I am back in Tororo for a brief visit. Only 2 weeks - much too short, but it's all I could fit in on this trip.
I am delayed by a day in Kampala due to car troubles, and when I finally arrive the next day, there are many hugs to be had. The midwives tell me they were excitedly waiting for me all day yesterday. It is wonderful to see them.
In the afternoon on the day I arrive, I am dashing out of the clinic to a meeting, and I see a woman sitting in the waiting area looking directly at me. When the patients who have come to see me (non-research patients) can't find me, they sit there, sometimes for hours, until they see me walking in or out. She is looking at me so intently that I know she must be there for me.
She approaches. She looks familiar, and I know I treated her for something, but I can't remember what. Maybe infertility? Pelvic pain?
"Are you looking for me?" I ask.
"Yes, for you," she says. "I have come many times for you, but they told me you are away."
"Yes, I am sorry, I have been away. What is your name?"
"P_____." I still can't remember what I saw her for, but it wasn't obstetric.
"Do you want to see me?" She nods. I can't see her now because of my meeting. I know that the next two days will be a blur of meetings because all of the investigators are coming to discuss all of the research that is going on. It should be calmer by Friday.
"Come and see me on Friday," I tell her. I give her my phone number and tell her to call before she comes, because I know that whenever I make plans like this, something comes up. I also tell her to bring any notes that I wrote, so that I can remind myself why I saw her and what I did.
The next morning, I find out that I need to go to Kampala for an urgent meeting on Friday. I feel guilty that I will miss P.'s visit, and I don't have any way to reach her. I hope she calls first. Just in case, I tell some of the study clinic nurses about her, and tell them that she should come back Monday.
While I am at work that day, I get a phone call from an unrecognized number. It is a different patient.
"Hello, Dr. Veronica! This is O______! The midwife told me you were here."
I recognize her name, because it is an uncommon name in Uganda. She is a college girl whom I treated after her illegal abortion went awry, and she had continuous heavy bleeding. I gave her misoprostol and the bleeding stopped. She was very grateful at the time and came to see me twice more to thank me before I left in July.
(The anxiety surrounding illegal abortion makes a mild complication feel life-threatening. The patients I treat after illegal abortion are often convinced I saved their lives, whether or not they were particularly ill.)
"Hello, O. How are you?"
"I am very OK, Doctor."
Now I am wondering why she is calling. Am I remembering the wrong person? Does she have an ongoing problem that I need to continue treating? There is an awkward pause. Finally, I ask.
"Are you calling me because you have a problem, or to say hello?"
"No, Doctor, there is no problem. I am only calling you to say hello and to thank you for helping me. I am very grateful. I am very happy."
The next day, I travel to Kampala. While I am on the road, I get a phone call from P. She asks if she should come on Friday and I tell her to come instead on Monday, but to call first. She agrees.
Half an hour later, I get a text from the same number: "Am so grateful thank you very much for the drug you wrote for me am happy and pregnant. God bless u. P_____."
It's good to be back.
On Monday, P. comes to see me, and I review my notes. She has HIV that is well-controlled on meds, and I had seen her for pelvic pain, infertility, and secondary amenorrhea (disappearance of menstrual periods). In order to try to determine the root cause of her amenorrhea, I started her on oral contraceptives for 1 month. When she started the placebo week of pills, she should have seen a period due to progesterone withdrawal. From my notes, it appears that she did not bleed after the 1 month of pills, so instead I gave her a 5-day course of progesterone, which is the same idea. Once the progresterone is stopped, she should see bleeding.
There are no more notes from me after I gave her the progesterone. She didn't come back.
She tells me that after the progesterone pills, she didn't see any bleeding, but about 2 months after that, she took a pregnancy test and it was positive. She is thrilled.
She had a history of two miscarriages, and had been unable to get pregnant for about 5 years. Her boyfriend (who also has HIV) left her because she couldn't produce a child. From my notes, I see that she had a hysterosalpingogram to see if her tubes are open, and she was told they are blocked. I surmise that I was reluctant to give her any ovulation-inducing agents in light of this information (no point in ovulating if the eggs can't get through the tubes), so instead I decided to focus on bringing back her menstrual cycle. As it turns out, somehow, unexpectedly (and without a period), she got pregnant.
I don't know if it was the medication I gave her that did it. I wouldn't have expected it, since she didn't have a period after either treatment. But she got pregnant soon afterward. Maybe the pills helped kick her regular cycle back into action, or maybe her pregnancy is just a coincidence. I don't know. Either way, we are both happy.
I confirm that she is still on her HIV meds and attending antenatal care. Her boyfriend is supporting her now that she is pregnant, although he is still in Kampala. Because she had no period, I decide to do an ultrasound to determine her gestational age. I'll admit that part of me is worried that the pregnancy is somehow abnormal or that it was a false-positive pregnancy test.
When I do the ultrasound, I see a healthy baby boy at 25 weeks. I turn on the doppler so she can hear the heartbeat. She glows.
As it turns out, her due date is in early January, and I just may be back by the time she delivers. I tell her to look for me when she goes into labor.
Wednesday, September 22, 2010
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.
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.
Thursday, July 8, 2010
Too Late
My phone rings, waking me up. I stare at the blurry phone – the time is 6:30am. The call is from the Labor Ward.
The midwife tells me that there is a patient who has had 1 previous cesarean delivery. She had been laboring well, and was expected to deliver vaginally. Now she is fully dilated, but the baby is not coming down. The midwives suspect she needs a cesarean, and they want me to come and assess.
I ask some questions to get more details about the urgency. How is the fetal heart rate? Is there meconium? How long has she been fully dilated? It is a struggle to get information because this midwife has a hard time understanding my American accent over the phone. It might be urgent, but maybe not.
I try to get up and out of the house quickly, but because it is early morning, and because this is Uganda and everything takes a long time, it takes longer than I would like. I ride my motorbike over to the hospital, and head to Labor Ward when I arrive. The night midwives are still there, and the point me toward the patient.
She doesn’t speak English, and I don’t have enough time to search for the chart to figure out details; the exam is more important. I listen for the fetal heart, but the mother is very uncomfortable and keeps moving. We don’t have electronic fetal monitoring here, only a fetoscope, which is a cone-shaped tool that is pressed to the mother’s abdomen, and the midwife presses her ear against the other end to hear a faint ticking sound, which is the fetal heartbeat. I can’t hear the heartbeat with the patient moving like that. I ask the midwife to help me (they are so much better at it than I am), and she finds it. I hear it, but it sounds really fast. Also, it could be the mother’s heartbeat. When the mother herself is sick or stressed, her heart rate can be high and can be mistaken for the fetus’. I make a mental note to check her pulse, but first I want to do the vaginal exam to see what is going on with the delivery.
I put gloves on and examine her. There is thick, green meconium spilling from the perineum. Meconium can be a normal sign – a full term fetus can pass meconium in labor. But it can also be a sign of trouble, and it’s hard to differentiate when it is an ominous sign. We try to differentiate the thickness of the meconium, assuming that thicker is worse, but it is still a weak predictive tool. Nonetheless, it makes all obstetricians nervous.
I palpate the presenting part. What I feel is very soft and bulging, almost like amniotic membrane. Are her membranes intact? I ask the midwife, and she agrees that it feels like membrane. But that doesn’t make sense, because meconium in in the amniotic fluid – the membranes have to be ruptured for the meconium to be visible.
I palpate further, hoping to feel a firm, hairy head beyond the membranes, but all I feel is mushiness and a strange contour. Suddenly I realize what I am feeling: the baby’s butt. The baby is breech.
I tell the midwife, and she is shocked. At the same time, she immediately realizes I am right – that is what they were feeling all along. It could also explain the slow descent of the baby, as breech infants are slower to deliver.
But what should we do now? The baby’s butt is extremely low in the woman’s pelvis. It almost feels like I could pull it out. If she were earlier in her labor, we just would have taken her for cesarean. But now the baby is close to being out. Moving her to theatre always takes at least an hour. If this baby is as stressed as it seems, it might not have an hour. Maybe I can get this baby out if I can help her push effectively.
I encourage her to push with the next contraction. I ask her to put her chin to her chest, curl around her baby, and lift her legs. She pushes better in that position. I have observed that the midwives often blame the patient for poor pushing when the presenting part doesn’t move (part of the culture here, it seems), but sometimes it isn’t the woman’s fault, it’s just the mechanics of the situation. I can see she is really pushing hard.
We try pushing through three contractions. At first it seems like we are making progress. The midwife notes that this is much more effective than before. But after 3 pushes, it is clear we are not getting anywhere. I don’t want to give up, but I don’t want to let this baby die, either. I call the cesarean.
It is not an easy call. Doing a second cesarean on a patient dooms her to a cesarean for life. And in Uganda, that means either 6 or more cesareans, or limiting her childbearing – which will damage her social standing with her husband and her husband’s family, and sometimes provides a reason for the husband to take on additional wives. Furthermore, what if she can’t get to a hospital for that third cesarean? That could be fatal. If only she could push the baby just a little further it would be out.
But I can feel that the hips are not oriented perfectly straight within her pelvis. They are tilted ever so slightly to one side, which could be what is limiting the descent. The longer I wait, the more chance that this baby will not survive.
I ask the midwife her opinion. “Doctor, that is for you to decide. I have tried and failed, and now I am asking you.” That settles it. They have tried, and I have tried. I ask them to prepare the patient.
Getting the patient to theatre always takes a while. There is no such thing as an emergency (or “crash” cesarean). It’s more like as soon as possible…..which is never very soon.
There are several reasons for this. The midwives are usually very few taking care of many patients. In order to prepare a patient for theatre, they need to have her sign the consent, they need to put in an IV, and they need to put in a urinary catheter.
In order to sign the consent, they need to find a midwife who speaks the patient’s language. With up to 5 local languages, this isn’t always easy. To put in an IV, they need to track down an IV needle, a “giving set” (what we call “IV tubing”) and a bottle of normal saline. None of these are guaranteed to be available. If they are, they are never all in the same place, usually stored in a different building. The midwives have to search several different places to see if there are any items hidden anywhere unexpected. If any item is not available, then the family member needs to be sent to town to buy it. To put in a urinary catheter, the midwives need to find that too, and if not, they need to send the family to town.
After that, the midwife needs to find the stretcher – a narrow, poorly rolling tray-on-wheels, both of whose guardrails are broken and hang limply. They drag the stretcher next to the patient, have her move onto the stretcher, and then they wheel her on the jagged, uneven concrete walkways to the theatre.
In order to cover the patient after the cesarean and to wrap the baby, the patient needs to have brought many sheets (usually large pieces of colorful cloth). If she didn’t, there are no sheets available, and this is another delay while the family buys them from town or finds a street seller who walks around the hospital selling cloth and plastic basins.
On top of all this inefficiency, the midwives are caring for many patients at once. Others may be delivering at the same time, so they need to shift their attention back and forth.
Lastly, there is little sense of urgency here. In the US, when there is a true emergency on the labor floor, every nurse, doctor, scrub tech and other staff member feels as if the action they take every single second could decide whether the baby lives or dies. People spring into action, nurses covering other patients come over to help start IVs, get medications, catheterize, whatever. Residents jump in – one consents the patient, another talks to the father of the baby, another prepares to move the stretcher, and another starts scrubbing. We know our actions will make a difference.
Here, that sense of empowerment is weak. The sense that 10 seconds can be life-or-death is not there. People see stillbirths all the time – it is thought of as nature: unpredictable, unchangeable. Although they know that their actions are important, the urgency is more of a broad feeling than a moment-to-moment tension. People sometimes do things right away, but never at a running pace. Seconds add up.
As usual, it takes about an hour to get to theatre. I find that whether or not I hover around the Labor Ward and anxiously implore people to move faster has no effect on how quickly the patient gets moved; it only makes me more anxious. I try to do other things while I am waiting, in order to distract myself and avoid frustration. But it is a difficult balance, because when I do this, I also feel a little bit like I am abandoning the patient.
When we get to theatre, we move the patient onto the operating table. That is when I remember that I didn’t check the patients pulse and compare it to the fetal heart rate I am hearing. There is a small but real chance that the heartbeat I heard could have been the mother’s, and the baby’s could be low, or the baby could even be dead. Nonetheless, would it change my current management? Not really. She has not been able to push out the breech fetus, and she has a previous scar on her abdomen, so even if the fetus was dead, I would probably have to do the cesarean anyway in order to avoid the very real risk of uterine rupture. If I were to wait for the midwife to go back to Labor Ward to get a fetoscope and bring it back, that would delay the cesarean even further. I decide to proceed.
The patient’s previous scar is a vertical scar on her abdomen. I prefer to use a low horizontal incision, called a pfannenstiel incision, because it has less postoperative pain and better wound healing. But when someone already has a previous scar, we usually use the old scar to avoid creating a T-scar on the abdomen, which would be ugly and heal poorly. I make the incision between her umbilicus and her pubic symphysis, following her old scar. When I get to the uterus, I find a cystic, bubble-like structure blocking my view to the rest of the abdomen. It is attached to the anterior lower surface of the uterus. It must be the bladder attachment – not the bladder itself (which I can see is lower down) but the filmy tissue that attaches the bladder to the peritoneum. It is hard to know when that tissue actually becomes the bladder, especially since it is completely stuck to the uterus. It bubble-like quality is also very strange; I wonder why it is bulging out like that. It could be that the pressure from the very low descended fetus is causing some compression and edema of the lower uterus and anything around it. That bubble might be part of the bladder, I can’t tell, and I can’t cut it, just to be safe.
The problem is that it is blocking the entire area I want to operate on. We usually make a horizontal incision in the lower uterine segment – a thinner, less muscular part of the uterus that heals well. But the lower uterine segment is blocked by this bubble. I have no choice but to do a classical incision – a vertical incision higher up on the uterus, through the thick muscular portion of the uterus. This tends to bleed more, take longer to repair, and have a higher risk of rupture with later deliveries, but at the moment I have no choice. I have to get this baby out, and fast.
I cut through the uterus, careful to avoid the bubble. The baby is easy to pull out. I can see that the baby is blue and not moving. This is not good, although a lot of the babies come out sedated and weak because the anesthetists here use general anesthesia (rather than spinal anesthesia, in which they are not trained) and this sedates the baby as well. They all look weak at first; it’s hard to know which ones will be ok right when I pull them out.
I hand the baby off to the midwife and start sewing. The classical incision bleeds heavy and fast. What’s more, after all this long labor, the uterus might easily be infected, and this also causes a lot of bleeding. I never think about the baby at this point. I need to focus completely on the mother, because she can bleed out in a matter of minutes. Once the bleeding is controlled, I can ask how the baby is, but not before.
It takes a while to close the uterus because of the vertical incision through thick tissue. It requires two layers. As I am finishing the second layer, I hear the anesthetist ask how the baby is.
The midwife says “Still not very good. Still no heartbeat.”
“Not very good” is a bit of an understatement – this is also known as dead.
The resuscitation skills of the midwives, while not exactly textbook, are pretty good. They do what they can. The big thing they usually miss is giving oxygen, and this is because the concentrator is usually unavailable or broken. But in this case it could truly be lifesaving. I ask the midwife whether she gave oxygen. Only then I find out that the oxygen concentrator is not in theatre. It was lent to some ward and no one knows which, and there is no oxygen for the baby. The baby might have been saved through aggressive intervention. Then again, it’s also possible that the baby has been dead since I first saw the patient. I don’t know.
I am sad for this mother. I have just done her second caesar, which dooms her to caesar forever. She will have to recover from this painful operation while grieving for her dead baby. The classical incision puts her at higher risk of complication in the next pregnancy.
If her breech presentation had been recognized earlier in labor and her cesarean performed, would the baby have survived? Probably. If I had been faster in getting to the hospital from home? Maybe. If she had been moved more efficiently from the Labor Ward to theatre? Possibly. If we had had oxygen in theatre? Hard to say – the baby was pretty bad, and might have required more aggressive intervention than we can give. Would her baby have survived if she had been pregnant and delivered in the US? Undoubtedly.
The midwife tells me that there is a patient who has had 1 previous cesarean delivery. She had been laboring well, and was expected to deliver vaginally. Now she is fully dilated, but the baby is not coming down. The midwives suspect she needs a cesarean, and they want me to come and assess.
I ask some questions to get more details about the urgency. How is the fetal heart rate? Is there meconium? How long has she been fully dilated? It is a struggle to get information because this midwife has a hard time understanding my American accent over the phone. It might be urgent, but maybe not.
I try to get up and out of the house quickly, but because it is early morning, and because this is Uganda and everything takes a long time, it takes longer than I would like. I ride my motorbike over to the hospital, and head to Labor Ward when I arrive. The night midwives are still there, and the point me toward the patient.
She doesn’t speak English, and I don’t have enough time to search for the chart to figure out details; the exam is more important. I listen for the fetal heart, but the mother is very uncomfortable and keeps moving. We don’t have electronic fetal monitoring here, only a fetoscope, which is a cone-shaped tool that is pressed to the mother’s abdomen, and the midwife presses her ear against the other end to hear a faint ticking sound, which is the fetal heartbeat. I can’t hear the heartbeat with the patient moving like that. I ask the midwife to help me (they are so much better at it than I am), and she finds it. I hear it, but it sounds really fast. Also, it could be the mother’s heartbeat. When the mother herself is sick or stressed, her heart rate can be high and can be mistaken for the fetus’. I make a mental note to check her pulse, but first I want to do the vaginal exam to see what is going on with the delivery.
I put gloves on and examine her. There is thick, green meconium spilling from the perineum. Meconium can be a normal sign – a full term fetus can pass meconium in labor. But it can also be a sign of trouble, and it’s hard to differentiate when it is an ominous sign. We try to differentiate the thickness of the meconium, assuming that thicker is worse, but it is still a weak predictive tool. Nonetheless, it makes all obstetricians nervous.
I palpate the presenting part. What I feel is very soft and bulging, almost like amniotic membrane. Are her membranes intact? I ask the midwife, and she agrees that it feels like membrane. But that doesn’t make sense, because meconium in in the amniotic fluid – the membranes have to be ruptured for the meconium to be visible.
I palpate further, hoping to feel a firm, hairy head beyond the membranes, but all I feel is mushiness and a strange contour. Suddenly I realize what I am feeling: the baby’s butt. The baby is breech.
I tell the midwife, and she is shocked. At the same time, she immediately realizes I am right – that is what they were feeling all along. It could also explain the slow descent of the baby, as breech infants are slower to deliver.
But what should we do now? The baby’s butt is extremely low in the woman’s pelvis. It almost feels like I could pull it out. If she were earlier in her labor, we just would have taken her for cesarean. But now the baby is close to being out. Moving her to theatre always takes at least an hour. If this baby is as stressed as it seems, it might not have an hour. Maybe I can get this baby out if I can help her push effectively.
I encourage her to push with the next contraction. I ask her to put her chin to her chest, curl around her baby, and lift her legs. She pushes better in that position. I have observed that the midwives often blame the patient for poor pushing when the presenting part doesn’t move (part of the culture here, it seems), but sometimes it isn’t the woman’s fault, it’s just the mechanics of the situation. I can see she is really pushing hard.
We try pushing through three contractions. At first it seems like we are making progress. The midwife notes that this is much more effective than before. But after 3 pushes, it is clear we are not getting anywhere. I don’t want to give up, but I don’t want to let this baby die, either. I call the cesarean.
It is not an easy call. Doing a second cesarean on a patient dooms her to a cesarean for life. And in Uganda, that means either 6 or more cesareans, or limiting her childbearing – which will damage her social standing with her husband and her husband’s family, and sometimes provides a reason for the husband to take on additional wives. Furthermore, what if she can’t get to a hospital for that third cesarean? That could be fatal. If only she could push the baby just a little further it would be out.
But I can feel that the hips are not oriented perfectly straight within her pelvis. They are tilted ever so slightly to one side, which could be what is limiting the descent. The longer I wait, the more chance that this baby will not survive.
I ask the midwife her opinion. “Doctor, that is for you to decide. I have tried and failed, and now I am asking you.” That settles it. They have tried, and I have tried. I ask them to prepare the patient.
Getting the patient to theatre always takes a while. There is no such thing as an emergency (or “crash” cesarean). It’s more like as soon as possible…..which is never very soon.
There are several reasons for this. The midwives are usually very few taking care of many patients. In order to prepare a patient for theatre, they need to have her sign the consent, they need to put in an IV, and they need to put in a urinary catheter.
In order to sign the consent, they need to find a midwife who speaks the patient’s language. With up to 5 local languages, this isn’t always easy. To put in an IV, they need to track down an IV needle, a “giving set” (what we call “IV tubing”) and a bottle of normal saline. None of these are guaranteed to be available. If they are, they are never all in the same place, usually stored in a different building. The midwives have to search several different places to see if there are any items hidden anywhere unexpected. If any item is not available, then the family member needs to be sent to town to buy it. To put in a urinary catheter, the midwives need to find that too, and if not, they need to send the family to town.
After that, the midwife needs to find the stretcher – a narrow, poorly rolling tray-on-wheels, both of whose guardrails are broken and hang limply. They drag the stretcher next to the patient, have her move onto the stretcher, and then they wheel her on the jagged, uneven concrete walkways to the theatre.
In order to cover the patient after the cesarean and to wrap the baby, the patient needs to have brought many sheets (usually large pieces of colorful cloth). If she didn’t, there are no sheets available, and this is another delay while the family buys them from town or finds a street seller who walks around the hospital selling cloth and plastic basins.
On top of all this inefficiency, the midwives are caring for many patients at once. Others may be delivering at the same time, so they need to shift their attention back and forth.
Lastly, there is little sense of urgency here. In the US, when there is a true emergency on the labor floor, every nurse, doctor, scrub tech and other staff member feels as if the action they take every single second could decide whether the baby lives or dies. People spring into action, nurses covering other patients come over to help start IVs, get medications, catheterize, whatever. Residents jump in – one consents the patient, another talks to the father of the baby, another prepares to move the stretcher, and another starts scrubbing. We know our actions will make a difference.
Here, that sense of empowerment is weak. The sense that 10 seconds can be life-or-death is not there. People see stillbirths all the time – it is thought of as nature: unpredictable, unchangeable. Although they know that their actions are important, the urgency is more of a broad feeling than a moment-to-moment tension. People sometimes do things right away, but never at a running pace. Seconds add up.
As usual, it takes about an hour to get to theatre. I find that whether or not I hover around the Labor Ward and anxiously implore people to move faster has no effect on how quickly the patient gets moved; it only makes me more anxious. I try to do other things while I am waiting, in order to distract myself and avoid frustration. But it is a difficult balance, because when I do this, I also feel a little bit like I am abandoning the patient.
When we get to theatre, we move the patient onto the operating table. That is when I remember that I didn’t check the patients pulse and compare it to the fetal heart rate I am hearing. There is a small but real chance that the heartbeat I heard could have been the mother’s, and the baby’s could be low, or the baby could even be dead. Nonetheless, would it change my current management? Not really. She has not been able to push out the breech fetus, and she has a previous scar on her abdomen, so even if the fetus was dead, I would probably have to do the cesarean anyway in order to avoid the very real risk of uterine rupture. If I were to wait for the midwife to go back to Labor Ward to get a fetoscope and bring it back, that would delay the cesarean even further. I decide to proceed.
The patient’s previous scar is a vertical scar on her abdomen. I prefer to use a low horizontal incision, called a pfannenstiel incision, because it has less postoperative pain and better wound healing. But when someone already has a previous scar, we usually use the old scar to avoid creating a T-scar on the abdomen, which would be ugly and heal poorly. I make the incision between her umbilicus and her pubic symphysis, following her old scar. When I get to the uterus, I find a cystic, bubble-like structure blocking my view to the rest of the abdomen. It is attached to the anterior lower surface of the uterus. It must be the bladder attachment – not the bladder itself (which I can see is lower down) but the filmy tissue that attaches the bladder to the peritoneum. It is hard to know when that tissue actually becomes the bladder, especially since it is completely stuck to the uterus. It bubble-like quality is also very strange; I wonder why it is bulging out like that. It could be that the pressure from the very low descended fetus is causing some compression and edema of the lower uterus and anything around it. That bubble might be part of the bladder, I can’t tell, and I can’t cut it, just to be safe.
The problem is that it is blocking the entire area I want to operate on. We usually make a horizontal incision in the lower uterine segment – a thinner, less muscular part of the uterus that heals well. But the lower uterine segment is blocked by this bubble. I have no choice but to do a classical incision – a vertical incision higher up on the uterus, through the thick muscular portion of the uterus. This tends to bleed more, take longer to repair, and have a higher risk of rupture with later deliveries, but at the moment I have no choice. I have to get this baby out, and fast.
I cut through the uterus, careful to avoid the bubble. The baby is easy to pull out. I can see that the baby is blue and not moving. This is not good, although a lot of the babies come out sedated and weak because the anesthetists here use general anesthesia (rather than spinal anesthesia, in which they are not trained) and this sedates the baby as well. They all look weak at first; it’s hard to know which ones will be ok right when I pull them out.
I hand the baby off to the midwife and start sewing. The classical incision bleeds heavy and fast. What’s more, after all this long labor, the uterus might easily be infected, and this also causes a lot of bleeding. I never think about the baby at this point. I need to focus completely on the mother, because she can bleed out in a matter of minutes. Once the bleeding is controlled, I can ask how the baby is, but not before.
It takes a while to close the uterus because of the vertical incision through thick tissue. It requires two layers. As I am finishing the second layer, I hear the anesthetist ask how the baby is.
The midwife says “Still not very good. Still no heartbeat.”
“Not very good” is a bit of an understatement – this is also known as dead.
The resuscitation skills of the midwives, while not exactly textbook, are pretty good. They do what they can. The big thing they usually miss is giving oxygen, and this is because the concentrator is usually unavailable or broken. But in this case it could truly be lifesaving. I ask the midwife whether she gave oxygen. Only then I find out that the oxygen concentrator is not in theatre. It was lent to some ward and no one knows which, and there is no oxygen for the baby. The baby might have been saved through aggressive intervention. Then again, it’s also possible that the baby has been dead since I first saw the patient. I don’t know.
I am sad for this mother. I have just done her second caesar, which dooms her to caesar forever. She will have to recover from this painful operation while grieving for her dead baby. The classical incision puts her at higher risk of complication in the next pregnancy.
If her breech presentation had been recognized earlier in labor and her cesarean performed, would the baby have survived? Probably. If I had been faster in getting to the hospital from home? Maybe. If she had been moved more efficiently from the Labor Ward to theatre? Possibly. If we had had oxygen in theatre? Hard to say – the baby was pretty bad, and might have required more aggressive intervention than we can give. Would her baby have survived if she had been pregnant and delivered in the US? Undoubtedly.
Thursday, July 1, 2010
Stick
I stop by Labor Ward to drop off an operative note I had written on a patient earlier that day. The midwife tells me “There are patients for you.” I tease her that she is drumming up too much business for me. Then I ask her the details.
There are 3 women who need D&Cs (uterine evacuation). One is a person I had seen yesterday who had an early pregnancy that failed. The plan is to do a D&C but she ate lunch, which means she can’t undergo anesthesia today. I write a prescription for misoprostol in the hope that she can avoid a D&C altogether, but at USH 3000 ($1.50) per pill and needing 4 pills, I highly doubt she can afford it.
The other two women are lying in beds on labor ward. Instinctively, one seems sicker than the other, so I start with the sick-looking one. The nurse tells me that she was “BBA” and she has “retained products”. BBA means birth before arrival, which implies a third trimester pregnancy in which the patient delivered at home (or on the way) but came in after delivery, usually for a complication. However, “retained products” implies that the patient had a first trimester miscarriage, but not all of the products of conception came out of the uterus at the time of the miscarriage, and she still has pain, bleeding and possibly infection.
It doesn’t make sense for the patient to be BBA and have retained products – but then I think that maybe the midwife means that part of the placenta is still inside. I try to ask the details, but it seems that the patient has been referred from elsewhere, and it wasn’t the midwives at TDH who diagnosed the “retained products.”
I find that often these terms are thrown around at random, and often the actual complaint has nothing to do with the supposed presenting description. I can’t count how many times I have been sent patients with “cervical prolapse” who actually turn out to have abdominal pain (and no prolapse at all).
So I always start from the beginning, by interviewing the patient. I walk up to the patient and greet her.
ME: Do you speak English?
PATIENT: (blank stare)
Often when the patients don’t speak English, they don’t recognize the word “English.” The word for English in the local languages is “Luzungu.” The prefix Lu- implies language, so the Baganda people speak Luganda. And –zungu comes from mzungu, the word for foreigner. So Luzungu is literally the language of mzungus (actually the prefix Wa- is for plurals, so more than one mzungu becomes wazungu).
ME: Do you speak Luzungu?
PATIENT: I speak.
(Which means she speaks English).
ME: So what happened?
PATIENT: (blank stare)
MIDWIFE: You tell doctor what happened!
PATIENT: (blank stare)
MIDWIFE: Did you have a baby?
PATIENT: Yes
MIDWIFE: Boy or girl?
PATIENT: Boy.
ME: Then what happened?
PATIENT: (blank stare)
MIDWIFE: You talk to doctor! Did the placenta come out?
PATIENT: No.
MIDWIFE: Who removed it?
PATIENT: Nurse.
ME: Then what happened?
PATIENT: (blank stare)
MIDWIFE: What happened after that. Why were you sent here?
PATIENT: (blank stare)
OK, we are not getting anywhere. The patient won’t give us any narrative at all, and I haven’t been able to discern why the other health center suspected retained products if the placenta was removed. Was it removed in pieces? Is she still bleeding?
I decide to examine her. I realize that if I need to remove products of conception from both patients, I will need 2 speculums.
ME: Are there speculums?
MIDWIFE: Yes. I sterilized.
ME: How many?
MIDWIFE: One.
Well, hopefully only one will need a speculum. The midwife brings me gloves to do a vaginal exam and see if the cervical os is open. Immediately, I feel that there is a large chunk of products hanging out of the os, which is open about 2-3 cm. The patient is uncomfortable, but I encourage her to bear the discomfort. If I can yank out this piece, this might be all she needs to stop bleeding and get her cervix to close. I might not even need a speculum. I pull it out, and see that it is a chunk of placenta.
I reach in again to palpate inside the cervix to see if there is any more placenta left inside. The cervix is so dilated I can actually reach inside the uterus. My finger touches something surprisingly hard inside the uterus. What is that? Is it bone? That doesn’t make sense – she said she delivered a live infant. Where would bone come from?
I reach further in and the patient struggles against me. The midwife admonishes her.
MIDWIFE: You bear! Doctor is helping you!
I manage to hook my finger around the hard thing and pull it out. It’s a stick. I stare at it in shock. The two midwives watching me both shriek with surprise.
MIDWIFE: It is criminal abortion!
I don’t like that term at all. I suppose in actual meaning it is no different from “illegal” abortion, but it sounds much more judgmental. It also reminds me of a quote I heard at FIGO: “The discussion is not ‘is the fetus a life from the time of conception and has moral value?’ The discussion is ‘should women who have abortions be criminalized?’” No law has ever stopped abortion; law has only made it illegal.
But at that moment I am too shocked to react to the term. I know that people use sticks to induce abortions. I have heard horror stories of patients coming in with holes in the uterus, sometimes with the sticks still poking through. But I have never seen it myself. I can’t stop staring at the stick. It is about 4cm long, such a hard, vulgar piece of plastic. I can’t believe I just pulled it out of this poor girl’s uterus.
Suddenly I realize that the midwives are talking loudly, chastising the patient, and public discussing the patient’s “criminal abortion” with the family member of the patient in the next bed. All three are shaking their heads and publicly bemoaning the discovery. I feel badly for this patient, who is probably terrified on several levels, and who was so desperate to abort this pregnancy that she let someone do this to her.
One of the midwives is telling the patient she could have died. I’ll admit: this is true. I get chills thinking about how easily that stick could have punctured her uterus. (In fact, it still might have, I need to evaluate her more thoroughly). The midwife tells her that last year, there was a woman who died after coming in with sticks in her uterus like that. The patient maintains her blank stare, which I suppose is an effective protective mechanism.
I try to get the midwives to stop loudly chastising the girl, and try to offer comments about how she must have been desperate, and how we should be sympathetic, but I am ignored. I decide to just move on to the next patient and hope they settle down.
But while I am trying to speak to her, I can’t even hear what she is saying because there is so much loud bemoaning. Finally I call for quiet, and they realize and stop.
Both patients need ultrasound. I go back to the clinic to get the machine. I am still pretty stunned from finding that stick in the uterus.
I scan the first patient, and find that her uterus is still thick with blood and probably some products, and she needs a D&C. A D&C is probably optimal because it will allow me to clear the rest of the uterine contents, and also to make sure there are no more sticks inside. There is no free fluid in her abdomen and she has no signs of uterine perforation, which is good. The second patient is fine and I send her home.
The D&C is uncomplicated, and I find no more sticks, only blood and some small amount of membrane. It could have been so much worse.
There are 3 women who need D&Cs (uterine evacuation). One is a person I had seen yesterday who had an early pregnancy that failed. The plan is to do a D&C but she ate lunch, which means she can’t undergo anesthesia today. I write a prescription for misoprostol in the hope that she can avoid a D&C altogether, but at USH 3000 ($1.50) per pill and needing 4 pills, I highly doubt she can afford it.
The other two women are lying in beds on labor ward. Instinctively, one seems sicker than the other, so I start with the sick-looking one. The nurse tells me that she was “BBA” and she has “retained products”. BBA means birth before arrival, which implies a third trimester pregnancy in which the patient delivered at home (or on the way) but came in after delivery, usually for a complication. However, “retained products” implies that the patient had a first trimester miscarriage, but not all of the products of conception came out of the uterus at the time of the miscarriage, and she still has pain, bleeding and possibly infection.
It doesn’t make sense for the patient to be BBA and have retained products – but then I think that maybe the midwife means that part of the placenta is still inside. I try to ask the details, but it seems that the patient has been referred from elsewhere, and it wasn’t the midwives at TDH who diagnosed the “retained products.”
I find that often these terms are thrown around at random, and often the actual complaint has nothing to do with the supposed presenting description. I can’t count how many times I have been sent patients with “cervical prolapse” who actually turn out to have abdominal pain (and no prolapse at all).
So I always start from the beginning, by interviewing the patient. I walk up to the patient and greet her.
ME: Do you speak English?
PATIENT: (blank stare)
Often when the patients don’t speak English, they don’t recognize the word “English.” The word for English in the local languages is “Luzungu.” The prefix Lu- implies language, so the Baganda people speak Luganda. And –zungu comes from mzungu, the word for foreigner. So Luzungu is literally the language of mzungus (actually the prefix Wa- is for plurals, so more than one mzungu becomes wazungu).
ME: Do you speak Luzungu?
PATIENT: I speak.
(Which means she speaks English).
ME: So what happened?
PATIENT: (blank stare)
MIDWIFE: You tell doctor what happened!
PATIENT: (blank stare)
MIDWIFE: Did you have a baby?
PATIENT: Yes
MIDWIFE: Boy or girl?
PATIENT: Boy.
ME: Then what happened?
PATIENT: (blank stare)
MIDWIFE: You talk to doctor! Did the placenta come out?
PATIENT: No.
MIDWIFE: Who removed it?
PATIENT: Nurse.
ME: Then what happened?
PATIENT: (blank stare)
MIDWIFE: What happened after that. Why were you sent here?
PATIENT: (blank stare)
OK, we are not getting anywhere. The patient won’t give us any narrative at all, and I haven’t been able to discern why the other health center suspected retained products if the placenta was removed. Was it removed in pieces? Is she still bleeding?
I decide to examine her. I realize that if I need to remove products of conception from both patients, I will need 2 speculums.
ME: Are there speculums?
MIDWIFE: Yes. I sterilized.
ME: How many?
MIDWIFE: One.
Well, hopefully only one will need a speculum. The midwife brings me gloves to do a vaginal exam and see if the cervical os is open. Immediately, I feel that there is a large chunk of products hanging out of the os, which is open about 2-3 cm. The patient is uncomfortable, but I encourage her to bear the discomfort. If I can yank out this piece, this might be all she needs to stop bleeding and get her cervix to close. I might not even need a speculum. I pull it out, and see that it is a chunk of placenta.
I reach in again to palpate inside the cervix to see if there is any more placenta left inside. The cervix is so dilated I can actually reach inside the uterus. My finger touches something surprisingly hard inside the uterus. What is that? Is it bone? That doesn’t make sense – she said she delivered a live infant. Where would bone come from?
I reach further in and the patient struggles against me. The midwife admonishes her.
MIDWIFE: You bear! Doctor is helping you!
I manage to hook my finger around the hard thing and pull it out. It’s a stick. I stare at it in shock. The two midwives watching me both shriek with surprise.
MIDWIFE: It is criminal abortion!
I don’t like that term at all. I suppose in actual meaning it is no different from “illegal” abortion, but it sounds much more judgmental. It also reminds me of a quote I heard at FIGO: “The discussion is not ‘is the fetus a life from the time of conception and has moral value?’ The discussion is ‘should women who have abortions be criminalized?’” No law has ever stopped abortion; law has only made it illegal.
But at that moment I am too shocked to react to the term. I know that people use sticks to induce abortions. I have heard horror stories of patients coming in with holes in the uterus, sometimes with the sticks still poking through. But I have never seen it myself. I can’t stop staring at the stick. It is about 4cm long, such a hard, vulgar piece of plastic. I can’t believe I just pulled it out of this poor girl’s uterus.
Suddenly I realize that the midwives are talking loudly, chastising the patient, and public discussing the patient’s “criminal abortion” with the family member of the patient in the next bed. All three are shaking their heads and publicly bemoaning the discovery. I feel badly for this patient, who is probably terrified on several levels, and who was so desperate to abort this pregnancy that she let someone do this to her.
One of the midwives is telling the patient she could have died. I’ll admit: this is true. I get chills thinking about how easily that stick could have punctured her uterus. (In fact, it still might have, I need to evaluate her more thoroughly). The midwife tells her that last year, there was a woman who died after coming in with sticks in her uterus like that. The patient maintains her blank stare, which I suppose is an effective protective mechanism.
I try to get the midwives to stop loudly chastising the girl, and try to offer comments about how she must have been desperate, and how we should be sympathetic, but I am ignored. I decide to just move on to the next patient and hope they settle down.
But while I am trying to speak to her, I can’t even hear what she is saying because there is so much loud bemoaning. Finally I call for quiet, and they realize and stop.
Both patients need ultrasound. I go back to the clinic to get the machine. I am still pretty stunned from finding that stick in the uterus.
I scan the first patient, and find that her uterus is still thick with blood and probably some products, and she needs a D&C. A D&C is probably optimal because it will allow me to clear the rest of the uterine contents, and also to make sure there are no more sticks inside. There is no free fluid in her abdomen and she has no signs of uterine perforation, which is good. The second patient is fine and I send her home.
The D&C is uncomplicated, and I find no more sticks, only blood and some small amount of membrane. It could have been so much worse.
Thursday, June 24, 2010
Sickler
One of the nurses on Female Ward wants me to see a friend of hers, who is having bleeding after delivering a baby recently. It sounds normal to me, but I tell her to send the woman to my clinic to see what is going on.
Later that day, the woman arrives in my clinic. She explains that she gave birth in March, and then in April, she had bleeding for about a week and a half, along with some right-sided abdominal pain. She was given antibiotics (as usual – they are given for everything here) and the bleeding stopped. She did not see bleeding again until just over a week ago, when she had bleeding for 1 week, which stopped on its own. The right-sided pain had never gone away; it was not associated with bleeding but did seem to be worse when she was bending over or lifting something.
It sounds to me like the woman is getting her period. I tell her this. She is surprised. She is breastfeeding, so she expected not to see her period. I tell her that she can have bleeding sometimes, even though she may not be ovulating and that, in fact, the bleeding can last longer than a usual period because the body doesn’t have its normal hormonal pattern, and so it doesn’t really tell the uterus when to stop bleeding.
As I am telling her this, I can feel the tension from the elephant in the room. The nurse who referred the woman had told me that the woman kept having babies with sickle cell disease. The woman looks profoundly sad – the kind of sad that is not just today, but that accumulates over years, until the person doesn’t even realize she is sad, because it feels normal.
I ask her about the sickle cell problem. She tells me that her three previous children were all born with sickle cell disease, but she has not yet tested the infant. Of the three, one died at age 6 – and before dying, that child had a major stroke, and then a second stroke with seizures that caused the death. Of the living children, her oldest, a 9-year-old girl, had a stroke a few years ago, and now can walk but has difficulty with speech, and her entire left side, including face, arm, hand and leg, are partially paralyzed. As she talks, I can see the weight of this burden emerging on her face. Her eyes become teary, but she keeps talking.
Finally, we get around to doing the physical exam. Although the bleeding sounds normal to me, I do an ultrasound to make sure there are no fibroids or other sources of abnormal bleeding. It is normal, and there is nothing on the right side where she notes her abdominal pain. I do a vaginal exam to make sure there is no palpable cervical cancer, but it is normal too. I explain that the bleeding is just her menses. The pain is in an odd location – far from the pelvis but not really near any specific organ, at the level of her umbilicus but far to the right. It is not tender. To check for a hernia, I have her sit up with her belly exposed. There is no hernia, but there is a large diastasis. During pregnancy, the abdomnal rectus muscles (in the front of the abdomen) can become very weak and separate to accommodate the enlarged uterus. After delivery, they remain weak and as a woman sits up, there is a visible bulge in the center of her abdomen where the muscles have separated.
My guess is that her pain (which she notes is worst when she is trying to use her abdominal muscles) is probably because she is compensating for the lack of midline abdominal strength by using her side abdominal muscles, and preferentially her right side. I can’t be sure that this is the case, but it is my best guess. I recommend a daily routine of increasing repetitions of sit-ups. I teach her how to do them. She can’t even do one without using her hands.
This leads us back to a discussion of her children. She tells me that caring for her disabled and ill children is very time-consuming and takes all of her energy. I can see it. “You look tired,” I say. She has no help other than a young housekeeper (a “house girl”). I tell her that she needs to take 15 minutes for herself every day to do these exercises so that her pain and strength will improve. In truth, the exercises are not life or death, but I sense that this woman needs 15 minutes to herself once a day. She gives the other 23 hours and 45 minutes to her children.
I ask her how many more children she wants. She doesn’t have an answer. I tell her about the statistics of sickle disease – that if both parents are carriers (and clearly she and her husband are), the chances are 1 in 4 that any one child will be born with sickle cell disease. She is very unlucky, having had at least 3 with the disease. I tell her that she needs to think about how big she wants her family to be. There is no way to predict whether her current infant, or future children, will have the disease, but that she should assume that any further children will also have it – because she has to be prepared for the burden that might come if they do.
She starts to tell me more detail about the sickle cell disease that afflicts her children. She tells me at what age each of them started having symptoms, and she tells me about the events that led to the death of the one child. She tells me about the difficulties of caring for the 9-year-old, who cannot attend school and probably will never care for herself. As she talks, tears start to roll down her face. She dabs at them with a handkerchief.
“What about your husband?” I ask.
“He is a teacher,” she says.
“Does he want more children?”
“We have not discussed it,” she admits.
“You need to discuss it. He needs to understand what it is like for you. Maybe he does understand, I don’t know. Because for a father it is also hard. But for a mother, it is even harder to see your children suffer. If your child suffers, the mother suffers 100 times.”
She nods and sobs. “You understand what it is like for mothers, doctor.”
Well, I can’t say that I understand from personal experience, but I have known enough suffering mothers that at least I can make that observation. But that’s all she wants from me – validation and understanding. I can give both.
I encourage her again to consider family planning. “You love your children, but I can see that you are tired. You need to take care of the ones you have, and you are a human, you can’t take care of 10 children when you already have ones who are very sick.”
She shakes her head and shudders at the thought of having 7 more children to take care of.
She promises me that she will discuss it with her husband. She agrees with me that she is too tired, and the burden is heavy. I have nothing to offer her in terms of help – no social services, no referrals, no therapy. I offer sympathy.
She wipes her tears, which have not finished coming. We both express our hope that her newborn infant does not have sickle cell disease. I tell her to come and find me if she needs anything else.
“You know where I stay now,” I tell her.
“Should I call through my friend, or I can come and disturb you?”
“I am here. You can disturb me anytime.”
After she leaves, I can’t get her out of my head - the sadness that emanated from her face. I hope I have helped by reassuring her that her bleeding is normal, but I couldn’t do anything about her real problem.
Later that day, the woman arrives in my clinic. She explains that she gave birth in March, and then in April, she had bleeding for about a week and a half, along with some right-sided abdominal pain. She was given antibiotics (as usual – they are given for everything here) and the bleeding stopped. She did not see bleeding again until just over a week ago, when she had bleeding for 1 week, which stopped on its own. The right-sided pain had never gone away; it was not associated with bleeding but did seem to be worse when she was bending over or lifting something.
It sounds to me like the woman is getting her period. I tell her this. She is surprised. She is breastfeeding, so she expected not to see her period. I tell her that she can have bleeding sometimes, even though she may not be ovulating and that, in fact, the bleeding can last longer than a usual period because the body doesn’t have its normal hormonal pattern, and so it doesn’t really tell the uterus when to stop bleeding.
As I am telling her this, I can feel the tension from the elephant in the room. The nurse who referred the woman had told me that the woman kept having babies with sickle cell disease. The woman looks profoundly sad – the kind of sad that is not just today, but that accumulates over years, until the person doesn’t even realize she is sad, because it feels normal.
I ask her about the sickle cell problem. She tells me that her three previous children were all born with sickle cell disease, but she has not yet tested the infant. Of the three, one died at age 6 – and before dying, that child had a major stroke, and then a second stroke with seizures that caused the death. Of the living children, her oldest, a 9-year-old girl, had a stroke a few years ago, and now can walk but has difficulty with speech, and her entire left side, including face, arm, hand and leg, are partially paralyzed. As she talks, I can see the weight of this burden emerging on her face. Her eyes become teary, but she keeps talking.
Finally, we get around to doing the physical exam. Although the bleeding sounds normal to me, I do an ultrasound to make sure there are no fibroids or other sources of abnormal bleeding. It is normal, and there is nothing on the right side where she notes her abdominal pain. I do a vaginal exam to make sure there is no palpable cervical cancer, but it is normal too. I explain that the bleeding is just her menses. The pain is in an odd location – far from the pelvis but not really near any specific organ, at the level of her umbilicus but far to the right. It is not tender. To check for a hernia, I have her sit up with her belly exposed. There is no hernia, but there is a large diastasis. During pregnancy, the abdomnal rectus muscles (in the front of the abdomen) can become very weak and separate to accommodate the enlarged uterus. After delivery, they remain weak and as a woman sits up, there is a visible bulge in the center of her abdomen where the muscles have separated.
My guess is that her pain (which she notes is worst when she is trying to use her abdominal muscles) is probably because she is compensating for the lack of midline abdominal strength by using her side abdominal muscles, and preferentially her right side. I can’t be sure that this is the case, but it is my best guess. I recommend a daily routine of increasing repetitions of sit-ups. I teach her how to do them. She can’t even do one without using her hands.
This leads us back to a discussion of her children. She tells me that caring for her disabled and ill children is very time-consuming and takes all of her energy. I can see it. “You look tired,” I say. She has no help other than a young housekeeper (a “house girl”). I tell her that she needs to take 15 minutes for herself every day to do these exercises so that her pain and strength will improve. In truth, the exercises are not life or death, but I sense that this woman needs 15 minutes to herself once a day. She gives the other 23 hours and 45 minutes to her children.
I ask her how many more children she wants. She doesn’t have an answer. I tell her about the statistics of sickle disease – that if both parents are carriers (and clearly she and her husband are), the chances are 1 in 4 that any one child will be born with sickle cell disease. She is very unlucky, having had at least 3 with the disease. I tell her that she needs to think about how big she wants her family to be. There is no way to predict whether her current infant, or future children, will have the disease, but that she should assume that any further children will also have it – because she has to be prepared for the burden that might come if they do.
She starts to tell me more detail about the sickle cell disease that afflicts her children. She tells me at what age each of them started having symptoms, and she tells me about the events that led to the death of the one child. She tells me about the difficulties of caring for the 9-year-old, who cannot attend school and probably will never care for herself. As she talks, tears start to roll down her face. She dabs at them with a handkerchief.
“What about your husband?” I ask.
“He is a teacher,” she says.
“Does he want more children?”
“We have not discussed it,” she admits.
“You need to discuss it. He needs to understand what it is like for you. Maybe he does understand, I don’t know. Because for a father it is also hard. But for a mother, it is even harder to see your children suffer. If your child suffers, the mother suffers 100 times.”
She nods and sobs. “You understand what it is like for mothers, doctor.”
Well, I can’t say that I understand from personal experience, but I have known enough suffering mothers that at least I can make that observation. But that’s all she wants from me – validation and understanding. I can give both.
I encourage her again to consider family planning. “You love your children, but I can see that you are tired. You need to take care of the ones you have, and you are a human, you can’t take care of 10 children when you already have ones who are very sick.”
She shakes her head and shudders at the thought of having 7 more children to take care of.
She promises me that she will discuss it with her husband. She agrees with me that she is too tired, and the burden is heavy. I have nothing to offer her in terms of help – no social services, no referrals, no therapy. I offer sympathy.
She wipes her tears, which have not finished coming. We both express our hope that her newborn infant does not have sickle cell disease. I tell her to come and find me if she needs anything else.
“You know where I stay now,” I tell her.
“Should I call through my friend, or I can come and disturb you?”
“I am here. You can disturb me anytime.”
After she leaves, I can’t get her out of my head - the sadness that emanated from her face. I hope I have helped by reassuring her that her bleeding is normal, but I couldn’t do anything about her real problem.
Tuesday, June 15, 2010
Know Your Limits
One of the most important things any resident learns is to know their limits. Some people don’t learn that lesson, and they are scary. But most of us learn it.
First and foremost, we are taught that in an emergency, you need help. You can’t do it alone. Even if you know what you are doing, you need another pair of hands there, just in case. It is the first thing taught in CPR classes, and it is the first thing every intern should learn.
When I was an intern and working with a team I liked, my chief resident and attending challenged me with a hypothetical scenario one night on call. “Your attending and both senior residents are upstairs in the main OR, and you are on the labor floor alone. You are watching the fetal heart rate tracings, and you see a deceleration. You call us, but can’t each us. The deceleration goes on and on. You try to resuscitate but it doesn’t work. The baby is going to die. What do you do?”
I thought about it, slightly panicked, both over the hypothetical scary situation, and the desire to get the right answer in front of my chief resident and my attending.
As I thought it through, they pushed me more: “Do you go ahead and do the c-section? You have nurses here.”
Could I actually do that? I had only done a few c-sections, I really didn’t feel comfortable. I cringed and answered honestly: “No?” Were they going to laugh at me?
Both of them smiled. “Right. You don’t do it. Because you could kill the mother. That baby might die, but you have to keep trying to get us, even if you have to run upstairs to the main OR and drag us down.”
Later, when I was a chief resident, I designed a lecture for the incoming interns on how to handle obstetric emergencies. In order to help them remember what do to, I created the three C’s: Call for help, Call for help, Call for help. They laughed as we reviewed it on the powerpoint slide, but it stuck with them. (Laughter is the best mnemonic.) Later, when working with one of the interns, I was pimping her on the maneuvers to relieve a shoulder dystocia. “What’s the first thing you do?” I asked. I was looking for “Put the patient in McRobert’s position.” Instead, she smiled and said “Call for help, call for help, call for help.” (Excellent!)
Many times in Uganda I have been faced with situations in which I almost had to decide whether I would do something I am not comfortable with or experienced enough to do.
I have often written here about things I have done here that I had “never” done before – but in reality, they are variations on things I have done before. The cornual ectopic, the abdominal pregnancy – those are situations that I haven’t actually seen, but had been well-prepared for in my training. In fact, I had never even operated on an ectopic pregnancy through a laparotomy – only laparoscopically. But I had done ectopics, and I had done laparotomies, so it isn’t a far stretch to put those two things together into one surgery.
But then there were situations that were less clear. On occasion, I have suspected a patient might have appendicitis. Would I be able to do an appendectomy? I have done quite a number of appendectomies in patients with cancer and it was actually remarkably simple – but their appendices were normal. Would I be able to do the same in an infected, inflamed appendix? I don’t know. Fortunately, none of the patients ever turned out to have appendicitis.
One day, I walk into clinic and see a wheelchair in the hallway (those are rare around here), and a hospital nurse inside one of the patient rooms. There is a young boy lying on the exam table, and an anxious-looking man sitting on a chair – the boy’s father. P, one of the study doctors, is examining the young boy, and asks for my help.
He tells me the situation. The boy is 12 years old. Two days ago, he fell off a bicycle, and the pedal punctured his abdomen, and his intestines came out. He was taken to a Level 3 Health Center, where they pushed the intestines back in, and stitched the hole closed. Since then, he has not passed stool or flatus, and he has severe abdominal pain and fever.
On exam, the boy looks terrible. He looks weak and dry, his eyes are sunken and he is clearly in pain. On the left side of his abdomen, the skin over the injury had been bunched up and stitched with silk suture – which needs to be removed at some point. When I palpate his abdomen, it is obvious that he is extremely tender everywhere, although too weak to make a lot of noise despite excruciating pain. There is also the distinct crackling sound of crepitus when I press on his abdomen. I try to do an ultrasound, but I can’t see anything and it causes him even more pain.
P and I consider the situation. When an abdominal injury causes the bowel to come outside the body, it is called an evisceration. In that case, not only the skin has to be sewn closed, but the fascia (the firm white internal sheath that holds in the intestines and abdominal contents) also needs to be closed. Did they close the fascia? We don’t know. In addition, once the intestines are exposed to the outside, there is a high risk of infection. He is on antibiotics, but the coverage is insufficient (which is ironic, because usually they give extremely broad coverage for every non-bacterial ailment here).
P and I agree that the boy needs an exploratory laparotomy. But who is going to do it? Neither of us is comfortable with extensive bowel surgery. It is hard to know exactly what we will find once the abdomen is open. There is a strong chance that the boy might need part of his bowel resected and re-anastomosed (reattached), or even a colostomy.
At home, I would call general surgery to see the patient immediately. Even if I didn’t expect to find a bowel injury before operating, I could call an intraoperative general surgery consult, and they would be there within minutes.
There is a regional hospital an hour away in Mbale that is much better staffed and equipped, and even has specialists. But if we send him there, will he make it? He would have to go in a matatu – I cringe just thinking about this poor kid suffering through a matatu ride in his condition. I can barely tolerate them when healthy. In addition, if he makes it to Mbale, will they treat him, or will they ask for a bribe first? His father looks extremely poor. Will referring him there be a death sentence?
P and I discuss the options. It’s possible that one of the two doctors here is comfortable with bowel surgery; they have seen it all. I try to call both, but their phones are off.
Plan B: There is an orthopedic surgery camp taking place in the theatre all week. Some consultant orthopedic surgeons came from Mulago Hospital in Kampala to work on children with orthopedic deformities. Possibly one of them might be able to assist with bowel, even if we open up the abdomen first.
I dash over to theatre to ask them. They are very nice about it, and agree that the boy needs a laparotomy. Still they are vague about their exact comfort level, and how much they would be able to help. They tell me to bring the boy. I’m not sure about this, but it might be his only hope. I don’t know.
I head back to the clinic and tell P what they said. “Dr. Veronica, I am not in,” he says.
He is right. We have no sense of whether the orthopedists would be able to help us, we have no other backup, and none of us are comfortable doing this. If we open his abdomen, we could kill him.
On to Plan C: Transfer to Mbale. I know that the hospital has an ambulance, and there might even be fuel in it. If we can transfer the boy in the ambulance, that might increase his chances of making it there, and of getting treated. I call the Senior Hospital Administrator, but his phone is off. I walk to the administrative offices of the hospital to find him, but every door is closed. What’s going on? It’s a Wednesday. Then I realize that it’s a national holiday, and everyone is gone.
As a last resort, I call the Junior Hospital Administrator, a young man who has always been friendly and helpful. He answers. He is around the hospital grounds. I tell him that I need his help with an emergency. “I can be there in 20 minutes. Is it OK?” It will have to be.
10 minutes later, I go to check in on the boy, but the bed is empty. Where has he gone? I find P, and he tells me that Dr. W, one of the hospital doctors, showed up on the ward, so they took him back to the ward to be evaluated by Dr. W, and possibly operated on. I am greatly relieved. I like Dr. W very much, and if he is able to operate on the boy, then he will be OK. I try to call Dr. W’s phone, but it is still off.
The Junior Hospital Administrator finds me a few minutes later. I explain the situation and tell him that things are probably OK, but that if the boy needs to be transferred, I will call him again. He explains that the ambulance is available and has a driver, but no fuel. If we can provide the fuel, then we can send the boy.
Sigh. The usual. I know that if the boy needs transfer, we will find the money for fuel. Maybe we will use money from the poor patient fund, or my own money, or whatever, but I will not let this boy die for lack of fuel. I thank the JHA and tell him I will contact him if the boy needs to be transferred. I don’t hear anything that day, so I assume that Dr. W was able to operate on him.
The next day, I decide to find out what happened to the boy. Dr. W’s phone is still off. Since the boy is 12, he would not be in the pediatric ward. There are so many patients admitted aged 5 and under that the huge pediatric ward is filled with them alone. Children over 5 years are admitted to the adult wards (if they are still quite young, then they are admitted to the female ward with their mothers). He must be in male ward.
I go to male ward, and scrutinize every patient there. It isn’t very hard, because there are no young boys. I walk through the entire ward, but I don’t see him. I find two nurses and ask them for help. I explain the situation. One of them goes out to the ward to announce the type of patient we are looking for (which would have been kind of funny if I had not been really worried about this kid), while the other one helps me search each bed.
The boy is not there. Both nurses agree that they have never heard of such a child, but there is nowhere else he could have been admitted. Disappointment.
I go back to our clinic and mention this to P. He tells me that the boy is in Mbale. Apparently, one of the other study doctors has an aunt who is sick and admitted in Mbale, and he went to visit her there. While there, he happened to see the boy, who was waiting to go into surgery just then.
I am relieved to hear that he made it to Mbale. I know that we did the right thing – if we had operated, we could have killed him. In my desire to save the boy, I considered it briefly, but it would not have been the best thing for him. The study doctor who saw the boy knows the surgeon who was going to operate, and promised me that he would find out what happened. It was hard to let go of a patient not knowing whether someone else would be there to help him. I will feel much better once I know the outcome.
First and foremost, we are taught that in an emergency, you need help. You can’t do it alone. Even if you know what you are doing, you need another pair of hands there, just in case. It is the first thing taught in CPR classes, and it is the first thing every intern should learn.
When I was an intern and working with a team I liked, my chief resident and attending challenged me with a hypothetical scenario one night on call. “Your attending and both senior residents are upstairs in the main OR, and you are on the labor floor alone. You are watching the fetal heart rate tracings, and you see a deceleration. You call us, but can’t each us. The deceleration goes on and on. You try to resuscitate but it doesn’t work. The baby is going to die. What do you do?”
I thought about it, slightly panicked, both over the hypothetical scary situation, and the desire to get the right answer in front of my chief resident and my attending.
As I thought it through, they pushed me more: “Do you go ahead and do the c-section? You have nurses here.”
Could I actually do that? I had only done a few c-sections, I really didn’t feel comfortable. I cringed and answered honestly: “No?” Were they going to laugh at me?
Both of them smiled. “Right. You don’t do it. Because you could kill the mother. That baby might die, but you have to keep trying to get us, even if you have to run upstairs to the main OR and drag us down.”
Later, when I was a chief resident, I designed a lecture for the incoming interns on how to handle obstetric emergencies. In order to help them remember what do to, I created the three C’s: Call for help, Call for help, Call for help. They laughed as we reviewed it on the powerpoint slide, but it stuck with them. (Laughter is the best mnemonic.) Later, when working with one of the interns, I was pimping her on the maneuvers to relieve a shoulder dystocia. “What’s the first thing you do?” I asked. I was looking for “Put the patient in McRobert’s position.” Instead, she smiled and said “Call for help, call for help, call for help.” (Excellent!)
Many times in Uganda I have been faced with situations in which I almost had to decide whether I would do something I am not comfortable with or experienced enough to do.
I have often written here about things I have done here that I had “never” done before – but in reality, they are variations on things I have done before. The cornual ectopic, the abdominal pregnancy – those are situations that I haven’t actually seen, but had been well-prepared for in my training. In fact, I had never even operated on an ectopic pregnancy through a laparotomy – only laparoscopically. But I had done ectopics, and I had done laparotomies, so it isn’t a far stretch to put those two things together into one surgery.
But then there were situations that were less clear. On occasion, I have suspected a patient might have appendicitis. Would I be able to do an appendectomy? I have done quite a number of appendectomies in patients with cancer and it was actually remarkably simple – but their appendices were normal. Would I be able to do the same in an infected, inflamed appendix? I don’t know. Fortunately, none of the patients ever turned out to have appendicitis.
One day, I walk into clinic and see a wheelchair in the hallway (those are rare around here), and a hospital nurse inside one of the patient rooms. There is a young boy lying on the exam table, and an anxious-looking man sitting on a chair – the boy’s father. P, one of the study doctors, is examining the young boy, and asks for my help.
He tells me the situation. The boy is 12 years old. Two days ago, he fell off a bicycle, and the pedal punctured his abdomen, and his intestines came out. He was taken to a Level 3 Health Center, where they pushed the intestines back in, and stitched the hole closed. Since then, he has not passed stool or flatus, and he has severe abdominal pain and fever.
On exam, the boy looks terrible. He looks weak and dry, his eyes are sunken and he is clearly in pain. On the left side of his abdomen, the skin over the injury had been bunched up and stitched with silk suture – which needs to be removed at some point. When I palpate his abdomen, it is obvious that he is extremely tender everywhere, although too weak to make a lot of noise despite excruciating pain. There is also the distinct crackling sound of crepitus when I press on his abdomen. I try to do an ultrasound, but I can’t see anything and it causes him even more pain.
P and I consider the situation. When an abdominal injury causes the bowel to come outside the body, it is called an evisceration. In that case, not only the skin has to be sewn closed, but the fascia (the firm white internal sheath that holds in the intestines and abdominal contents) also needs to be closed. Did they close the fascia? We don’t know. In addition, once the intestines are exposed to the outside, there is a high risk of infection. He is on antibiotics, but the coverage is insufficient (which is ironic, because usually they give extremely broad coverage for every non-bacterial ailment here).
P and I agree that the boy needs an exploratory laparotomy. But who is going to do it? Neither of us is comfortable with extensive bowel surgery. It is hard to know exactly what we will find once the abdomen is open. There is a strong chance that the boy might need part of his bowel resected and re-anastomosed (reattached), or even a colostomy.
At home, I would call general surgery to see the patient immediately. Even if I didn’t expect to find a bowel injury before operating, I could call an intraoperative general surgery consult, and they would be there within minutes.
There is a regional hospital an hour away in Mbale that is much better staffed and equipped, and even has specialists. But if we send him there, will he make it? He would have to go in a matatu – I cringe just thinking about this poor kid suffering through a matatu ride in his condition. I can barely tolerate them when healthy. In addition, if he makes it to Mbale, will they treat him, or will they ask for a bribe first? His father looks extremely poor. Will referring him there be a death sentence?
P and I discuss the options. It’s possible that one of the two doctors here is comfortable with bowel surgery; they have seen it all. I try to call both, but their phones are off.
Plan B: There is an orthopedic surgery camp taking place in the theatre all week. Some consultant orthopedic surgeons came from Mulago Hospital in Kampala to work on children with orthopedic deformities. Possibly one of them might be able to assist with bowel, even if we open up the abdomen first.
I dash over to theatre to ask them. They are very nice about it, and agree that the boy needs a laparotomy. Still they are vague about their exact comfort level, and how much they would be able to help. They tell me to bring the boy. I’m not sure about this, but it might be his only hope. I don’t know.
I head back to the clinic and tell P what they said. “Dr. Veronica, I am not in,” he says.
He is right. We have no sense of whether the orthopedists would be able to help us, we have no other backup, and none of us are comfortable doing this. If we open his abdomen, we could kill him.
On to Plan C: Transfer to Mbale. I know that the hospital has an ambulance, and there might even be fuel in it. If we can transfer the boy in the ambulance, that might increase his chances of making it there, and of getting treated. I call the Senior Hospital Administrator, but his phone is off. I walk to the administrative offices of the hospital to find him, but every door is closed. What’s going on? It’s a Wednesday. Then I realize that it’s a national holiday, and everyone is gone.
As a last resort, I call the Junior Hospital Administrator, a young man who has always been friendly and helpful. He answers. He is around the hospital grounds. I tell him that I need his help with an emergency. “I can be there in 20 minutes. Is it OK?” It will have to be.
10 minutes later, I go to check in on the boy, but the bed is empty. Where has he gone? I find P, and he tells me that Dr. W, one of the hospital doctors, showed up on the ward, so they took him back to the ward to be evaluated by Dr. W, and possibly operated on. I am greatly relieved. I like Dr. W very much, and if he is able to operate on the boy, then he will be OK. I try to call Dr. W’s phone, but it is still off.
The Junior Hospital Administrator finds me a few minutes later. I explain the situation and tell him that things are probably OK, but that if the boy needs to be transferred, I will call him again. He explains that the ambulance is available and has a driver, but no fuel. If we can provide the fuel, then we can send the boy.
Sigh. The usual. I know that if the boy needs transfer, we will find the money for fuel. Maybe we will use money from the poor patient fund, or my own money, or whatever, but I will not let this boy die for lack of fuel. I thank the JHA and tell him I will contact him if the boy needs to be transferred. I don’t hear anything that day, so I assume that Dr. W was able to operate on him.
The next day, I decide to find out what happened to the boy. Dr. W’s phone is still off. Since the boy is 12, he would not be in the pediatric ward. There are so many patients admitted aged 5 and under that the huge pediatric ward is filled with them alone. Children over 5 years are admitted to the adult wards (if they are still quite young, then they are admitted to the female ward with their mothers). He must be in male ward.
I go to male ward, and scrutinize every patient there. It isn’t very hard, because there are no young boys. I walk through the entire ward, but I don’t see him. I find two nurses and ask them for help. I explain the situation. One of them goes out to the ward to announce the type of patient we are looking for (which would have been kind of funny if I had not been really worried about this kid), while the other one helps me search each bed.
The boy is not there. Both nurses agree that they have never heard of such a child, but there is nowhere else he could have been admitted. Disappointment.
I go back to our clinic and mention this to P. He tells me that the boy is in Mbale. Apparently, one of the other study doctors has an aunt who is sick and admitted in Mbale, and he went to visit her there. While there, he happened to see the boy, who was waiting to go into surgery just then.
I am relieved to hear that he made it to Mbale. I know that we did the right thing – if we had operated, we could have killed him. In my desire to save the boy, I considered it briefly, but it would not have been the best thing for him. The study doctor who saw the boy knows the surgeon who was going to operate, and promised me that he would find out what happened. It was hard to let go of a patient not knowing whether someone else would be there to help him. I will feel much better once I know the outcome.
Thursday, June 10, 2010
Fusion
I had stopped by the operating theatre to try and schedule a case. When I was there, the anesthetist asked me to see a patient he had in the waiting area.
The patient was a 9 month old baby girl, the daughter of a clinical officer at TDH. Both parents were there looking concerned. The problem, they reported, was that the baby's genitalia were abnormal.
They removed the baby's clothes so that I could look, and immediately I saw the problem. There was no vaginal opening. I could see the urethra (where the urine comes out) and the rectum was normal, but the labia were sealed shut, almost as if she had had a female circumcision.
It was unlikely. There is only 1 tribe in Uganda that does female circumcision, and although they are not far from Tororo, they would not do it in a child this young. I ask the parents, but they are not from that tribe, and they did not have any circumcision done to the child. They don't know how long the labia have been that way.
I am perplexed. I was expecting something more like ambiguous genitalia. But this is clearly a girl - there is no penis. Maybe it isn't a girl? Should I do an ultrasound and confirm the presence of a uterus and ovaries? Would I even be able to see them at this age? I can't think of anything else to do.
It could also be an imperforate hymen or a vaginal septum. But this appears to be the labia. An imperforate hymen would be inside the labia, and normal labia would still be visible. A vaginal septum would be even more internal.
Well, I don't know what it is, but would I need to do anything about it? The girl isn't going to menstruate for another 10-13 years or so, and operating on a small infant is more difficult than operating on a child or adolescent. The urethra appeared normal, so she can urinate without a problem.
The parents do report that the girl cries every time she urinates for the last 2 months or so. It's possible that this closure is causing some partial blockage of the uretral meatus, preventing the urine from exiting efficiently and allowing infection to build. If that is the case, she might then need surgical correction.
I decide to do some research and have them come back. I tell them to get a urinalysis to look for infection, and to return to me next Wednesday when I normally hold my clinic. They are grateful, and very worried that their little girl might need surgery - or worse, might have a permanent abnormality.
In the meantime, I call a trusted obstetrician in Kampala, Dr. O. I have enormous respect for this man. He is well-known in the field of global Obstetrics & Gynecology, and has made great efforts to reduce maternal mortality in Uganda. He is one of the investigators on my research projects. He is also an extraordinary clinician, a firm but patient teacher and unfailingly professional and polite, even when juggling multiple acute responsibilities. I have called him with questions many times, and he never fails to help me. When he comes to visit the study site, he is able to briefly tour the faciluty and then present a list of ideas for improvement and progress that are always perfectly on point.
When I reach him, I tell him about the problem.
"Oh yes," he says, "I have seen this before. The parents are not washing the baby properly. They are failing to wash the labia, and the baby develops a mild infection and inflamation of the skin, and the labia fuse together."
I am stunned. "Really? That's it? You have seen this before?"
"I have seen this many times. I have even had babies referred to me by urologists."
"What should I do?" I ask.
"It is very easy to manage. You just take a piece of gauze, and you pry open the labia manually. They will come open easily."
I am skeptical. "The labia looked really fused together. Do you really think it will come open, just like that? I am worried about hurting the child."
"You will be surprised, he says. "You will not hurt her. She will cry. You will have to have someone hold her down, and maybe have the parents wait outside the room because they will become upset. But you will not be hurting her very much, and she will stop crying when you are finished. I have done this many times, it is always fine."
I trust this man, but I am pretty nervous about this. "Ok, I will try it. Just in case, if I can't open it, can I take a photo and send it to you?"
"You can send me a photo if you need," he says. He sounds like he knows I won't need to.
The parents return and find me in the clinic. S, another clinic doctor who shares my office, is present. The little girl is as cute as ever. The parents report that the urine result was negative, and the symptoms have gone away.
I tell them what Dr. O has told me. I explain what I am going to do. I ask if they want to be in the room when I do it to hold her, or if they want to wait outside.
The husband turns to his wife. "Do you want to hold her?"
She looks unperturbed. "I can hold her."
"Ok," I say, "women are strong. They can push, and they can hold the crying baby. Men, they cry and they faint." We all laugh. Everyone here likes African-women-are-strong jokes.
I ask S to help me with this, just in case I need a hand. We take the baby into the other room. The mother undresses her. She leaves on the string of beads tied around the baby's waist. Many girls and women wear these beads. They have some kind of cultural significance that I'm not sure about, but they are very pretty. I almost want some.
We lie the baby on the bed and she is already crying. The mother bravely holds her legs. We look at the perineum. The labia look totally fused. There is a line of fusion, but it really doesn't look like it is going to come apart. I am nervous.
Gently, I take a piece of cotton and use light pressure to try to spread the labia. The baby is crying but the mother is holding her well. As I apply pressure, a small depression appears along the fusion line. S is surprised, as am I. He helps me to continue applying gentle pressure. Magically, the labia appear. There is a normal vaginal introitus. The labia have a tiny bit of blood on either side, but otherwise are fine. I can't believe it.
It takes me a few seconds of staring to realize that it actually worked. We instruct the mother on proper cleaning of the labia so that it does not happen again.
The baby is crying, but as soon as the mother picks her up, she stops. She even looks content. Amazing.
The mother is very grateful. I reinforce the cleaning procedure, and she leaves.
S and I are still quite surprised that it actually worked. Now I am even more in awe of Dr. O. Maybe this is something that pediatricians see all the time - I don't know - but I have never seen or even heard of it. S remarks to me that he knows of a 13-year-old girl who has to go for surgery soon to have the same thing fixed, but he didn't realize that a simple hygiene lapse was the cause of it. If the labia had stayed fused for years, this baby would later have required surgery because the fusion would have been too severe for manual separation.
Ten minutes later, my phone rings. Her husband is calling.
"Doctor, I am very grateful! I had to go back to work, so I have not seen her, but my wife has passed the message that she is fine and you have cured her. Thank you so much! I am very relieved and very grateful."
The patient was a 9 month old baby girl, the daughter of a clinical officer at TDH. Both parents were there looking concerned. The problem, they reported, was that the baby's genitalia were abnormal.
They removed the baby's clothes so that I could look, and immediately I saw the problem. There was no vaginal opening. I could see the urethra (where the urine comes out) and the rectum was normal, but the labia were sealed shut, almost as if she had had a female circumcision.
It was unlikely. There is only 1 tribe in Uganda that does female circumcision, and although they are not far from Tororo, they would not do it in a child this young. I ask the parents, but they are not from that tribe, and they did not have any circumcision done to the child. They don't know how long the labia have been that way.
I am perplexed. I was expecting something more like ambiguous genitalia. But this is clearly a girl - there is no penis. Maybe it isn't a girl? Should I do an ultrasound and confirm the presence of a uterus and ovaries? Would I even be able to see them at this age? I can't think of anything else to do.
It could also be an imperforate hymen or a vaginal septum. But this appears to be the labia. An imperforate hymen would be inside the labia, and normal labia would still be visible. A vaginal septum would be even more internal.
Well, I don't know what it is, but would I need to do anything about it? The girl isn't going to menstruate for another 10-13 years or so, and operating on a small infant is more difficult than operating on a child or adolescent. The urethra appeared normal, so she can urinate without a problem.
The parents do report that the girl cries every time she urinates for the last 2 months or so. It's possible that this closure is causing some partial blockage of the uretral meatus, preventing the urine from exiting efficiently and allowing infection to build. If that is the case, she might then need surgical correction.
I decide to do some research and have them come back. I tell them to get a urinalysis to look for infection, and to return to me next Wednesday when I normally hold my clinic. They are grateful, and very worried that their little girl might need surgery - or worse, might have a permanent abnormality.
In the meantime, I call a trusted obstetrician in Kampala, Dr. O. I have enormous respect for this man. He is well-known in the field of global Obstetrics & Gynecology, and has made great efforts to reduce maternal mortality in Uganda. He is one of the investigators on my research projects. He is also an extraordinary clinician, a firm but patient teacher and unfailingly professional and polite, even when juggling multiple acute responsibilities. I have called him with questions many times, and he never fails to help me. When he comes to visit the study site, he is able to briefly tour the faciluty and then present a list of ideas for improvement and progress that are always perfectly on point.
When I reach him, I tell him about the problem.
"Oh yes," he says, "I have seen this before. The parents are not washing the baby properly. They are failing to wash the labia, and the baby develops a mild infection and inflamation of the skin, and the labia fuse together."
I am stunned. "Really? That's it? You have seen this before?"
"I have seen this many times. I have even had babies referred to me by urologists."
"What should I do?" I ask.
"It is very easy to manage. You just take a piece of gauze, and you pry open the labia manually. They will come open easily."
I am skeptical. "The labia looked really fused together. Do you really think it will come open, just like that? I am worried about hurting the child."
"You will be surprised, he says. "You will not hurt her. She will cry. You will have to have someone hold her down, and maybe have the parents wait outside the room because they will become upset. But you will not be hurting her very much, and she will stop crying when you are finished. I have done this many times, it is always fine."
I trust this man, but I am pretty nervous about this. "Ok, I will try it. Just in case, if I can't open it, can I take a photo and send it to you?"
"You can send me a photo if you need," he says. He sounds like he knows I won't need to.
The parents return and find me in the clinic. S, another clinic doctor who shares my office, is present. The little girl is as cute as ever. The parents report that the urine result was negative, and the symptoms have gone away.
I tell them what Dr. O has told me. I explain what I am going to do. I ask if they want to be in the room when I do it to hold her, or if they want to wait outside.
The husband turns to his wife. "Do you want to hold her?"
She looks unperturbed. "I can hold her."
"Ok," I say, "women are strong. They can push, and they can hold the crying baby. Men, they cry and they faint." We all laugh. Everyone here likes African-women-are-strong jokes.
I ask S to help me with this, just in case I need a hand. We take the baby into the other room. The mother undresses her. She leaves on the string of beads tied around the baby's waist. Many girls and women wear these beads. They have some kind of cultural significance that I'm not sure about, but they are very pretty. I almost want some.
We lie the baby on the bed and she is already crying. The mother bravely holds her legs. We look at the perineum. The labia look totally fused. There is a line of fusion, but it really doesn't look like it is going to come apart. I am nervous.
Gently, I take a piece of cotton and use light pressure to try to spread the labia. The baby is crying but the mother is holding her well. As I apply pressure, a small depression appears along the fusion line. S is surprised, as am I. He helps me to continue applying gentle pressure. Magically, the labia appear. There is a normal vaginal introitus. The labia have a tiny bit of blood on either side, but otherwise are fine. I can't believe it.
It takes me a few seconds of staring to realize that it actually worked. We instruct the mother on proper cleaning of the labia so that it does not happen again.
The baby is crying, but as soon as the mother picks her up, she stops. She even looks content. Amazing.
The mother is very grateful. I reinforce the cleaning procedure, and she leaves.
S and I are still quite surprised that it actually worked. Now I am even more in awe of Dr. O. Maybe this is something that pediatricians see all the time - I don't know - but I have never seen or even heard of it. S remarks to me that he knows of a 13-year-old girl who has to go for surgery soon to have the same thing fixed, but he didn't realize that a simple hygiene lapse was the cause of it. If the labia had stayed fused for years, this baby would later have required surgery because the fusion would have been too severe for manual separation.
Ten minutes later, my phone rings. Her husband is calling.
"Doctor, I am very grateful! I had to go back to work, so I have not seen her, but my wife has passed the message that she is fine and you have cured her. Thank you so much! I am very relieved and very grateful."
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