Monday, July 12, 2010

Sub-Optimal

I stop by the Labor Ward to ask the midwives to prepare two women who need cesareans. They are not urgent – both repeat cesareans. When I walk onto the Labor Ward, I call out my usual greeting: “Hello! How are you?”

Two midwives are there. One of them says “We are not very fine, doctor. We have this lady with APH [Antepartum Hemorrhage] and…..it must be….abruptio placenta?”

Abruptio placenta (placental abruption) is when the placenta partially or completely comes off the uterus while the fetus is still inside. It can be fatal for the fetus, and even sometimes for the pregnant women if the blood loss is severe enough.

She hands me the patient’s file, and I see the results of an ultrasound that was done today. It shows a placenta previa. The scans aren’t very reliable here, but I would tend to believe this type of finding. I am wondering if I should re-scan, when I walk over to look at the patient. There is a pool of blood with clots about 3 feet from the bed. She is lying on her side. There is old blood covering her legs, down to the bottom of her feet. Her pink skirt is not pink – it’s white, but covered in blood.

When I see the skirt, I realize she needs a cesarean NOW. She doesn’t have time for me to go and get the ultrasound and start dilly-dallying. At home we would be doing a crash c-section, which means that we would load her onto a stretcher and literally run the stretcher into the OR. We would have all hands on deck. There would be people available to move the patient, set up the OR, arrange for blood to be available, notify pediatrics, help anesthesia, and do the crash. It would be organized but effective chaos. It works.

Here, there is no such thing as a crash c-section. I go to the midwife who told me about the patient and tell her that I agree – the patient needs a cesarean urgently. I ask her to prepare the patient immediately, including consent and an IV. She agrees, then walks over to another patient, looking very unhurried. Another midwife arrives, and I tell her as well. She agrees too, but doesn’t really take action either.

I know that they will do it eventually – they always do. But there is no sense of urgency here. I have had so many situations already where I have seen that even the most urgent situations can take 1-2 hours to get into the OR. At home, I would do it myself. But here, I can’t consent the patient because I don’t speak Japadhola. I can’t put in the IV because I can’t access the supplies.

I see a third midwife who has just come from theatre, from another cesarean. She still needs to bring her patient back to the ward. I tell her about the bleeding previa. She is distracted because she is thinking about her other patient.

I come back to the clinic because there are people waiting to be seen by me that I want to manage before I go to theatre. When I get back to my office, I know I need to push more to get this patient to theatre. I call the third midwife because I know she is effective (and I have her phone number) and I re-emphasize the need to move this patient to theatre immediately. I can tell she gets the urgency this time.

In the clinic, I treat a patient who is still having bleeding after an illegal abortion. Just as I am finishing, another midwife comes by to show me the lab result of the bleeding patient. Her hemoglobin is 8.8, which is actually not that bad (for here). However, we don’t trust it very much. The lab is sometimes unreliable and what’s more, the patient is still actively bleeding, so by the time we are getting her to theatre, she will be lower.

She tells me that they have moved the patient to theatre. I walk over, and find the anesthetist preparing the materials for the cesarean. The patient is there. The anesthetist speaks basic Japadhola. As a formality, I ask him to ask her if she wants a tubal ligation. I ask almost as a reflex – because most of the time when I am doing a cesarean, the women have had a lot of children already. She says she wants one, but when I look at her chart, I realize that she is only 23 years old. She had given birth to 2 children, but only 1 is alive. I try to counsel her through the anesthetist, but his Japadhola is limited. She keeps insisting she wants me to cut the tubes, even if this baby dies.

Even in the US, this would give me pause. I would seriously try to discourage a 23-year-old from a tubal ligation. There is the problem of regret – she has at least 20 more years of potential fertility ahead of her, and she may change her mind in that time. Or she might end up with a different partner, and decide she wants children with that person. Or she might just want the option of fertility, even if she doesn’t ever have another child.

But here, it’s even more concerning. Fertility is paramount. A woman who can’t/doesn’t produce many children is considered inferior. Of course, maybe she doesn’t care. Maybe she genuinely doesn’t want more children, and I can’t blame her for that. But what if her husband leaves her for that reason, or beats her, or takes another wife? Can she support herself?

I tell the anesthetist to ask her husband. In my opinion, I don’t need his permission to do it, but I am thinking that if they discuss it together, maybe he will get her to realize what she is asking for. The husband answers that he doesn’t want her to have a tubal ligation. As I am trying to get the anesthetist to have the husband discuss it with the patient, the patient again calls out that she definitely wants the tubal ligation. The husband changes his mind. “Do what she wants,” he tells the anesthetist.

Aargh. Even more confusing. Does that mean he’s just scared right now, but later he’ll leave her when she can’t have any more children? Or does he really agree?

The anesthetist encourages me to do it. His argument is that in the next pregnancy, she could have another antepartum hemorrhage, but she will be in the village and will not be able to get a cesarean, and she will die. Infertile is better than dead.

The scrub tech agrees, although he is more timid about his opinion.

I open the sutures I will need for a tubal ligation. I am feeling really nervous about this. Should I do it? Should I not?

We move the patient onto the operating table from the stretcher. I realize that perhaps I can convince her to accept an IUD – I can even put one in during the c-section. I know that there is cultural resistance to IUDs, though, and convincing someone to accept one takes good translation and good counseling, neither of which I can give her right now. I tell the scrub tech, who can also speak Japadhola, to offer an IUD. She answers tersely. “She wants you to cut her tubes,” he translates.

Sigh. What to do?

A midwife arrives. I tell her the situation. She immediately offers her opinion.

“Don’t cut her tubes! In Africa, we women must have children. She has only one, if she can’t have more, he will leave her. She is just saying that now because she is in pain, but she doesn’t know what she wants. If you do it, then she will wake up, and she will realize she didn’t want it. She is just scared now. Don’t do it.”

Oh nooooo, what do I do? The anesthetist makes his point again. The midwife makes her point again. Both, I have to admit, are good points.

The worst part about this, for me, is that either way is completely paternalistic. In medical school and residency, there is a huge effort to emphasize patient autonomy. Patients should always be aware of and agree to the course of action. If a patient is making a bad decision, you sit down and discuss it with them. Of course you can decline to do things that are medically unsound (for example, I would decline to do a elective cesarean section with no medical basis, but I would refer the patient to someone who was willing if she wanted.)

Even in a situation like this, with a 23 year old wanting a tubal ligation, I would probably refuse to do it (except under very special circumstances), but I would have a long discussion with the patient. I would explain my concerns. I would explain the risk of regret, the risks of the procedure, the fact that there are alternatives that are just as effective and that are reversible. I would never, ever just make a decision and not explain it to the patient as much as possible beforehand.

But here I have no choice. I don’t have adequate translation. I don’t have people who understand how to counsel for contraception. I don’t even have an emotional connection with the patient – she won’t make eye contact with me. I am cursing myself for even offering a stupid tubal ligation. Why didn’t I look at her chart first?

I try to get the midwife to talk the patient into an IUD, but the midwife doesn’t speak Japadhola. The midwife encourages me to just do the IUD. She goes over to the family planning clinic to get one. The scrub tech tries to convince her again.

While he is talking, I look at the blood pressure monitor and realize that her blood pressure is 60/40. Holy shit. I’m here hemming and hawing over contraception, and she’s bleeding to death. What am I doing?

I race over to the sink to scrub. Just as the anesthetist has put her to sleep, the midwife arrives with the IUD. I tell her to open it.

“It is the right thing, doctor,” the midwife encourages me. “She can remove it later if she wants.”

I’m still not sure, but I can’t think about it right now because I’m thinking about her bleeding previa and how it took us an hour and a half to get her to the OR.

When I reach her uterus, it is small (she is 36 weeks pregnant), but there is enough space between her uterine arteries to make the normal, horizontal incision on the uterus. Because of the placenta previa, I consider for one second doing a classical (vertical) incision, but I decide that there is no indication. I can deliver the infant through the horizontal incision, and if she ever gets pregnant again, it will be safer for her.

I cut, and luckily where I make my incision is just above the placenta. I can see it filling the lower uterine segment, still intact. The infant is breech, as expected. I need to pull out both legs to bring the hips out. I can reach the left leg, but I can’t find the right. The hips are oriented strangely, the baby is curled up on itself in an odd position. I decide to bring the hips out first, but they won’t move. The placenta has taken up a lot of space within the uterus, and it is really hard to move the baby around.

I try all of the maneuvers I learned in residency – I try to pull one foot out, hoping the second will come. It doesn’t. I try to move the hips toward the incision. They are stuck. I reach my hand way in, and try to turn the baby so that I can deliver the head-first. It won’t move. I try to extend my uterine incision. The scissors are dull and it’s difficult, but it doesn’t help anyway.

At this point, I start to curse. It helps me focus. I kept trying the maneuvers, but it becomes clear that they are not going to work. It has now been several minutes. Given the severe hemorrhage from the placenta previa, this baby might have already been compromised. It won’t tolerate much longer inside the uterus like this.

I know what I need to do, but I am really unhappy that I need to do it. I decide to T the incision. That means that rather than extending the sides horizontally (which runs the risk of cutting into the uterine arteries), I will cut upward from the center of the incision into the thick muscular uterine tissue. It forms an upside-down T on the uterus.

This is never good. Making a T-incision means that the point where the 2 lines meet will always be a weak point. Because of that weak point, and because a vertical incision on the uterus is much weaker than a horizontal one, the patient can never try to labor in the future because the risk of uterine rupture is too high. We always have to counsel such patients strongly that they must not try to labor, and they will require a planned cesarean delivery before going into labor.

The problem is that this is a poor patient who lives in some village somewhere. Will she be able to make it to a planned cesarean in advance of labor? If she does go into labor, will she be able to come emergently from her village to the hospital? Will she be able to communicate to her providers then that she requires a cesarean, and why? Will she even make it for antenatal care at all in the next pregnancy?

Well, I can’t worry about that now because her baby is going to die if I don’t get it out soon. I grab the dull scissors, protect the baby’s body, and cut vertically.

Finally, I can grab the right leg and pull it out. I deliver the infant breech. The baby is alive, but very weak. I pass her to the midwife, and turn back to the patient.

The uterus looks terrible. The T-incision is never pretty, but the horizontal portion has extended due to my multiple attempts to deliver the baby, and it looks almost as if the uterus is partially amputated from the cervix, with only the posterior portion attached. Miraculously, the uterine vessels are intact. This is going to be a difficult repair. I briefly consider doing a cesarean hysterectomy, but that seems crazy since I just spent so much energy trying not to have to tie her tubes.

I look at the blood pressure monitor. Her blood pressure, which had improved to 70/40 with some fluid before the surgery, is now 58/28. Good grief. I tell the anesthetist, but he is helping the midwife resuscitate the infant, who is also looking crappy.

I can’t decide if I should insist that he attend to the patient immediately, or keep helping the infant.

Just then, the power goes out. Fan*$%@#tastic.

I have no choice, I have to sew now or she will bleed to death. I can see just enough from the natural light coming in through the windows. It will have to do. I stitch as fast as possible, but I have to be careful to avoid the engorged blood vessels nearby, and to re-approximate the extensive uterine incision. I have to close the vertical portion and the horizontal portion separately. All the while, I am looking at the patient’s blood pressure.

I ask the anesthetist to check the patient’s heart rate. He puts a finger on her wrist and tells me “The pulse is there.” I wasn’t asking to see if she was alive, although the thought that we even need to is rather frightening.

I ask the anesthetist to put in a second IV in order to run in more fluid while we call for blood. Fluid resuscitation can maintain her temporarily, although she will need the blood to survive.

It is difficult to put in a second IV. We can’t put it in her other arm because that is where the blood pressure cuff is attached. There is lots of wandering around and delay without putting in the IV, and I am focused on stopping the bleeding and getting the patient’s abdomen closed, so I don’t notice for a while. General anesthesia could also be artificially lowering her blood pressure, so the sooner I can get her finished and out from under anesthesia, the better.

Once I am suturing the skin, I can stop and ask again. I can see that no second IV has been placed. “There are no giving sets,” I am told. Without the IV tubing to attach fluid, there is no point in putting in the IV needle. Sigh. I ask them to run the fluid as fast as possible, and recheck the blood pressure. I will put in the second IV after I finish.

When we are finally done with the surgery, I write the operative note, change out of my scrubs, and head to the Labor Ward to discuss this patient with the midwife in person. It is now evening, and the evening midwife is usually on alone, which means that she doesn’t have time for the delivered patients because she has to worry more about the laboring ones. But this one needs urgent attention.

When I reach the Labor Ward, I am happy to see one of my favorite midwives, H, who is very hardworking and always greets me with a broad smile. She is already with my patient, receiving her on the postnatal ward. I tell her about the antepartum hemorrhage, the surgery, about the T-incision, the low blood pressure. I see that the blood is already hanging – the anesthetist must have drawn the blood for crossmatching and requested the blood while we were in theatre. But it seems that the giving set is faulty, and we cannot see whether the blood is running into the tubing or not. The midwife and I try to adjust it, but it doesn’t work. If it is not running, it could sit there all night and the patient will get no blood. She dashes off to find fresh IV tubing somewhere. I am glad this midwife is on – she gets things done.

The patient’s husband is there, kneeling at her bedside and holding her hand as if he is holding onto her life. Her mother is on the other side of the bed, holding the patient’s other hand. They are both staring intently at her as if something might happen. They are terrified. I try to reassure them, but I know that this is not the time to talk about details like IUDs and T-incisions. I tell them to watch the blood carefully and make sure it all goes in tonight.

The next day, I go to see the patient. I am relieved to see her alive, but she still look weak and sick. I take her pulse, and it is elevated. (The baby, luckily, looks fine.) I look at the patient’s conjunctivae – the inside of her lower eyelid – to check for anemia. If someone is not anemic, the conjunctivae are pink and have visible tiny red blood vessels coursing through. Someone who is slightly anemic might have conjunctivae that are a lighter shade of pink. If someone is extremely anemic, the conjunctivae are deathly white. This patient’s conjunctivae are very, very white.

Not all patients need a transfusion at the same hemoglobin level. The most important factor in whether or not to transfuse is how she is feeling. This patient is weak and has a high heart rate, which means she is not tolerating the anemia well. Just to make sure that these symptoms are, in fact, from anemia and not infection, I ask the midwife to draw a sample of blood to check the hemoglobin level.

In the US, the minimum level of hemoglobin that we generally tolerate without recommending transfusion (regardless of symptoms) is around 7. Americans are not typically very anemic, because our nutrition is so much better. Even patients who are considered to have “severe” anemia in the US are pretty much average here. Depending on the circumstances, someone with a hemoglobin of 5 may or may not require transfusion, and the level needs to get to 4 or lower to be really compelling.

My patient’s hemoglobin, after the single unit that was transfused postoperatively, was 3.2. A level that low would kill most Americans. I can only imagine what it was during the surgery. I go back to the ward to ask the midwife to crossmatch her for more blood and transfuse another unit. The midwife I encounter is not the most motivated person, and she doesn’t really move when I tell her. It is mid-afternoon and the evening person will be arriving in an hour or so. This midwife tends to slow down around this time and let the evening person take care of it. I have the feeling it won’t get done, so I make a mental note to come back.

When I return in late afternoon, the same evening midwife is on, who had transfused the blood the day before. Before I say anything, I see she is already heading toward the patient with a syringe and needle to draw blood for crossmatching.

An hour later, I run into her on the hospital grounds. “Doctor,” she says, “the lab has refused to give the blood. They have said that the hemoglobin level is 5.3, and it is too high for transfusion.”

You have got to be kidding me. This woman just bled out 90% of her blood volume and underwent surgery yesterday. Not needed?? Obtaining accurate hemoglobin levels is difficult because the tube that the blood is collected in has an anticoagulant, which can sometimes affect the hemoglobin reading. So it’s hard to know whether our lab was correct or theirs was. But regardless, the patient is clearly symptomatic and nees blood. Unfortunately, it is now 6pm and the blood bank is closed for the night. The patient will have to make it through the night. I instruct the midwife to give more fluid as needed and to watch her closely.

The next day, I am relieved to see her looking better. The blood bank won’t budge on giving the blood, but her heart rate is improving, and she looks less weak. I encourage her to start eating food and sitting up.

Her recovery is slower than most, but she progressively improves each day, and is out of bed relatively rapidly. One day I come to her bedside to find her sitting up and smiling. Every time I operate on a patient here, I know they have turned the corner when the smile reappears.

Now I need to explain to her about the T-incision and the IUD. I had already briefly mentioned to the husband before that I didn’t cut the tubes, and he looked stricken and said “But I told you to cut them.” The patient was still weak at the time, so I felt it would be better to talk about it once she had improved.

Now I need a translator in order to talk to her. The midwife comes over to translate, but she doesn’t speak Japadhola. The midwife brings over another patient from a neighboring bed who does speak the language. I speak to the midwife in English, who translates into Luganda, and then the neighbor-patient translates into Japadhola. Yes, these are optimal circumstances under which to discuss life-threatening hemorrhage and family planning options.

I start to explain, and, as usual, there is a lot of back-and-forth before anything is translated back into English for me. At this point, I have realized that when people translate for me here, they are not just language translators, but cultural translators as well. If they were to translate what I say word-for-word, it would still be an awkward and highly unnatural conversation because the way that I think and express myself is so foreign. As long as the translator knows what needs to be communicated, I give them leeway.

I get enough translated to understand that the patient still feels that she does not want more children, especially because she almost died this time. That’s good. Now I need to explain the IUD. I need to tell her that it is as effective as cutting the tubes, and that if she doesn’t want more children, she can leave it in place. But because I put it in without asking her, I feel that I need to express to her that she has every right to have it removed, and I will do it myself if she wants. The midwife responds to me (before translating) that the patient should leave it in so she doesn’t get pregnant. I tell the midwife that I agree, but I want the patient to have options, because I didn’t give her any when I did the surgery.

The midwife understands and explains this to the patient. It sounds like it is going well, when a patient from another bed (who I did a cesarean on the day before this patient) chimes in. She seems to be giving strong words of advice to the patient in Japadhola. Then other people in the ward also shout in comments. I ask the midwife what they are saying. She explains that they are all advising her to keep the IUD in, and they are telling her their own life-threatening birth experiences and how dangerous it is, and how she should accept the family planning so she doesn’t die.

I chuckle a little because this situation is the opposite of what I had been taught to do. No privacy, people shouting random advice about their own experience, a telephone-game of translation, and a sullen patient. But then, she seems to be coming around to the advice, and she finally agrees that she will keep the IUD in for now, and that if they ever decide to have another child, she knows she can remove it later. I am still uncomfortable about the lack of privacy, but who am I to say that my culture’s counseling methods should be imposed here? Sometimes I just need to go with the flow and hope it all works out for the better.

The patient steadily recovers, and the baby does well. The husband seems content, and finally she is ready to go home. This patient was the closest I have come to having someone die under my care in Uganda, and she survived by a hair. I hope she keeps that IUD in.

4 comments:

Casimir said...

Veronica,

You're doing amazing work. And the way you capture it here is fantastic.

I spread the word a bit on this blog if you don't mind and am looking forward to more updates.

I'm rooting for you.

Lara said...

Veronica,
God, it's unbelievable how many steps in the process fall apart... I can just picture the scenario you describe. I assume all the time the anesthetist was resuscitating the newborn, no one was manually ventilating the pt? That was the weirdest experience, realizing that the 'pulse' in the 60s was actually an O2 sat! I'm impressed you've stuck it out so long - it's draining over time. Take care and say hi to everyone for me. Best, Lara

aaaapquik said...
This comment has been removed by the author.
Chris said...

Veronica,

I'm so impressed you do all of this and then have the wherewithal to write it so clearly and compellingly. This is some of the best perspective I've gotten on another culture, and I imagine it's just a piece of what it's really like. Thank you so much for sharing this.

-Chris R.