Friday, December 28, 2012

Decisions : Good and Bad

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.

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