Death of a mother

Early in the morning, I arrive to find the wards in absolute chaos. We have a transfer patient with post-partum hemorrhage. We have 2 surgical evacuations of incomplete abortions. And we have an emergency c-section for fetal distress. Dr. Wadeya is on day theatre duty, but he is busy on the wards, in the midst of the second evacuation.

“Dr. Wadeya, what can I do so that you can go to theatre?” I ask him. “Can you take care of this PPH patient for me?” No, that’s about the only thing I can’t do. “But it’s an EMERGENCY c-section. EMERGENCY. Doesn’t that mean anything around here?” He looks at me. He starts a line on the PPH patient, books two units of blood for her, packs her vaginal vault to slow the bleeding, grabs one of the midwives, and tells her to go check on the PPH patient. “It’s the middle bed in the labour suite. Make sure you stabilize her. Tell one of the other interns to work on her. Stat.” Then he rushes off to theatre.

We continue on with rounds. A few hours later, one of the midwives comes into the doctor’s duty room. “Come quick. We need your help in the labour suite.” We rush in. It’s the PPH patient. The medical officer is using sponge forceps to pull pieces of placental tissue off of her uterine wall. The patient is in hemorrhagic shock. She is confused, trashing around as we’re trying to get a second line in her. She has lost so much blood that her veins are collapsed, and four of us trying at the same time all fail to get a single line in her. We even go for her external jugular, to no avail. She has only received one unit of blood. We put the second unit on the only line she has. We call one of the anesthetist, who arrives in about 5 minutes, and manages to get a second line in her. We run NS wide open. The students leave to go clerk the patients. There is not much we can do for the PPH patient at this point.

After a while, the MO comes back into the doctor’s duty room. “I’ve managed to stop the bleeding. She had an accreta, and I had to pull the placenta off her uterus manually.” I was skeptical. I’ve always learned that the proper treatment for accrete is surgery, not manual removal of the placenta. But who was I to question the MO? Anyways, why was this mother allowed to labour in the first place? She had two previous c-sections, which is a direct indication for a third c-section. But she had been allowed to deliver vaginally at the health centre where she had presented, and was transferred here to SRRH with a retained placenta.

“Back when I was an intern, we did 6 months on each ward. These days they only do 3 months. That’s really not enough. But with 6 months, you see everything. You do everything. You learn so much. I once diagnosed an extra-uterine pregnancy just with palpation!” Wow, that indeed sounds impressive. Afternoon tea arrives, and we take our tea break. Soon, a midwife comes into the room. “Come check on the PPH patient. She’s not doing well. She’s gasping for air.” “Really?” the MO asks. She looks at Ema and me. “Go check on her.” We run. I went straight for her carotids. No pulse. I press my stethoscope down on her chest. Hard. No heart beat. “Maybe it’s just so weak I can’t hear it.” I desperately hope that it’s my inadequate clinical skills which explains the lack of a heartbeat, not the actual lack of a heartbeat. We start chest compressions. Dr. Opero rushes in. He takes over from us. Meanwhile, we call the consultants for help. One is away in Kumi (40 kilometres away). One is “far”, or so he says on the phone. One is not answering his phone. Since we do not have intubation equipment on the ward, we stick a nasopharyngeal tube in the patient, and drag the oxygen tank over from the annex (the private patient ward), and hook the patient up to oxygen. In the end, we manage to get ahold of one of the seniors. When he arrives, he uses the stethoscope to listen for a heart beat – he hears none. He listens for breath sounds – there is none. I shine my penlight into the patient’s eyes – fixed and dilated. We pronounce the patient dead at 3.13pm.

Dr. Wadeya returns from his c-section. It was a super complex caesar, tons of adhesions, grossly distorted anatomy. The whole surgery took him 4 and a half hours; a usual caesar takes him around 25 minutes. We tell him about the PPH patient. He checks into the situation. Apparently, the midwife he had told to check up on her had gone to the wrong bed, had worked on the wrong patient. So the PPH patient had been left alone for much longer than anticipated. And then when we did start working on her, instead of taking her straight to theatre, we had delayed definitive surgical treatment for her. Through our mistakes and delays, we had caused her death. We could have saved her. I know we could have. We should have. Dr Wadeya turns to me. “MY. That was the patient I was going to work on, when you chased me off to theatre.” A terrible cold chill swept over me. “Dr. Wadeya. If I hadn’t rushed you to theatre, she would still be alive.” “You can’t know that,” he replied. But I do know. I know with absolute certainty. Dr. Wadeya would’ve saved her. He’s a surgeon. He thinks like me. I know it. If I hadn’t hustled him off for the emergency c-section, he would’ve taken the patient straight to theatre as soon as he realized she had an accreta – that mother would still be alive. Why? Why had I interfered?

We go talk to the family. We explain to them what had happened. I felt so terrible for the baby who never met its mother. “Where’s the baby? Who’s taking care of it?” I ask the family. “The baby died during delivery.”

To lose a patient you couldn’t have saved – that’s a tragedy; to lose a patient you could’ve, you should’ve saved – that’s a travesty.

Emergency C-section

So we get a lot of emergency c-sections here at Soroti Regional Referral Hospital. The most common indication is for fetal distress, as diagnosed by fetal heart rate auscultated with either a fetoscope or a stethoscope. And when fetal distress is diagnosed, there is a complex chain of events that follows. Allow me to illustrate with just one example.

We get called for an emergency c-section for fetal distress. We go to the labour suite to prep the patient. We call the attendants of the patient over, and give them a list of things they have to go buy at a nearby pharmacy – urinary catheter, 8 bottles of normal saline, and 20 IU of pitocin. No we do not have those things here on the Obstetrics ward. We then go outside to get the trolley for patient transport. It is not there. We ask one of the sisters to go find it. We start an IV on the patient, and once the cannula is in, we look all over the ward for some strapping to secure the cannula – there is none. So we send another attendant to go buy some strapping, and the patient holds her own IV line in place while awaiting the arrival of the strapping. Finally, the trolley arrives. We put the patient’s cavera onto the trolley, and ask the patient to transfer herself over. The attendants then roll the patient from Ward 4 (Maternity) to theatre (OR), all the way on the opposite end of the hospital. There is no direct paved path, so they have to cut diagonally across half the hospital, and cut diagonally back across the other half of the hospital. The pavement has potholes all along it, making for a very bumpy ride for the labouring mother and her distressed fetus. The journey that usually takes around 3 minutes at a leisurely stroll over the grass lawn takes the patient and her attendants around 10 minutes to complete. Finally, we get to theatre. We ask the patient to transfer herself from the ward trolley over to the theatre trolley. Hopefully, by this time, the attendant who was sent to buy the normal saline has also arrived, and we start running the fluids. Oops, the blood has clotted off this line. We try to find a syringe to flush the line, but the supplies closet is locked, and only the anesthetist has the key. We call the anesthetist on duty – the day-shift anesthetists have just left, and then night-shift anesthetist came for a split second, and then split. The number written on the duty sheet is no longer in use. We call another anesthetist asking for the on-call anesthetist’s number. Meanwhile, one of us runs back to the ward to get a syringe. When the syringe arrives, the line is flushed, and the normal saline starts flowing. We finally get ahold of the on-call anesthetist, and he is on his way.

While we await the arrival of the anesthetist, the theatre staff scrubs the theatre with Jik bleach and water. When we go to change into scrubs for theatre, we realize that they are not there. One of the theatre staff goes over to the other theatre to get some. Meanwhile, we iron our cloth scrub caps and face masks in order to “sterilize” them. Suddenly, the power goes off, and everything goes dark (it is now past dusk). We write a note requesting the presence of the superintendant in charge of the generator, and tell the attendant to go run the note over to the superintendant’s home. Meanwhile, we get our torches ready, preparing for the possibility of operating under torchlight (we found 2 torches). The linens arrive, and we change into scrubs, and put on our theatre boots. We don our theatre aprons (they make me feel more like a butcher than a surgeon, as the front is usually always stained with blood, especially towards the end of the day, after multiple caesars and before the nightly cleaning). Suddenly, the lights come back on. The superintendant has finally arrived and started the generator. We check to make sure that the patient has received 1L of fluids, and then roll her into theatre. One of us dons some gloves and places the urinary catheter (no lubricants are used, since we have none). The anesthetist arrives and prepares to give the patient spinal anesthesia. He changes into theatre garb, “scrubs”, dons some sterile gloves, and heads into the theatre. Now we scrub – by scrubbing, I mean basically wash our hands with sterile soap, and then use possibly unsterile water from a can (since with no power, we usually have no water either) to wash the soap suds off. We then grab our reusable cloth sterile gowns, and use the lower edge to dry our hands and arms off. We don the gowns, and put on our sterile gloves (there are only size 8 gloves today; sometimes we are lucky and have size 7.5 gloves – back home, I wear size 6.5 Micros on the bottom with size 6 Esteems on top). We head into theatre, dragging out mayo tray with our instruments in with us.

The anesthetist is placing the patient in position for spinal anesthesia. “Sit up straight! Bend your head down! Come on, sit up straight! Now bend your head down!” He loses patience with her and pushes her head down roughly with the backs of his sterile-gloved hands. “Sit up straight! Straight!! Come on!” He inserts the needle into her back with no local anesthesia given beforehand. She jumps at the pain. “Don’t move!” he yells at her. He tries again, she jumps again. “Stop moving! What’s wrong with you? We try to help you. You don’t cooperate!! The more you move, the more I’m going to have to stick you. So don’t move!” He tries again. He finally gets CSF flow. He injects the anesthetic. “Move down, down! Lie down! Hurry up!!” The patient scoots down. We take the sponge forceps, and use our sterile cotton wool soaked in iodine solution (we have iodine today; yesterday we didn’t, so we simply cleaned the patient with normal saline) to sterilize the patient’s skin surface. We put the reusable cloth drape over the patient, wipe the iodine/normal saline dry with a piece of gauze, use the toothed forceps to pinch the patient’s skin to check for adequate onset of anesthesia. No pain response. Scalpel! Cut! No wait. The midwife who was supposed to catch the baby and resuscitate it has been called back to the ward since they were shorthanded. We send another attendant to run and fetch the midwife.
“You run. Speed. Speed.” The midwife arrives. We start the caesarian. Time elapsed since fetal distress was diagnosed – usually anywhere from one to three hours, though it may be significantly longer than that. Sometimes if it’s really chaotic on the wards, and there is a more urgent emergency such as APH, PPH, or ruptured ectopic, the emergency CS gets put on hold (saving mothers is more important than saving fetuses, because the government and all major politicians are involved in preventing maternal mortality, so when we lose a mother, the hospital gets into a lot more trouble and gets a lot more unwanted attention).

When we finish the surgery, we find another “emergency” c-section awaiting us. This is a transfer from a health centre 3. They have spent an hour on the road to get to us, and have been waiting for about 20 minutes outside the theatre. I take out a piece of paper, and write down the things they need to buy. I hand the paper to one of the attendants. “You go buy these things. Run. Speed. Speed!” He dashes out. I look for a cannula to start a line. It is not there. I walk back to the ward to get one. I don’t have to run, because the normal saline will not arrive before I do.

Neonatal resuscitation

I stepped into the hospital early in the morning, and was hustled into the labour suite by a midwife. There, I found the whole team standing next to the bed of a mother with polyhydramnios and her fetus in breech presentation. Dr. Ogwal, one of the interns was dressed in a delivery apron, in the middle of conducting a breech delivery. How exciting!! I’ve never seen a breech delivery, and probably will have very few opportunities to see it back in the US (only under very specific conditions in multiple gestations, as far as I know). Soon, only the fetal head remained undelivered. Dr. Ogwal flipped the baby’s body over onto the mother’s abdomen in its first somersault, and its head slipped right out. What a sight!

However, the baby was not doing well. It had a grossly distended abdomen, and its lungs seemed underdeveloped. Apgar scores – 4/10 at 1 minute, and it didn’t get much better with time. We immediately started resuscitating the baby, but the baby warmer was not working since the hospital had lost power. So we manually warmed the baby with friction. Its heart rate was about 60, so we did chest compressions. It had central cyanosis, so we bagged it with a face-mask, but all the air seemed to be entering its stomach rather than its lungs. There was no ET tube, so we couldn’t intubate it. Dr. Ogwal fashioned a makeshift nasal-pharyngeal tube with a small piece of tubing for running IV fluids to more effectively deliver oxygen.

The baby’s heart was slowing down more and more – 40 at last count. We had asked for epinephrine over 20 minutes ago, and finally, the sisters managed to find some. However, we only had 18-gauge cannulas – way too large for the baby’s small veins. So we decided to do an intracardiac injection. Nobody knew how exactly to do it, so I looked it up on my iPhone with its super slow internet. The only thing I could find was a rough reference on Wikipedia – “4^th intercostal space between the ribs” it read. So I plunged the needle in the 4^th intercostal space, immediately medial to the nipple. I pressed down on the plunger, delivering the epinephrine into what I hoped was the left ventricle of the baby’s heart. We listened with the stethoscope – no heart beat at all. I shone light into the baby’s eyes – pupils were fixed and dilated. Admist all the hustle and bustle of trying to find the right equipment and medication, etc, we had lost the tiny life that had shone its light so briefly onto this world. The baby’s mother never even got to hold it or see it while it was still alive. I looked at Dr. Ogwal. “I really thought we were going to save it.” “Me too,” he replied. Everyone started walking away from the resuscitation table to join the morning rounds. I slowly wrapped the baby in its blanket, leaving its tiny face peeking out from its blanket. It looked like it was peacefully sleeping, if you ignore the bluish tint in its face. I stared at it. I couldn’t tear my eyes away from this tiny patient whom we had failed so miserably. “I’m so sorry, baby. I’m so sorry.” I started crying. I couldn’t believe it. I really thought our creative efforts and desperate attempt at resuscitation would work. It always did in movies, with the intracardiac injection magically bringing the patient back to life – the patient would awake with a big intake of breath, look around and ask “Where am I?” Why didn’t that happen? Why couldn’t we save this baby?

“Don’t take it home with you,” Dr. Ogwal told me. But why not? Taking our patients home with us will make us better doctors. It will scorch the lessons painfully learned from our failures deeply into our memories, so that we will never commit the same errors again. Or if these failures are the result of unfortunate situations, then it will motivate us to change the situation, to fight for our future patients so that they will not suffer the same unfortunate circumstances. I’m taking this baby home with me. I’m keeping it in my memories and my regrets forever.

ObGyn at SRRH

My first day on the Obstetrics and Gynecology wards – what a surprise! The consultants actually came to round on the patients on weekends, in contrast to Mulago, where consultants came to round on the patients once in a blue moon coinciding with an eclipse. Halfway through rounds, an emergency c-section secondary to fetal distress presented itself. So I went with one of the interns, Dr. Opero, to theatre. On the way, he asked me whether I’ve ever been to theatre, whether I’ve ever scrubbed, whether I’ve ever assisted on a c-section, etc. “Yes. I’m basically done with medical school. Of course I’ve been to theatre,” I exclaimed. “Well, I don’t know, some people go through medical school without having been in theatre,” he replied. My goodness, what kind of medical school graduates students who have never been in theatre? Such ridiculous claims shall not be tolerated.

When we got to the operating table, I was in for a surprise. There was no iodine available, so we cleaned the abdominal wall with normal saline. We did a SUMI instead of a pfannenstiel incision. We wiped the blood up with a “mop”. And when the mop was soaked through with blood, I tried to get the other clean mop, but was stopped by Dr. Opera. “No, no. I’m saving that for cleaning the abdominal cavity later.” And he wrung the blood-soaked mop until it was dry, and re-used it. Over the course of the surgery, we wrung the mop about 10 times, so that our gloves were sticky with dried blood. It definitely took some getting-used-to. And at the end of the case, they wash the mops, sterilize them, and reuse them over and over again. I was horrified by the resource scarcity. I told them that we use many many laps per case, so many that we have to do a lap count after each case. And we throw the laps away after use. They were horrified by the resource wastefulness.

Anti-progress

Boni and I went to the Soroti Regional Referral Hospital (SRRH) to check things out. We ran into the head of Obstetrics and Gynecology, and stopped to talk to him. I told him that I was here to work with Dr. Wilson over the weekend, and he suggested that I talk to the Hospital Director. So Boni and I went to the Director’s office, and waited for 2 hours before we finally got to see the Director. When we went into his office, the Director welcomed us warmly, and apologized for keeping us waiting for so long. He then went on to tell us (mainly talking to Boni though) how he really admired China, and how China had made so much progress over the years, etc. One thing he said that struck a note with Boni – he said that China and Uganda had been pretty much on par with each other 20 years ago (I would say maybe more like 30-40 years ago), but since then, China has progressed greatly, joining the ranks of the world superpowers, whereas Uganda has stagnated.

Boni did not agree. Instead of stagnating, Uganda has regressed. We walked to town after the hospital visit, and the road we used was broken up on all sides, with a narrow slim of intact tarmac in the centre. “This road used to be nice and new when I was young, maybe around 20 years ago. Cars used to be able to run on this road. Look at it now.” Boni commented as we walked on the broken road leading up to the local branch of the National Road Authorities. What a statement. When we reached town, I spotted a cinema, and got really excited to see what kind of movies they played. “Oh that cinema used to be functional 20 years ago, but it’s now closed. We no longer have a cinema in this town.” And when dusk came, the street lights remained dark. “These lights used to work 20 years ago, but now they’re all broken.”

We finally got to the reason that we went to town in the first place – to get some ice-cream from MY SUPERMARKET. As we sat on a ledge near the supermarket, eating our Koopsky and Simka ice-cream (both very good, and much better than Fidodido, in my opinion), I commented “Well, at least now your power is reliable enough that you can have access to ice-cream. That’s some real progress.”

“Nobody really eats ice-cream around here,” Boni remarked.