-walled circular structure just behind (posterior to) the uterus. Ding. I evaluate the structure more closely, and inside I see a very small yolk sac – the earliest stage of pregnancy development that is visible on ultrasound. Dingdingding. Ectopic pregnancy.

I scan further, and the ectopic seems to be more toward the right side than the left, although it is not certain. Toward the left side, I see a normal ovary, but toward the right, I see only the ectopic. It is usually hard to visualize tubes on ultrasound, but around 98% of ectopic pregnancies are in the tube, so if you see a mass in the adnexa, it is usually a tubal pregnancy.

She needs to go to theatre, but it is after 5 and they will never take her at this hour. She is quite stable, and there is no evidence that the ectopic is ruptured or leaking. I explain the need for surgery, and I offer to let her stay overnight, or come back in the morning. She needs to care for her children, so she will come back in the morning. I call the anesthetist and we agree to do the case at 10am. I tell her to come at 8am. I give her the ultrasound report, and write our plans for surgery, and instructions to admit her to Female Surgical Ward tomorrow. I also write my phone number at the bottom, just in case.

The next day, between 9 and 10, I am looking for the patient. I have been told that she came to clinic looking for me, but left. I go to the Female Surgical Ward, but she is not admitted there. I find her sitting outside, and she says that no one has admitted her yet. I help get her admitted and we discuss the consent. Yesterday, I had told her that one of her tubes probably contained the ectopic and would have to be removed, and I asked if she wants more children (she had 5, but only 3 are living). She said “I am old!” and laughed (she is 34). She stated clearly that she doesn’t want more children and that she wants both tubes cut. Today, she is here with her husband. (In Uganda, usually both the husband and the patient need to consent for a tubal ligation. When I told the midwives that in the US, only the patient needs to consent, one of them said “That is because in America, you are advanced!”) I speak with her and the husband together, and both very clearly agree to cut the tubes.

L, the family medicine resident from the previous case, has agreed to assist me in this one as well. Once the patient is asleep, we make a small incision on her abdomen called a mini-laparotomy. There is just a little blood inside, which actually might be from our incision, it’s hard to tell. I spot her small, normal uterus right away. This is what the other patient was supposed to look like. I follow it to the right, and grasp the right tube with a gentle instrument, looking for the ectopic. I reach the fimbriated end of the tube – no ectopic. Hmm. The ectopic must have been in the left tube,

I drop the right tube and go back to the uterus, following it to the left to find the left tube. I grasp it and pull it up – and again I reach the fimbriated end, but no ectopic. What?? Where is the pregnancy? I can see her left ovary just next to the tube, and it is completely normal. So now there are three options – either the ectopic pregnancy is on her right ovary (ovarian ectopic – very rare), or it is in her abdomen (abdominal ectopic, exceedingly rare but fascinating when it happens), or I was wrong altogether and there’s no ectopic. I think hard about the third possibility – certainly I’m not infallible, but that ultrasound was strongly suggestive of an ectopic. And I saw her uterus very clearly – there was no ambiguity. Still, I would feel terrible if I took her to the OR for no reason.

I go back toward the right side and pull up the tube again. I feel a little resistance to pulling it any higher, and I can’t see the ovary. I put my hand in behind it to free the posterior aspect, and feel some clotted blood. Then I free the ovary and pull it up – and lo and behold, one side of the ovary is covered in ugly ectopic pregnancy and clotted blood. An ovarian ectopic!

I had always heard about these in residency as a theoretical possibility, but I had never seen one. They are problematic, because you can remove a tube easily, but ovaries are needed for hormonal maintenance in premenopaual women. A woman who loses one ovary is usually fine and can be hormonally normal with just one ovary, but still it’s a shame to take out an ovary in a young woman. Ovaries bleed more than tubes – they are highly vascular. They are also very hard to stitch – the tissue is mushy because it’s mostly just ovulatory tissue. So often when you start mucking around with an ovary, you end up needing to remove it just to stop the bleeding.

First, I clear the pregnancy off the surface of the ovary. It is mushy and dark grey. I know I have removed it all when I have only white, smooth tissue left. Unfortunately, that white soft tissue is bleeding, and half the ovary’s capsule is gone with the pregnancy, so I can’t use it to stitch. I tell L, “I’ll try to throw some stitches to stop the bleeding, but if I can’t, we’ll have to remove the ovary.” At this point, the anesthetist and theatre nurse are fascinating. “That’s the ovary?” they ask me several times. They also register my excitement over the fact that the pregnancy is in the ovary itself.

I recently rearranged the entire suture closet for the OR. I really don’t like chromic suture, but it’s all that people use here. I would occasionally find Vicryl – my personal favorite – but the closet was a mess and it was hard to find what I needed. So I spent an hour one day sorting the suture by type – absorbable, non-absorbable, size, type, etc. And I put everything in neat stacks with the non-absorbable suture (like silk and nylon) in the back, because I never need it. I also figured out which generic sutures are similar to Vicryl and Monocryl. My organizational work really paid off, because now I am able to pull out the sutures I want before each case, and I don’t have to use chromic.

For this case, I pulled out a 4-0 Monocryl, intending to use it on the skin. But now I clearly need it for the ovary. Sutures are named for their size and their type. Monocryl is a single-strand synthetic absorbable suture material, whereas Vicryl is a braided synthetic absorbable suture material. There is also chromic, which is catgut (from animals, but not necessarily cats), very versatile but stiff and very slippery. Some people love it; I don’t. Vicryl is strong and is nice to work with because it feels like thread, and isn’t as slippery when wet. Monocryl feels more plastic-y and slippery, but dissolves nicely under the skin and causes very little friction on friable surfaces – like ovaries. The numbering system tells you the size. If the number is written as 1-0, 2-0, 3-0, then the size of the thread gets smaller as the number gets higher. If the number is written as 1, 2, 3, then the thread gets bigger as the number gets higher. so a 4-0 vicryl would be a very small suture, and a 2-vicryl would be a thick suture. A 0-vicryl, which we often use in cesareans, is in the middle, good for stitching uterus and fascia. Plastic surgeons will use sutures as small as 6-0, and once I even saw a 9-0 in the suture closet, which must be practically invisible.

I request the Monocryl, and throw some very, very careful stitches across the bleeding surface of the ovary. Although I have never done an ovarian ectopic, I have discussed it many times in residency as a what-if. In addition, I have been in surgeries – mostly hysterectomies or ovarian cystectomies - in which scarring around the ovaries caused some bleeding, and required delicate repair. From these experiences, I adapt what I know to create stitches that will hopefully stop the bleeding without damaging the ovary too much. To my surprise, it stops bleeding. I tie (and cut) the tubes easily as I had been taught in residency. Then I look back at the ovary, and it is not bleeding. Wow! I am very excited.

We close the incision with another 4-0 monocryl. When we bring the patient back to the ward, I tell the family about the ovarian ectopic and that we tied the tubes, but I’m not sure they understand. The next day, she is looking well, but hasn’t walked or eaten yet. I give her permission to do both. The second postop day, late morning, I go to see her, and she has already been discharged. She had been looking so well that the nurses sent her home. I know she is a mother in our studies, so she will come back.

Today, I am in the clinic when one of the study doctors tells me she is here and wants to see me. I find her in the waiting area. Her English is better than she had let on – the first thing she says is “When will you take out the stitches?” I tell her I won’t – they will dissolve. She smiles broadly and exclaims “Eh!” Most doctors here make huge vertical incisions and use non-absorbable suture to close the wound, which then needs to be removed after 7 days. It’s a painful process and leave scars and ugly keloids. Instead, my subcuticular closure is pretty and heals into a miniscule line. I have been getting many jokes from the midwives about my pretty incisions (and about how they don’t get infected like the big ugly ones).

I bring her inside to examine her. She is still wearing the original bandage. I remove it, and the scar looks great. I have someone explain in her language that there is no need for suture removal, and she is thrilled all over again. I ask how she is doing. The pain is very little, and she is doing well. She is glad she doesn’t have to worry about pregnancy anymore, and her husband is happy about the tubal ligation as well. She thanks me with a warm Ugandan handshake.

Later, she pulls me aside in the hallway, and shows me the original ultrasound report that I had written for her, with my orders for admission and my phone number. She points at the phone number and says (in English) “I want you to give me this one. So that I can call you if I have problems.” I ask her why she can’t keep the form. “Who is keeping this form?” She says she doesn’t know.

In the US, I never gave out my phone or pager number. Here, patients have limited access to a phone, so if they call you, it’s because they really need something. In fact, I’ve never gotten a call from someone at home. Some patients have gotten my number off the sign in Labor Ward and called me with questions while in labor, but they never called me from home after that. And I have given my number to some postop patients, or Antenatal clinic patients, and not one has called me. I am happy to give it out here to the ones who really need it, because I want to do anything I can to increase their access to care.

“The form is yours,” I say. Keep it, and my phone number is there. You can call me if you need.” We shake hands again, and both walk away happy.

Monday, February 15, 2010

Kidney Failure

In the large grassy yards of the hospital, women and children (patients and caretakers, usually) sit outside during the day. Sometimes the children have IV lines in their arm - or in their head, in the case of severe malnutrition in which a vein cannot be located. The presence of the patients outside creates a kind of pleasant social scene, and it's nice that the kids aren't trapped in the depressing cage-like wards all day.

I am walking past the Pediatrics Ward when I notice all of the mothers in the yard outside Peds leap up and sprint toward the window of the Peds Ward. I wonder if something crazy is going on inside - maybe someone has collapsed? - so I walk over to see if I can help. As it turns out, the charts are being handed out before rounds, and the mothers are just collecting them. The nurse who tells me this then says "Doctor, I want you to come and see this child. He is very sick."

I don't know anything about children, and have negative interest. They're cute and all, but Pediatrics was my most painful rotation in medical school. Which is why I am always glad when Pediatricians are around - it means I don't have to do it. (I know most doctors feel that way about Gynecology). I try to defer by saying I am a Women's doctor, but she persists, saying he is very ill. "I'll take a look at him, and maybe I can call the other doctors in my clinic," I say.

She calls the mother over, who comes walking with her little boy, and immediately I see what is wrong. He is 5 years old, and his abdomen is huge with ascites (fluid in the abdomen), his legs are edematous (swollen), and even his eyes are puffy with fluid. He is reaching up to hold his mother's hand as they walk with difficulty across the yard, and as he reaches, his red shirt pulls up above his waist. He is not wearing pants or underwear, and almost gasp when I see his scrotum - it is hugely swollen, to the size of a newborn baby's head. The penis is swollen too, the skin taut.

As the mother walks him inside the door, he realizes that they are walking toward me (the scary mzungu) and he starts to cry. She keeps walking, and then he screams bloody murder. He tries to run, to fight, but she is holding his arm and he lunges toward her leg in fear of me. Of course I am not offended (I'm very used to this), and it's almost funny except that he looks so sick. I feel badly for making him so afraid, but I need to examine him. The nurse chastises him for screaming so wildly, and they pretty much have to drag him into the examination room.

Trapped in the room with me (and his mother and the nurse), he starts to almost lose his mind screaming. He doesn't stop. I decide to review him quickly without touching him and go get the Ugandan doctors I work with, who know much more about kids anyway. I notice that the penis is so swollen that the foreskin, which is swollen to the size of a finger, is constricting around the head of the penis, choking off any possible urination. Ugh. How awful. When I even lift a finger to point at something to ask the nurse, the boy screams even louder. The poor kid is so terrified.

I call Gloria, one of the doctors I work with, and she tells me to have the nurse bring the child to the clinic so they can look at him. By the time I get back to clinic they are already examining him in a room. He is upset but not crying. They are discussing what to do. Most likely, this is some kind of kidney failure, but what kind and why, we don't know. We decide to send off some labs using our Poor Patient Fund, and to attempt diuresis with Lasix. We discuss the constriction of the penis, which is the most pressing issue. He hasn't urinated in 3 days, and unless we can drain his bladder, the Lasix will just cause the kidneys to fill the bladder and he'll be in even more pain.

Victor touches the penis to examine the constriction. The child whimpers and then cries loudly when Victor does this. Victor lets go. I reach out a hand to point at his abdomen (about 3 feet away), and the boy starts to scream his head off until I back out of the room. Fear beats pain.

We need to put in a catheter. We think that a suprapubic catheter - one that goes in the abdomen just above the pubic bone - is the best option. He also needs some kind of incision on the foreskin to protect the penile shaft from constriction. In an adult, we could do this easily with local anesthesia, but a 5-year-old boy will never tolerate this. But how can we give him anesthesia when it looks like his kidneys are failing? What kind of sedative can he metabolize? Will he end up toxic and need a respirator, which doesn't exist here? We need to speak to the anesthetist.

I run off to find the anesthetist. It is about 4pm already. I try to call but his phone is off. He is not in theatre. Someone in theatre tells me he is in the big staff meeting that is happening just next door to our clinic. I tiptoe up to the meeting and ask a nurse I know for the anesthetist. "He is inside," she says.
I creep around to the side of the building, but the side door is locked. I peer through the window, and I see him sitting there, bored and not listening to the meeting. I wave for him to come outside.

Gloria and I explain the situation. He offers to do the case tomorrow. Gloria insists that it needs to be now - this could get rapidly worse, the urine could back up into his kidneys and destroy them even more. Plus, he is in pain. "Ok," he says, "We go. Bring him."

While I dash back to Labor Ward to deal with some patients there who need ultrasound, Gloria and Victor organize getting him to theatre. While I am scanning, I get a call from the anesthetist, telling me that Gloria and Victor have requested that I bring the ultrasound. I race over there.

When I arrive, Gloria and Victor are in scrubs, already operating on the boy. The anesthetist has given him Ketamine for sedation. They attempted to place the catheter suprapubically, but couldn't find the bladder through the incision they made. Now they are trying to free the penile shaft. They have made an incision on the foreskin, and the glans is easily visible. They place the catheter in the urethra, and 100cc of urine drains immediately. We discuss what to do about the foreskin. Removing it is the best thing for him - who knows when this edema will resolve - but is it ok to do a circumcision without express permission? Victor, who had spoken with the mother, knew that she was aware that we would probably be cutting the foreskin, and although we hadn't called it a circumcision, there was no doubt it was medically necessary. We went ahead with it.

I have done hundred of circumcisions in residency, but this is more challenging because the anatomy is distorted by all of the swelling, and because children and adults bleed more than newborns, so often stitching is required, whereas it is almost never needed in newborns. Victor does an excellent job. As we are stitching gently to stop the bleeding, the boy starts to wake up. The anesthetist already gave him more Ketamine earlier, but now he has stepped out of the room and there is none left in the syringe. The boy is still groggy, but he starts to wake more and more, crying out for his mother, then crying out in pain and reaching his hands downward. The nurse holds his arms, and Victor works quickly and skillfully under pressure. We finish before he opens his eyes. Meanwhile, I start dodging out of his line of vision, because if he is crying now, he will really lose it if he sees the scary mzungu standing there.

We call his family in and they come and carry him back to the ward. We explain what we did, but it's hard to know how much they understand.

The next day, I stop by the Peds Ward to see him. He looks a little worse - his feet are even more swollen. He cries loudly again when he sees me, screeching and twisting away from me. I realize he isn't getting the Lasix we wanted. I order a pediatric dose (which Gloria had reviewed for me) and ask the nurse to give it, and she does.

Over the weekend, he misses 1 of the Lasix doses, but does get 3 doses total. When I see him today, Monday, he looks even worse. Now the eye puffiness is gone, but his entire face is swollen. The nurse helps me ask if the mother agrees with my observation, and she does. His legs look the same, and his scrotum is the same or maybe better, I can't tell. His abdomen looks bigger to me. And now, because of the catheter, he stays in bed, not walking around.

The nurse notices the soiled sheets and tells the mother that she needs to change them. (Patients bring their own colored cloths to use as sheets, blankets, cleaning rags, etc. Nothing is provided by the hospital, and patients usually bring a stock of these cloths.) The mother replies that she had only brought 2, and has no one with her to send home for more. No one from her village has come to check on her. Her husband died years ago, so she is alone.

My heart breaks for this child and this woman. Gloria had told me before that the woman noticed symptoms in the boy over the last year, but has been using "herbal medicine" to treat him. It's hard to know when he got this bad, but the whole situation is tragic. I don't know what is causing the kidney failure - some causes are reversible or temporary, but require aggressive care until the problem resolves. Other causes are permanent. Any cause could be deadly for this little boy, who is getting very little care. I look at the woman and the little boy looking up at me. Today, he cried a little when I arrived, but stopped quickly. He lets me listen to his heart and his lungs without a peep. I touch his swollen legs and talk with the nurse for a long time. He doesn't cry at all. This might be a good thing - maybe he is getting used to me. But it could be a very ominous sign - he might be too weak to scream the way he did before. My time in Uganda has taught me that a loud child is a healthy child.

I don't know what else to do right now. There is 200cc of urine in the bad with a little sediment. Has the bag been changed since we operated? If not, he has put out 100cc of urine in 5 days - that's 20cc per day, which is close to nothing. I found out today that Gloria had wanted him to get some IV steroids, but he hasn't been getting it, so I am going back to the ward now to ask them to give it. The labs we sent are still pending - they should come back today. If we refer him to a hospital in Mbale or Kampala, his mother will still needs money for medications and tests, which she doesn't have. Gloria knows about a program in Kampala that sometimes takes very poor, very sick kids and gives them acute care. It might be his only hope.

Friday, February 12, 2010

Everything You're Not Supposed To Do

I stop by labor ward to see a patient who needs a D&C, and a midwife asks me to review a different patient. She is 16 years old, having her first baby, and according to the midwife, has been stuck at 6cm.

I look at the chart. The last note was at 7pm last night,and she was 4cm. It is now 11:30am, and there is no documentation of 6cm. I ask the midwife - she says the patient was examined this morning, but not by her and she doesn't know when. She is sure that whoever examined her said she was 6 cm.

According to her last period, she is about 34 weeks pregnant. At 34 weeks, the baby is preterm, but usually survives unless there is another problem like infection. Even here, a 34-week baby has a very good chance of survival.

Her belly looks at least 34 weeks, if not full term. Rupturing her membranes might help speed up her labor (and avoid medication, which is difficult to use here because you don't have a pump and no one really watches). However, if the baby is preterm, having the water broken for a long time before delivery could predispose toward infection, and preterm infants are much more at risk. A 34-week fetus should be ok, but you don't want to take chances. Then again, a cesarean here is highly morbid - most people get infected and require antibiotics, transfusions are hard to get even when lifesaving, and the potential for complications in the next pregnancy is very, very high. And she might have 8 or 10 pregnancies ahead of her. This girl is 16 - I don't want to doom her to all of that if she can have a vaginal delivery today. And who knows - gestational age is quite unreliable here and the baby might be full term after all.

I examine her, and find that she is, in fact, 6cm dilated and her membranes are bulging. As I am considering whether or not to break the water, the tense bag ruptures suddenly. I jump back to avoid being doused with amniotic fluid. The fluid is a mild green color - meconium, although light, which is ok. It can sometimes be a sign of stress, but can also be present during labor or when the baby is full term. I feel the head, and it is quite low. She will likely deliver vaginally.

As I am writing the note, I hear her start to groan with discomfort from contractions. This often happens after rupture of membranes - the contractions pick up in frequency and intensity. The midwives agree that she will likely deliver soon.

I go to theatre for the D&C, and then I get some more research work done. Around 4pm, my work has slowed down, so I decide to check on her and a few other patients.

When I arrive on Labor Ward, the evening shift midwife is sitting at the nurses' desk, writing. I greet her and ask about the 16-year-old patient. "She has delivered." I am glad to hear that. I knew they would have called me if she had needed a cesar, but still it is nice to hear when things go well.

I look up her name in the delivery book and see that she delivered at 2:30pm - about 3 hours after I ruptured her membranes. Pretty good. "She pushed for almost 30 minutes," says the midwife, disapprovingly. This seems fine to me. Women at home push for 1-2 hours, even 3 if they had an epidural. But then I notice the Apgar scores are 3 and 4. The Apgar score, invented by Virgina Apgar, an anesthesiologist, is a method of grading the baby at delivery, and is thought to be predictive of future outcome in term infants. The score is determined through clinical evaluation of the infant at 1 minute and 5 minutes (and sometimes 10 minutes) after delivery. A perfect score is 10 and 10, although most infants score 9 and 9.

Apgar scores of 3 and 4 are terrible. The midwife tells me, "They worked on that baby. He is over there." I don't know if that means he's dead or alive. I go over to the baby, who is in the bassinet under the heating lamp. He is small, and not moving. His face is pale. I uncover his head and hands - they are blue. Is he dead? I listen to his heart - the heartbeat there, but it is below 100 (a baby's heartbeat should be high, around 120-150).

I know the midwives tried to rescusitate. I have been present when they are rescusitating, and the are quite skilled. They have taught me a few things. Usually they have little to work with, but just yesterday we had some visitors from Kampala who fixed the oxygen concentrator and the suction machine. The midwives also usually inject some saline with glucose into the umbilical cord during resuscitation.

Nonetheless, I try again. How can I not? I bring the baby over to the oxygen concentrator, which I can see was recently used, probably on him. There is a bulb suction there, a nasal cannula for the oxygen, and 3 Ambu-Bags for pumping air into the baby's lungs. I can pretty much guarantee that none of these things are clean, much less sterile, but they are all I have. The hospital has run out of money, and so can't buy soap or bleach at the moment. I weight my options, and use what I have.

I know oxygen doesn't attach well to the Ambu-Bag, so I try the nasal cannula first. It is for an adult, so it is too big for him, but I put it in his nostrils anyway. I look around for a breathing mask, but there isn't one. His heart rate seems to pick up. I measure it, and it is 108. Still low, but improving.

I need to pump the air into his lungs. I can't get the oxygen tube to attach to the part of the bag I think it should, but I see another attachment where it might fit. Will this actually get oxygen through the mask? Unclear, but I try. When I test it, I feel some air coming through. I start bagging the baby. He is still blue, except for his face, which is pale.

I keep my stethoscope on his chest listening to his heart while I pump. No change. I keep going, but it doesn't help. After a while, I try the oxygen nasal cannula again.

After a good 30 minutes of alternating between pump and cannula, plus doing some chest compressions, nothing changes. The midwife who had spoken to me earlier is still sitting at the desk. She knows it is hopeless. I bring the baby back into the bassinet.

An old woman arrives, and she manages to tell me that she is the grandmother. "The baby is not good," I say. "Not good," she repeats. "It is not going to live. Does the mother want to hold him?" She doesn't understand.

When I was a medical student, I saw a baby born with a lethal anomaly. Her face was terribly deformed - only the baby's mouth looked normal. The parents held her immediately after delivery. They took turns holding her lovingly until she died.

I don't know what the culture is here. I don't know if everyone would feel the same way or not. I decide to go ask the mother. She is only 16, and this may haunt her for the rest of her life. Would she want to have seen her baby while he was alive? Would she want to know that she showed him love before he died?

I walk with the grandmother to the Postpartum Ward. The girl is there, and she won't make eye contact. She stares out the window, looking upset or angry. The grandmother (her mother) encourages her to talk to the "mzungu" but she won't. I need a translator.

I walk through the ward, but there is no nurse there, and the medical students have left. I find one patient getting some sort of IV fluid. Her husband speaks English and she speaks even better English.

In medical school, we are taught the ethics of using a translator. Never use a family member - they could be biased. Never ever use another patient - it is a breach of confidentiality. The best is to use a professional translator, either in person or by phone. Otherwise, you can use a staff member who speaks the language, but they must maintain patient confidentiality. When patients would come in speaking Arabic, Bengali, French or even languages like Quechua, Wolof and Mandingo, we could call a phone translation service and they would link us with a professional translator over the phone. (Sometimes for Wolof and Mandingo, you had to schedule the translator in advance, which really doesn't work when you need to do an emegency cesarean).

Here, most of the time, there is a nurse or staff member around who speaks the language. Most of the patients speak Japadhola, Ateso, Swahili and/or Luganda. But sometimes, you get someone who speaks Lugizu or some other language, and often other patients are used to translate. Confidentiality, what?

I stand there thinking about whether this is ok. But what choice to I have? The grandmother says something to the English-speaking patient, and the patient translates:
"She is saying her daughter has delivered a baby, and now the baby is dying."
"I know," I say. "The baby is dying now, and I want to know if she wants to hold him. Come and speak to her for me."

She takes her IV bag with her and we walk over to the girl, who is still staring out the window, looking upset and angry. She tries to speak to the girl, but the girl won't answer. I try to explain about the baby, and ask what she wants to do. The grandmother speaks. The translating patient replies. Finally, the girl says something brief.
The translating patient says "They are waiting for someone now."
"Who?" I ask.
"That I don't know," she says.

Just then, about 10 people stream in though the door. I don't know if they are family, or what. There are 2 men, and another woman with a baby on her back, and some more women who stay in the background. One of the men sits on the bed next to the grandmother. He is the girl's husband.

I say to the husband "Do you speak English?" He nods. "The baby is not well. He is going to die. We have tried everything, but he has refused to breathe. I want to know if your wife wants to hold him now before he dies." He looks at me, then stares at the ground. He looks angry, although I can't really tell. He says nothing. No one says anything. The translating patient looks as confused as me.

Thinking that I no longer need translation, the translating patient leaves. But has the husband understood me? And should I be talking in front of all these people? Who are these people? And why won't the patient talk to me? The grandmother seems responsive, but she won't answer this question.

In the gathered crowd I spot E, a patient I know. She has twins at full term, and she is waiting to go into active labor. She speaks very good English. Since confidentiality is already out the window, I summon her to translate. She speaks more confidently to the family. The husband says little, but the grandmother speaks. E doesn't always translate immediately, sometimes responding first. But she gets what I am trying to say, so I let her.

She turns to me "The relatives are saying they want her to go home now, but she doesn't want to go. The midwives have told her she should stay tonight and go tomorrow, but the family doesn't want."

The girl says something brief. "You see? She doesn't want." says E.

I realize that while my primary concern is the baby, this is their most pressing issue, so I address it first. "She should stay," I say. "The problem with the baby could mean a problem for the mother, too, like infection. She needs to stay to be observed tonight."

There is more discussion. The grandmother pipes up, as well as the husband. Even the woman with the baby on her back says some things. E tells me they are still saying they want to take her home. She tries to convince them to let her stay. The girl insists she wants to stay.

"Now they are saying that they take the baby's body tonight, and then tomorrow they will come and collect her. She can sleep here tonight."

"Well, the baby is still alive, but he is dying. That is why I want to know if they want to see him, or if I should bring him here so she can hold him."

This is confusing, and E explains to them until they understand that the baby is sick but not dead yet, and will likely die.

"They are asking if you can do everything you can to save the baby, give him medicine." says E.

"I have tried everything. And the midwives have tried everything. We have given him oxygen and tried to force breathing but he has refused to breathe. We have tried for two hours." E translates this. It takes a few repetitions to sink in.

"Does she want to hold him now?" I ask. E translates. The husband says no, and the grandmother says no.

"They are saying no," says E.

"What does she want?" I ask. E asks her several times. Finally she speaks.

"She doesn't want," says E. Then the husband pipes, up and the grandmother says something seemingly in agreement. She points to me and then herself and then the door.

"They want to go and see the baby again with you." E says.

I thank E for her help and take the husband, the other man, the grandmother, and the lady with the baby on her back over to Labor Ward. I show them the baby, and explain how he is not breathing and his heartbeat is slow. I lift his arms and he has no muscle tone. (At this point, even if he does live, he is probably severely brain damaged from lack of oxygen. I can't even figure out how he is alive without breathing for 2 hours).

"You try to help him," says the husband.

"I have tried and tried," I say. "He does not want to breathe."

"You try again," he says.

I pick up the baby - who is limp and lifeless - and bring him to the rescusitation table. I show them the oxygen. I attach the oxygen to the Ambu-Bag, and try to pump air into him. I listen to the heartbeat - no difference. I bag for a while, then look for breathing. I show them that there is no breathing. Occasionally, the baby makes large gasps, sometimes waiting several seconds before releasing. These are terminal breaths - adults make them too, while dying. They are infrequent and slightly scary.

I switch to the nasal cannula, which is still too big for the baby. I put it in his nose, but it just seems mean because it stretches his nostrils to the sides. I try that for a while, and show them that he is still blue and not breathing. I try putting it in his mouth, where at least it stays. Nothing. I let the father listen to the heartbeat with my stethoscope, and explain that it is too slow.

I switch back and forth between cannula and Ambu-Bag, until it just becomes pointless. I tell the father "You can stay here with him. I will bring you a chair to sit. Do you want to hold him?"

At first he refuses, so we stand there watching the baby with the cannula in his nose, not breathing, not changing, still blue. Then I try again. I offer to let him sit, and he doesn't refuse. I bring him a stool to sit on, and he sits with the baby and watches him. The grandmother had given up at some point during the rescusitation and left.

My rescusitation efforts were pathetic. I don't know much about it. Even if I had learned more in residency, there is not much here we can do. We can't intubate the baby, the oxygen barely works. I feel badly that I saw the mother in labor and that the outcome was bad. But thinking over my actions, I can't think of what would have been different. The heart rate was fine, and the rupture of membranes did help her deliver. Maybe this baby was infected before delivery, and therefore weak. It might explain why she delivered preterm. The baby isn't so small that it seems less that 34 weeks. In fact, it looks like a small term infant. I suppose the good side is that she didn't get a cesarean for a baby who died. It's possible that a cesarean would have saved the baby. It's also possible that it wouldn't have. But at the time that I saw her, she had no indication for it. Still, it doesn't feel good.

Thinking about the crappy rescusitation, the discussion with the devastated teenage mother translated through other patients and in front of 10 people who may or may not have been related to the patient, my lack of ability to get her to make eye contact with her or explain anything gently, I think of how everything is the opposite of what you are supposed to do. You are supposed to give people privacy, compassion, confidentiality and dignity. I wish I could say that I persisted and gave this patient the closure, but I didn't. This girl will go home, and the loss of this baby will haunt her forever. Many women here lose at least one or two children if not more - so many that it is often shocking. Birth asphyxia, malaria, pneumonia, diarrhea, malnutrition. It would make us feel better to think that they are less affected by the loss because it is so common. But I saw that girl's face, and I have seen the faces of women recounting their obstetric history to me, telling me about infants or children who died. They are devastated, but they receive no validation, no support and no compassion.

Sunday, February 7, 2010

Frozen Pelvis

It has been a long time since I have done much Gyn surgery. I have done a bunch of cesareans since residency, but not much else. I had been nervous about how quickly I would jump back into it, but a recent challenge put some of my fears to rest.

A generalist physician I greatly respect here in Tororo asked me to review a patient on Female Ward. The patient had marked abdominopelvic tenderness, but no discernible pelvic mass. An ultrasound at TDH had reported an ectopic pregnancy, but he didn't trust that sonographer and wanted me to evaluate her.

I brought my portable ultrasound to the ward, accompanied by L., a Family Medicine Resident recently arrived from Madison, Wisconsin. I spoke to the patient, who thankfully spoke English, and got a history. She was 24, and had one prior pregnancy that resulted in an early miscarriage. Her period was sometime in November, which would put her between 9 and 12 weeks of pregnancy. Back in early January, she started having light spotting, and the next day pain. The pain was most severe on the second day, when she went to a clinic in Kampala, where she was told they had to "remove the pregnancy." It sounded like they did a D&C, but nothing else. Since then, she has had pain and light spotting.

I started scanning her and immediately I saw an empty uterus. To the right of the uterus there was what I can only describe as a huge bunch of crap. It was about 8 cm by 4 cm, and was probably a whole bunch of clotted blood. The right side of her lower abdomen was also remarkably tender. I looked at her left ovary and found it easily, looking quite normal.

The most likely diagnosis is an old ruptured ectopic pregnancy. I didn't see any free fluid, which is how liquid blood would look. The size of the mass meant that it was unlikely to be just an ectopic - but one surrounded by clotted blood could easily be that big. Although sometimes ectopic pregnancies can resolve on their own, there is no way to predict that. They are so often deadly, and one that bled before could still be bleeding or could bleed again. When an ectopic pregnancy is diagnosed, action must be taken.

In the US, if an ectopic pregnancy looks intact (not ruptured), it can be treated with an injection of methotrexate - a chemotherapeutic agent that is toxic to the pregnancy. It allows that abnormally located pregnancy to detatch from the tube, ideally without bleeding much. The advantage to this method is that it spares the tubes, and avoids surgery. An ectopic pregnancy that may be ruptured or has other contraindications to methotrexate can be managed with a laparoscopic surgery - using a tiny camera inserted in the umbilicus, and two other instruments inseted through tiny holes. Recovery is quick, and sometimes patients even go home the same day. Here, neither is an option. Ectopic pregnancies must be managed with a laparotomy - a larger incision on the abdomen. So, this was the plan.

We notified the theatre, and I dashed over to Labor Ward and Antenatal clinic to see a few patients waiting for me. I was finishing up when I got the call that the theatre was ready. Sweating in the 95 degree heat, I grabbed my scrubs and bought 2 hard-boiled eggs for lunch (the only quick food available here, 25 cents for 2) and dashed to the theatre, peeling eggs on my way.

I tried opening a mini-laparotomy, a smaller incision about 4-5cm, hoping to complete the surgery with minimal skin trauma - which didn't work. The surgery was incredibly difficult at every stage. Getting into the abdomen was tough. As soon as I managed to open the peritoneum, I should have seen a nice small uterus, two tubes and two ovaries (with ectopics, sometimes you have to clear out the blood first, but the anatomy is consistent). In this case, I couldn’t see anything. What on earth WAS that? I tried to feel, but couldn’t get my hand in. I expanded the incision more than once, until it was the size of a large cesarean incision. I could put my hand it, but couldn’t see or feel anything recognizable.

Was that clot? Or bowel? Or clot adherent to bowel? I stuck my hand in to palpate the organs, and felt very little. Lots of stuck crud. Where was the uterus? For that matter, where was the tube or ovary? Bowel, bowel, bowel, and crud. How. The. Hell. Am. I. Going. To. Do. ANYTHING.

The situation was what we refer to as a "frozen pelvis." It means that the adhesions (scarring) inside the abdomen are so abundant and dense that every organ in the pelvis is essentially stuck in place. They don't move much, and any attempt to enter results in tearing of adhesions off of the surface of organs - which can cause damage to the organs.

I didn't want to touch the bowel in any way. It was so stuck, and if I tore it, there would be no General Surgery consult to come and repair it for me. It would be a horror show. And for that matter, where was the bladder?

I heard the voice of my former MFM fellow from residency explaining to me how he got through a really difficult cesarean section: "You just have to establish normal anatomy, right?" Right. OK. I saw something that looked like maybe the right tube. Then I found the front of the uterus. Both the “tube” and the uterus were completely stuck from behind – probably to bowel.

I wanted to confirm that the structure I thought was tube was actually tube. I asked for different kinds of instruments - better for grabbing tissue. Shockingly, I got them! After using multiple laps to wipe up the blood, I commented to L that I would give my kingdom for a suction. "Suction?" the anesthetist said, and walked out of the room, returning with.......suction! What a revelation!

(Toward the end of the case, I muttered, "This is where I would really love to have cautery." And the anesthetist said "Cautery? We have, but you didn't ask for it, so it is not set up. Next time." A bovie?!? That works??! Who knew? Next time, I'm going to ask. Any chance of a laparoscope?)

I was finally able to identify the tube definitively by finding the fibmbriated end. I also found the pelvic sidewall, the round ligament and the infundibulopelvic ligament. I kept searching for ovary, and finally found a glimmer of white where the ovary should be. It was either ovary or organized clot. "What does it feel like?" asked L. "Crud," I said.
Nonetheless, I got some sense of the surrounding pelvic structures. Unfortunately, the posterior surface of the tube was densely adherent to something, and I wouldn't be able to get to it. How could I possibly remove her damaged tube and her ectopic pregnancy when I can't even see the whole tube?

I saw a hole starting to form in the thin surface of the tube. I had an idea: cut the tube open, identify the parts of it better, remove what I can, and stop the bleeding. Anyway, I had no better ideas.

I did it, and it actually worked. I cut out the free edges of the tube, stitched, and the bleeding stopped. Phew! OK, should I do more? Most of the tube was still left, so she could easily have another ectopic pregnancy. But trying to dissect out more would run the risk of damaging bowel - not worth the risk.

At this point, the theatre was HOT. There is no air-conditioning, and there is one functional but irrelevant fan. It was 95 degrees that day in Tororo, and in the OR it felt like 110. We were already drenched with sweat. Still, we pressed on. We evaluated the abdomen carefully for bleeding. I got some saline for irrigation, and looked for bleeders. Nothing. Phew.

Closing the fascia, we had to pause once to check for bleeding, but it was ok. I got to the skin, and started my subcuticular closure. The needle became damaged, and eventually had to be replaced. Ugh. I started really sweating, and getting so dizzy. I had been sick with strep throat for about 2 weeks, and this was the first day I had finally felt better. Now I was beyond dehydrated, and feeling it. I kept going. I paused for deep breaths occasionally. My scrubs were drenched, I felt sweat dripping all over. I kept stitching, and started complaining (it helps me get through). L was sympathetic, and very patient. I'm sure she was dying for me to finish. As I complained, the anesthetist said "Why don't you just do the big stitches we do?" Meaning those huge nasty things right through the skin. No way - I had to finish this.

I pulled it together, using all my energy to focus on stitching, and in the end the repair was quite nice. Afterward, L and I raced to the clinic, plopped chairs in front of the water cooler, and downed countless cups of water. She was a real trooper through the whole thing - not one complaint. We checked the time, and realized we'd been in the OR two and a half hours.

Sadly, I really doubt this girl will ever get pregnant. Her left tube is probably as bad as her right, and I couldn't even find it. If she does get pregnant, I hope it's not an ectopic, because I don't know how they will find it. If it is a normal pregnancy, I hope she doesn't need a cesarean.

The question is, why was this case so bad? I’ve done my share of bad ectopics at home – with 3 liters of blood in the belly, huge clots, weirdly positioned ectopics, unstable patients. But none of the operations came close to being as difficult as this one. The only cases I've seen that were this bad were Gyn Oncology patients - with bad cancer. But in those cases, I was operating with an experienced Gyn Oncology attending and fellow, so I had plenty of guidance.

In this case, the ectopic probably ruptured 3 weeks ago, when she had the futile D&C. She likely bled into her abdomen, and then the clot that formed created a tamponade that prevented additional bleeding from the tube. Most women just bleed to death at that point. She is lucky to be alive. But all the blood in her abdomen gave her the continuing pain. Eventually the blood clot became organized – looking more whitish and dense, hard to differentiate from normal tissue. This was part of the difficulty in the OR – I couldn’t tell if it was bowel or clot. But also, the inflammation from the blood created scarring in the abdomen, which caused her bowels to stick to everything. Three weeks later, the scarring had solidified into a frozen pelvis.

In the US, women with ruptured ectopics come to the hospital, get an ultrasound, and get the appropriate treatment. If the diagnosis is missed at first (it can be confusing), it is caught within 1 or 2 days. We can check BHCG, do transvaginal ultrasonography and laparoscopy. When her D&C showed no products of conception, we would have immediately done a laparoscopy. But here, that’s not the case. I have never seen an ectopic this bad because almost no one would be sent away in her condition. We just don’t see people coming in who have had large amounts of blood in their abdomen for 3 weeks.

It was such a tough case, and I am pleased that I was able to get through it, although I watched her nervously for several days. I talked it over with some doctors here, and they all agree that these cases are really rough. I'm glad I didn't cause any major injuries. At home, we would follow her BHCG (blood pregnancy level) to make sure the ectopic pregnancy is really gone, since I didn't take her whole tube. Here, we can't do that. Over several postoperative days, she was gradually able to control her pain, get out of bed and eat - these are all good signs. She went home recently, and I am keeping my fingers crossed for her. Most of all, I hope she never needs another surgery.

Monday, February 1, 2010

She Is Fitting

One of the midwives shows up at our clinic around 3pm. "Doctor, there is a lady we would like you to see. She is fitting."

'Fitting' here means 'having a seizure.' Any pregnant woman having a seizure is assumed to have eclampsia until proven otherwise, both because of statistical likelihood and danger level. Eclampsia, which occurs only during or immediately after pregnancy, is a combination of elevated blood pressure, protein in the urine, and seizure. It is one of the most common causes of death in pregnancy worldwide. A woman who has high blood pressure and proteinuria (without seizure) has preeclampsia, which can lead to seizure eventually. Preeclampsia is also dangerous for its risk of stroke, flash pulmonary edema (sudden fluid filling the lungs), fetal growth restriction, fetal death and maternal death. A woman who becomes eclamptic is at high risk of death, even if she reaches the hospital.

When a woman has preeclampsia/eclampsia, the only cure is delivery. At term, her labor is induced to protect both her and the infant. If she is preterm, the doctors must weight the balance between the fetus' prematurity and the disease. A dead mother has a dead baby, so their interests are connected. Often, if the preeclampsia is severe enough, the fetus must be delivered severely premature, with only hope and a NICU (or here, hope alone) to keep them alive. I saw this happen often enough in the Bronx, and the baby did not always survive. Sadly, sometimes the mother didn't either.

As soon as the midwife tells me that the patient is fitting, I grab my white coat and race over to the Labor Ward. She is in the enclosed private room (the sign on the door says "Preeclampsia"). She is not conscious, but she is not seizing either. She has an IV hanging, and the nurses tell me they already gave a bolus of magnesium, which is what stopped the seizure. I try to wake her up. She opens her eyes, rolls them around blindly, sees nothing, and closes them again. She turns onto her side to curl up. She is clearly still postictal.

I get some background on the patient. She is 15 years old (born the year I graduated from high school - oy vey). This is her first pregnancy. She is 34 weeks and 2 days pregnant. Yesterday, she complained of a severe headache and abdominal pain to her mother. I look at her antenatal card and see that she had one visit 2 weeks ago. At that visit, her blood pressure was 140/90 - she was already preeclamptic, and it was not noticed. Around noon today, she seized at home, and that's when her family brought her in. (It is now 3 hours later. I can't imagine a seizing pregnant woman in the US ever waiting 3 hours to get to the hospital after a seizure). She seized again on arrival in front of the midwives, and didn't stop until she got the magnesium. After the seizure, her blood pressure was 160/120 - severely elevated.

I tell the midwives to give her the maintenance dose of magnesium, which here is 2 injections in the buttocks (at home it is given IV). I also tell them to give a dose of hydralazine IV push. They do both right away.

I keep trying to wake her up. She keeps her eyes open now, but she doesn't respond. I tell the nurses to warn the anesthetist that we will need to do a cesarean once she is stable. The only thing that will cure her right now is delivery, but I can't operate on an unstable woman - it could kill her. She needs to wake up from the seizure and stabilize her blood pressure first. I ask the nurses to obtain a urine protein, blood smear (for malaria) and an urgent hemoglobin. Even though the diagnosis of eclampsia is highly likely, malaria is so common here that I don't want to miss anything.

About half an hour later, she is still not improved. She wakes up, but is totally disoriented. She has no idea who the nurse is or where she is. Her blood pressure is 160/120 - not improved. We try to wake her up more, to get her to respond. We ask where she is, she has no idea. We point at her mother and ask "Who is that?" She looks at her mother and says weakly, "...Nurse?" The anesthetist has come to see her, but he sees how unstable she is. "Let them stabilize her first," he says, and he leaves.

The nurse turns to me "It is 4. He will go away now, and we will not be able to get him for the cesar."
I can't believe what I'm hearing. "He's going to leave? But he knows she needs the cesar," I say.
"It is what happens. They go, and we can't ring them. Sometimes their phone is even off! And if he is home, we have no fuel for the ambulance so we cannot collect him or the doctor," the midwife tells me.
I say, "I'm staying here until she is ready for the cesar, so you don't have to worry about the doctor. But how can he leave? She'll die if she doesn't get a cesar tonight."
The midwife agrees. "Should we refer her, then?" she suggests.
"If we refer her like this, she'll die before she reaches the next hospital," I say.

This cesar has to happen. This girl is 15 years old. She should die because she seized in the afternoon and the anesthetist couldn't be bothered to wait around? She cannot die. My mind is racing, trying to think of all my options.

Point one: I know she will die tonight if she doesn't get a cesar.
Point two: I have always been taught never to operate on an unstable pregnant woman because it could kill her. But how certain is that principle? Is it a 100% chance of death? A 1% chance of death? Is it worse to try to operate while she is unstable, or is it worse to wait and potentially lose the window of opportunity for surgery?

I try to envision what it would be like if I operate on her and she dies on the table. I shudder. I think about sitting there helplessly, letting the fetal heart disappear, and watching her continue to seize and die overnight. Shudder.

I got all this teaching in residency, but no one ever taught me what to do when the anesthetist wants to leave at 4 and the patient is seizing.

I decide I need to buy some time. I send one midwife to tell the anesthetist one hour, and I proclaim "She WILL be stable in an hour." I have no idea if I will be able to do that, but if she's not stable in an hour, she doesn't have much longer anyway. I tell the other midwife to give double the dose of hydralazine.

I spend 10 minutes ringing my hands and panicking. The labs return - her hemoglobin is 10.8, which is good. There is no blood smear and no urine protein (too much to ask, I suppose). I go back in to check on her, and she wakes up. "Where are you?" we ask. "Hospital" she says. "Who is that?" we say, pointing at her mother. "Mama," she says. We make her repeat these basic facts a few times - she is coherent. The anesthetist comes and sees her more responsive. I take her blood pressure again - it's 160/120. I don't tell them the blood pressure, because I realize that she needs the cesarean, full stop. This has to count for stable. "Let's do the cesar," I say, and everyone springs into action.

While the nurses start preparing to take her, I decide to try to explain to her what is happening. Her mother has to give consent because she is underage and not competent right now, but I figure she should at least be aware. "You are very sick because of the pregnancy," I tell her. "You had a seizure. The pregnancy is making you sick. We have to do a cesar to get the baby out. If we don't do the cesar, you will die. The baby is big enough, it will be ok. Can we do the cesar?" She shakes her head no. "No?" I ask. She shakes her head again and moans. I keep asking and explaining the dire situation, but she keeps saying no. "Do you want to die?" I say. She shakes her head again.

The mother doesn't speak English, so I can't tell her to talk to the daughter. I pull a midwife in and tell her what is going on. They speak in Swahili. The nurse explains to the mother, and both of them talk to the daughter. Quickly, she agrees. I say again to her in English, "We can do the cesar?" She nods her head. The nurse verifies in Swahili.

We drag her onto a stretcher (she is too weak to move herself), obtain written consent from her mother, and bring her to theatre. The anesthetist puts her under general anesthesia. The cesarean is uncomplicated. The scrub tech keeps trying to tell me what to do, mainly because she is unfamiliar with my technique. I don't say anything, I just keep operating. I take her advice when she's right - especially on how to adapt to the crappy instruments. But often, she's wrong. Occasionally, the anesthetist comes around the table to watch, and periodically tells the scrub tech to shut up, that I am doing it right. (I know she means well, but it gets distracting).

I insist on closing with a subcuticular stitch. There are no staplers here, and usually the incision is vertical (I use a pfannenstiel, or "bikini-cut") and they use thick suture non-absorbable material straight through the skin with large ties on the outside. It leaves huge scars and has to be removed after 7 days, and (unlike staples) is quite painful to remove. The subcuticular stitch, which I use, is a small suture sewed just below the skin. The suture can't be seen once it's closed, and it absorbs eventually. They try to give me a huge size suture material, but I insist on smaller. It is still not as small as I would like (2-0 chromic for the medical people out there), but it will do. I ignore the scrub tech's commentary and close the incision beautifully, if I do say so myself.

The next day, the patient is awake and looking well. She is shy and doesn't speak to me at first, until the midwife berates her into talking to "the mzungu doctor who saved your life." She tells me she feels ok. Her blood pressure is quite high - 170/130 - but at least she got magnesium for 24 hours (I think). I ask them to give her some nifedipine.

2 days later, she is doing even better. She smiles just a tiny bit when I arrive on the ward (more embarrassment than happiness) and tells me she feels well. The midwife who had originally come to get me before says "Doctor, we are all appreciating the incision you have repaired. It is very nice, like it is not even there!"

It is no small miracle that this girl lived, even with my intervention. I know that one of these days, I am going to lose a patient due to the extremely limited resources here, and I don't know how I will handle it. For the time being, there are 2 doctors (besides me) and 2 anesthetists, although everyone is difficult to reach at night. There is no fuel for the ambulance, which is used to collect the doctor and the anesthetist when there is an emergency, so any patient in crisis at night is up a creek. What's more, that ambulance is also used to drive the evening shift midwives home (they leave at midnight) - so the midwives have to choose between their own safety and the patients. If they stay late, they have to walk home in total darkness, which is very dangerous. If they leave, they leave the patients alone with no midwives until the night shift arrives. And lastly, there is no airtime purchased for the Labor Ward phone, so even if a midwife needs help at night, she can't call me (or anyone).

I thought that by getting a medical degree and all this training, I could really make a difference. But the problems here are so much bigger than me. For the time being, I can do a lifesaving cesarean on one 15-year-old girl and it is definitely rewarding. But I am realizing that there is so much more to the whole problem of maternal mortality than one cesarean, or one doctor, or one donation, and I don't really know what to do about that.