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.