Spinning Cotton |
The other day I saw tears rolling down the face of a woman
sent from the Outpatients Department for me to review. For about three years
she had been complaining of abnormal bleeding and nobody did anything other
than change her from one form of contraception
to another and back again. I examined her! She had an advanced cancer
and even in the West it would be regarded as incurable, but amenable to
palliative radiotherapy, which would at the very least control the bleeding –
but here? Well there is no radiotherapy in the Faleghewot Referral Hospital at
Bahar Dar, and nobody knew if it was even available in Addis. We carefully
explained to her the serious nature of her condition, though I didn’t say it
was terminal, and said she must go to Bahar Dar for another opinion. That was
when I saw the tears and realised I hadn’t ever seen anyone cry here before.
And then yesterday I saw tears again – these were on the
face of a relative of a woman who needed an emergency life saving operation but
didn’t want me to operate on her. The operation itself was going to be
hazardous because try as we might, we couldn’t
get blood for her. One of her relatives did turn out to be a match, a wiry
middle aged man, but he was excluded at the last step in the process because he
weighed 46kg and the rule was that donors had to be at least 50kg. I decided to get my own blood checked against
hers, because being O Pos I was a potential donor as well. I have previously said
I was happy to give my time and any skills and knowledge they could use, but
not my blood. However I changed my mind on this occasion because the woman was
in this predicament largely as a result
of decisions I had made. She had arrived two days before and appearaed to be in
strong labour but was only half way through her pregnancy and the baby was
already dead. We waited for it be born but after a few hours this had not
happened and her labour pains went away. I waited till the next day, hoping
they would return, but when they didn’t we put her on a drip but still, after several
hours nothing happened. She was at risk of developing serious infection, and bleeding
problems as well so I used the only other option, a drug called Misprostol
which makes the uterus contract. There was minimal response to the first dose
so the next day, yesterday we put in a second dose. A few hours later her pains
returned but not long after that she developed very severe pain and her abdomen
seemed to swell up and become tense, her blood pressure dropped and her pulse
jumped up to 130. I was phoned to see her urgently, and quickly concluded her
uterus had ruptured and she was bleeding. . They asked if we could transfer her to Bahar Dar – this would
entail a potentially fatal delay of at least six hours but possibly provide her
with better access to blood – however on enquiry, both Hospital Vehicles were “non
functional” . So she was trapped here .
A large crowd of family members and nursing students and midwives were crowded
round her bed trying to convince her and then her husband to have the surgery .
And at that moment a woman I had seen a couple of weeks before arrived in labour. Her four previous babies had all died at
birth because of what sounded to me like a very small pelvis through which
babies would only fit with great and obviously traumatic difficulty. My plan
was that when she returned in labour, if the babies head was not in the pelvis
she would need an immediate caesarean section. It wasn’t and she did.
So now we had two women requiring immediate surgery, but my
thought was we have to do the one to save the mother before the one to save the
baby! I asked the midwives to prepare the second patient and as the discussions
continued with the first one, I went to get my blood tested against Emaways,
and to my really awful disappointment, it was incompatible.
Back in Maternity the family finally agreed to let me
operate, and with great trepidation my brave anaesthetist put her to sleep,
telling me she may not survive the anaesthetic. The uterus had indeed ruptured
and the dead foetus still in its amniotic sac, and the placenta had been
expelled out of the side of it into a structure called the broad ligament which
is ordinarily a thin fold of membrane but was now distended to football size
with clots and the uterine contents. Its never easy operating here because the
lighting is poor, the instruments are a grab bag of discards from western
hospitals, there are language difficulties so when I ask for say a Clip I get
scissors – which are invariably blunt – and this sort of surgery is really way outside
the sort of thing I am used to doing - difficult
complex surgery such as this is the domain of experienced cancer surgeons – but
to add to all that in the back of my mind was the other woman waiting in line
for her caesarean. There was some troublesome bleeding, much of which in the
West would probably be quickly dealt with by electro-cautery – but without
that, each bleeding vessel has to be
laboriously tied with a stitch, and
often, passing a needle through these delicate tissues other vessels are
punctured and they too have to be tied off. At one point my anaesthetist, Amanu
said “she is deteriorating” and at another her blood appeared to be losing its
ability to clot by itself, a natural mechanism which if lost results in every
bruised and damaged surface leaking blood, a phenomenon which is unstoppable
without access to fresh blood.
Shadrach, Meschak and Abednego in the Fiery Furnace - and a priest ringing a Bell for Donations. |
I put a big wad of cotton packing over the raw edges from
where I had by now removed the uterus and the right fallopian tube and ovary,
applied pressure and just waited, watching the clock ticking and thinking about
that woman in labour waiting for her caesarean. It was starting to look like
Emaway wouldnt survive. After five minutes
we carefully removed the pack, and the bleeding seemed to have settled. We
closed her abdomen and then waitied as she slowly started to wake up – when she
took her first breath by herself we all felt tremendous relief. She was going
to survive the operation at least – now it remains to be seen if her recovery
will continue – today we will make further efforts to get her the blood she
desperately needs.
And the other lady? We quickly cleaned up the theatre,
brought her down and did the Caesar to deliver a gorgeous chubby little girl. Today
they are both well.