Tuesday, August 26, 2014

The Medical Record

I had a half hour walk in the market on Friday
I did a caesarean this morning on a beautiful young woman who had the most exquisite skin, incredibly soft and smooth and a very deep chocolate brown, not a stretch mark or blemish to be seen anywhere on it. I delivered a beautiful baby boy that was in perfect condition. The operation went really well, there were no complications, the blood loss was minimal, the spinal anesthetic worked perfectly and it was such a pleasure to be part of the team in the operating room.

In contrast, we rushed a woman in there late Saturday night to do an emergency operation after she unexpectedly collapsed with unrecordable blood pressure a few hours after she had given birth to her seventh baby. Such women often lose a lot of blood at the time of the birth or shortly after and need resuscitation, but she hadn’t, so it was a perplexing turn of events. Dr Abdul, the Medical officer on the ward called me in and we both agreed she must have ruptured her uterus and was bleeding internally. Unusally, for catastrophes that occur here, this was something I had seen before, in Australia - once -  a woman collapsing after giving birth with a uterus that must have ruptured almost at the moment the baby was born – at any earlier time in labour the baby would not have been born, or survived. I had seen it once but Abdul had seen it innumerable times….

So we ordered lots of blood and rushed her into theater. I asked Abdul to assist me because he was vastly more experienced than I am in this sort of catastrophe, and though I had managed another ruptured uterus in theatre a few days earlier without too much trouble it was nearly midnight and I was already exhausted. So we opened her up and as expected, as soon as we entered the abdomen, blood flooded out like a bath being emptied onto the floor. We reached into the pelvis and lifted up the uterus, looking for the rent in its side – or at the front – or behind? – and found nothing amiss.  The ovaries? Normal!  And still the blood welled up and the clots were scooped out as we began a search for the source of all this blood.  This was completely beyond anything I had ever experienced, and I was relieved when Abdul said he hadn’t come across anything like it either – we found a massive clot in the middle of her abdomen and it was from underneath it somewhere the blood had been coming – or so we suspected. Clearly a major vessel had burst somewhere and I decided I wasn’t going to go anywhere near it. I consulted the other Specialist who supports MSF,  Dr Gaya a Nigerian from a major town nearby who shares call with me – and, wonderful kind Muslim man that he is, he came bustling in at about 1am and agreed, we should just pack the abdomen with cotton surgical packs and close her up. We could then transfer her to somewhere else in the morning – if she lasted till then.

By now we had measured blood loss of over 5 liters of  and whole blood was pouring into her arms at a great rate. Her tongue and conjunctivae and teeth were all the same colour - bright white, the blood in her veins looked like pink water and her pulse was almost uncountable and very weak. But there was no more we could do – except pray as everyone often will tell you, if its Gods will she will live.

And in the morning, remarkably she was still alive, she spoke a few words, her blood pressure was restored and the transfusions had bought a little pinkness to her tongue. And later, she was transferred out, alive but still in desperate circumstances to a hospital where a vascular surgeon will have to  reoperate, gingerly remove all the packs and see if he can repair the blood vessel that has burst in her abdomen. It will be vey difficult.

But the woman I operated on this morning – what was that all about you may have been wondering? Her story is also quite remarkable, though not at all unusual in these parts. Like almost all the women here she cannot read or write – women sometimes receive “Islamic” education which apparently is Arabic religious instruction and that’s all. Her first baby died and after the second one she developed a fistula, a false passage that allowed urine to drain continuously down her legs. The fistula has now been repaired , and to protect the repair, any more babies that she might have need to be born by Caesarean. 

The photo above is of the front page of her Record from the Fistula Hospital. It is worth reading closely – in particular it mentions where she was living when her periods started (Menarche), underneath that it gives her age when Married, and right at the bottom her medical history records “Eclampsia”, a condition regarded as the most lethal of all obstetric diseases. Those three facts are all unremarkable here, but anywhere in the west would be regarded as shocking. 

But she has survived all these traumas, and at least today I hope is feeling a little happier about the future.

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