I have never seen this before

Entrance to Maternity Ward....my home sweet home at the hospital.

 

Kristen here…

“I have only read about this, but I have never seen this before.” That seemed to be the theme of my week at the hospital and the mantra I kept repeating day after day.  It started last Sunday night and continued with multiple patients culminating Thursday evening when a pregnant mother showed up with what I think was congestive heart failure and cardiomyopathy.  A deadly condition in pregnancy - one with a 50% mortality rate in the best of circumstances and these certainly weren’t the best of circumstances.  This dreaded condition is one that I have read about, one that shows up as an abstract question on a board exam, but not one that many will ever see in their career as an OBGYN.  I certainly never saw this is residency and even if I did, I would not be surprised at all if that patient would have been transferred to a bigger, more critical facility because the stakes are just that high.

 I took one look at this mother lying on the bed in front of me and knew I was in trouble. Her legs were swollen to the sizes of small tree trunks.  Her pulse bounding at 180 beats per minute.   Every beat of her heart caused her entire torso to shake because she was working so hard to stay alive.  She was talking in incomplete sentences in her native language to the nurses around me.  Breathless, we put a pulse ox on her and saw that she was only satting at 80%, a far cry from the near 100% that you and I are breathing right now.  A quick ultrasound put an estimation on the age of her unborn child….7 months gestation.  1.6kg.  2.4kg is the weight needed for a baby to thrive here.  Anything less and the baby may struggle or not even make it.  I called one of the other medical officers down to help me.  We had a tough decision to make.  She needed an echo to confirm my suspicions, but that is not available at our hospital.  The toll the increased stress this pregnancy was placing on her heart made me uncertain if she would even survive the night.  All of the text books would say to do an immediate delivery.  Mother’s in such a serious condition have a much better chance of survival if they are not pregnant, but what about her baby?  1.6kg.  It was a gamble.  I don’t know that I had the right answer.  I got another medical officer involved and the anesthesiologist.  They both came to examine her.  She was alone.  There was no family with her.  No one to discuss the grave choice we had in front of us.  Our option was to do a c-section within the hour, an operation in which she may not survive or to watch her struggle to breath the remaining few hours of her life as she surely wouldn’t make it until morning.  With heavy hearts we moved her to the operating room.  I placed my hand on her arm and prayed silently, choking back tears knowing that there very well could be one, if not two deaths on my watch that night and there was very little I could do to stop it.  Just before the spinal was placed the whole operating room stopped as she was prayed over in her native tongue. We all knew what the next minutes could bring.  We proceeded with a rapid c-section as she was not able to lay flat for very long and keep up her respiratory efforts. 

After the baby was born the room was silent.  This is one of the worst sounds in the world for an OBGYN as I tried to focus on finishing the surgery all the while praying to hear the sound of a cry from the life that had just been born.   The minutes seemed to drag on.  The mother’s heart rate plummeted.  I glanced at the anesthesiologist to get some sort of clue as to how he thought the patient was doing.  Nothing – I couldn’t read his face.  Just keep going Kristen, just keep going.  Finish the surgery so we can stabilize the patient. 

Finally, there was a squawk from the corner of the room.  It wasn’t the sound of a healthy cry, but it was something.  Something resembling life in that newborn.   One small victory.  The resuscitation team continued to work on the baby.  My job was the mother.   I placed the last stitch and the mother was still alive.  Praise God!  Tearing off my surgical gown I walked over to the baby.  There was respiratory effort – though strained, the baby was at least trying to breath.  A good sign.  Shortly thereafter one of the nurses took the baby to our NICU for further care.  It seemed like this baby might have a chance.  The mother’s heart rate had come back up and her blood pressure was stabilizing.  She was still a long ways from recovery, but she had survived the surgery and her body seemed to be responding well to not having the stress of pregnancy straining her heart.  Still tachycardic and requiring oxygen, I knew that she was in critical condition.  I talked with the medical officer about the best course of treatment for her.  My text books listed off a bunch of cardiac drugs to give a patient in her situation, but none of them listed the doses nor had I ever given a patient these drugs before.  Back home, this would have been under the care of a cardiologist.  We don’t have one.  I knew I was way out of my league, but there wasn’t anyone else to care for her. 

I stayed up most of the night at her bedside watching her vital signs fluctuate and praying over this patient.  We didn’t have the equipment or exact medication that she needed, but we were giving her what we had.  Our human medicine is so imperfect.  The next bigger hospital that may possibly have more in the way of resources than us is a good 2-3 hours away on treacherous roads.  Sending her in the middle of the night in the back of a pickup truck to that hospital without the ability to monitor her just wasn’t a good idea. 

The patient’s family showed up late that night.  How do I explain to them what has happened?  How do I convey that I did an emergency c-section and possibly jeopardized the life of her child to save the life of the mother who may not make it through the night?  How do I explain something as complicated as congestive heart failure to those that still go to the witch doctor when they are sick to get rid of evil spirits?  With the help of some of the OR staff I bumbled through what had happened and my concerns for the patient.  The family graciously accepted what had been done and the situation at hand.  I am always amazed.

I walked back into the “ICU” where she was laying.   My prayers continued, “God show me what to do.  I am so lost.”  In residency you always have the comfort of knowing that though you might be managing a patient there is always an attending, a senior doctor looking over your shoulder.  You have someone to turn to and ask a question when you are unsure, someone to bounce ideas off of, someone to go over a patient with you to make sure you are not overlooking any details.  It is much different here.   There isn’t anyone else to ask.  I am alone.  A good friend of mine who is also a physician recently told me that feeling of grave responsibility and aloneness hit her too when she was first out of residency and it taught her a lot about prayer.  She learned that though she doesn’t have a physical attending looking over her shoulder any more she does have the Lord.  Her words, “Kristen, let God be your attending now,” just kept echoing through my mind during those early morning hours sitting at her bedside.  I definitely needed a senior doctor to give me guidance.  This was the cry of my heart as I prayed.

The patient was so sick that she wasn’t able to keep down any of the medications we gave her.  She needed these desperately.  Our hospital does not have the IV forms of these medications so the only way to give them was orally.  My heart sank with each failed attempt.  Her heart rate started to climb. 

As the first light of dawn broke over the ridge of the nearby mountains the patient was still alive.  She had made it through the night.   I watched her the next day as she finally began to be able to keep down some medications.  I wrote to several colleagues and talked to some missionary doctors on the phone in other parts of Kenya to get their input.  Every idea they had we were not capable of at this hospital.  We began again to talk to the family about trying to transfer her to another hospital.  This might be her only hope and if it can be done in the daylight it would be much safer.  After long negotiations over the cost of transport and hospital bills it was settled and I walked with the gurney and watched as the patient was lifted into the “ambulance” – more of a glorified truck with a covering over the bed.  I prayed as the vehicle pulled away.  It would take a miracle to save the life of this new mother. 

I learned a lot from this one patient.  Her name and face will forever be ingrained on my heart.  Holding life so delicately in your hands comes with a weight of responsibility I cannot begin to describe.  I have never seen a case like this before and hope in my deepest being that I never do again.  I do know though, that God is my attending.  My short comings are many, but my senior physician is never wrong.  That is where my hope must always remain even in the most dire of circumstances.   I may have never seen this before, but He has seen it all.