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Judy and Kristen after operating. Our surgical gowns aren't water proof.
Sometimes we get a little messy. |
Kristen here….
We recently had the privilege of having some visitors from
home come to our hospital. They are all
members of a Rotary Club that came to support the hospital. They brought with them so many needed medical
supplies it completely blessed our socks off.
They also brought with them some general practitioners, a dentist,
ophthalmologist, veterinarian and an OBGYN!
I had no idea I was going to have a partner in crime for a couple of
weeks. I am so grateful Judy was there with me,
especially on the last day of their visit.
It started out like any other day. We did rounds, checked on the laboring
patients and were starting to see the line of outpatients that had come for
care. A nurse came to me from another
ward and asked me to see a patient that had been admitted that morning. She said that the patient had abdominal pain
and needed an ultrasound. They hadn’t
gotten her labs yet to confirm anything, but they suspected she was
pregnant. I told the nurse to bring her
down and we would take a look.
I looked up a little while later to see the nurse bringing
the patient in by wheelchair. “Uh
oh.” I muttered as I raised an eyebrow
and followed the patient into the room with the ultrasound. The patients here are incredible
resilient. They are almost never brought
by wheelchair if they have any capacity to walk at all. The fact that this patient wasn’t walking was
my first clue that something wasn’t right and she needed immediate attention.
I pressed on the patient’s belly and watched for her
reaction. I got nothing. She came with complaints of abdominal pain,
but never winced with any of my exam.
This stoic exterior is so typical of the patients here. I asked the nurse why she brought the patient
by wheelchair and she stated that the patient was too dizzy to walk. Hmmm….more red flags were raised. Judy and I did the ultrasound and it was
clear that she was collecting fluid in her abdomen. On inspection of her uterus there was no
evidence of a pregnancy inside, but on my visual sweep through the pelvis I saw
a walled off collection of fluid just to the side of the uterus that didn’t
look right. I couldn’t tell if there was
anything inside this collection of fluid, but it didn’t look normal. My
suspicions were high for an ectopic pregnancy – a pregnancy located outside of
the uterus. If this was an ectopic it is
fatal for the pregnancy and can be fatal for the mother as well. It often becomes an emergency.
I asked the nurse to get a second IV line started and
collect some labs as I went to the OR to notify them we had a patient coming
their way. I didn’t have a positive
pregnancy test nor was I completely sure that I had seen an ectopic pregnancy,
but the amount of fluid in this patient’s abdomen told me we needed to go to
the OR. I returned to check on the
patient and help move the bed to the “Theater” as we call the operating room
here only to find that the staff were having trouble placing that second line
and could not draw her labs. It had been
less than 10 minutes since the ultrasound and Judy and I already noticed a
change in the patient’s cognition. She
was becoming more listless and responding more slowly to the nurses as they
worked around her. They tried again to
stick a needle into her skin and I could see her face grimace. Good, at least she still was responding to
something. I tried to be patient as I
let the nurses do their work because hurrying the process or becoming agitated
in this culture doesn’t help the process become any more efficient and can
actually be detrimental, but I knew we were working against precious time. I walked back up to the theater and told the
anesthesiologist I was in trouble. They
couldn’t get a second IV line placed or draw her labs and her condition was
deteriorating. I could see the
understanding in his eyes. He knew we
had to move quickly. He told me to bring
the patient to the theater and he would take care of it. He was the only anesthesiologist working that
day and had already started another case, but he got up, left the room and
mobilized the OR staff to be ready for our arrival.
We brought the patient up and placed her on the operating
table. She was barely responding. The anesthesiologist placed a large needle in
the vein in her neck. No response from
the patient, no blood returned from the needle.
Not good. We hurried through
draping the patient as she drifted off to sleep. I looked up for a moment and saw that her
blood pressure had fallen to 63/18. We
had to work fast. Her abdomen was opened
in seconds and blood started spilling over the sides of the table. The fluid we saw on the ultrasound ran
red. I reached blindly into her abdomen
and grabbed the patient’s uterus and brought it up to the incision. As soon as I took a look at what I was
holding another “uh oh” came from my mouth.
That pocket of fluid I had seen sitting next to the uterus on ultrasound
was most definitely the culprit of this morning emergency. The ectopic pregnancy was found, but it was
not just any ectopic, it was a cornual ectopic.
This is a pregnancy that forms where the fallopian tube meets the uterus
and is one of the most dangerous types of these obstetric emergencies. They are rare, known to bleed in incredible
amounts and can be a challenge to remove.
I was so thankful Judy was across the table from me. Like so many other times in Kenya this was
something I had only read about, but never actually seen before. It was so nice to have a more senior physician
working with me to walk me through the steps of this emergency. God’s timing is perfect.
We removed the ectopic that had ruptured and was
bleeding. We repaired her broken uterus
and cleared 2 liters of blood from her abdomen.
The patient was being transfused and her vitals started to improve. It was with a sigh of relief and a prayer of
thankfulness that we closed her belly and transferred the patient out of the
operating room alive.
I was thankful for many things that day, thankful that the
patient had come to us when she did. Had
it been even an hour later we could have had a drastically different outcome.
Thankful that she presented during the day and not in the middle of the night
when it is much harder to mobilize the necessary staff and resources needed to
care for such a patient. Thankful that I
had OR staff that understood the gravity of the situation and dropped
everything and moved quickly to save this patient’s life. Thankful that the hospital had blood that day
to transfuse this patient (this is not always the case here at Kapsowar). Thankful to have the shoulder of another
obstetrician to lean on when I was treading through new waters in a situation
where time was not our friend.
