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.


Lady B said...

Oh vey, indeend V! But you saved two lives, and this in itself is important. And by being in Tororo and showing midwives and scrub techs and anaesthesiologist pfannentiel incisions and subarticular stitches and a work ethic that values all patients lives you are making a difference beyond that single patient - however little it may be.

I also question constantly how big the problem of maternal/newborn mortality is in many parts of the world and how little is being achieved on a 'macro' scale. So much time and money is being wasted while women in rural Uganda (and many other places) die. But until the politic-ing changes its head down, bum up... two lives saved is better than none!

Paul said...

nice, nice, nice work. The 1-hour stall time was particularly brilliant (and thankfully, actually worked!). I agree-the textbooks can't teach you what to do in that case. wow.

BolaB said...

This is a rough story with a beautiful ending. You handled the situation so well. Thank you for sharing your experience.

I understand your fears about getting all the training abroad but finding that it requires so much more to practice successfully out there. I am very worried about going back to Nigeria upon completion of my education here in the U.S. for the very same reasons...