Sunday, 14 July 2013

When it rains, it pours...

Remember my previous post about the little boy dying? Well, the days that followed made that a week of horrors, really. What's about to follow is a series of clinical vignettes so feel free to skip ahead if you're non-medical (or even if you're medical and don't want to hear any more about our work that seems all too pervasive at times!).

1. Postpartum haemorrhage
A multigravida lady presents just before dawn having delivered a stillborn infant at home and is now in the throes of delivering its previously-undiagnosed twin. Sadly, the second bub is also stillborn. Just after our morning staff devotions are completed at around 9am, my senior colleague receives an urgent phone call from the nurse who was at her bedside as the patient is now unresponsive. Apparently she had been slowly bleeding out the entire time and her uterus remained boggy despite an oxytocin infusion and methylergometrine. On examination, she was found to have a ruptured (!!!) uterus.

Rushed to theatre, the anterior tear (which I never got to see since I was on the other side of the drape doing "anaesthetics") was successfully repaired but it was rocky to say the least. She kept having periods of apnoea when we had to bag her and periods of bradycardia requiring boluses of adrenaline (without concurrent ECG monitoring due to our not having metaraminol, ephedrine or even just plain atropine). Maintaining blood pressure was a nightmare since the only intravenous fluid we have is normal saline and 5% dextrose (no Hartmann's, let alone gelofusine, voluven or albumin - 4%, 20% or otherwise). She did have two 16G IV cannulae, thank God, so we had blood running through one drip and normal saline through the other. Even obtaining the blood was a complex process since we didn't have any of her blood type left in our fridge and we had to find a suitable donor, bleed him/her and then get it to the patient (which takes at least 15, usually 30, minutes).

There was also a frustrating difference in opinion as I was all for pouring the fluids in asap since she was obviously in hypovolaemic shock but my colleagues were reluctant to push her into fluid overload. I had to argue that she was more likely to die at this point from an inadequate circulation rather than pulmonary oedema that we could offload later on (which we often do in ICU with frusemide infusions) before we came to some form of consensus. And the pulse oximeter wasn't working - partly because she was so shut down peripherally and partly because the actual machine wasn't functioning properly (I tested it on myself). My requests that we find one that work were repeatedly ignored since "there would be no change in management"; fair enough, but having a pulse oximeter means not having to manually measure her falling heart rate (causing us to be one nurse short who had to auscultate her chest every few minutes to get this number) and having a beat-to-beat report on at least two of her vital signs. The donated monitors that we received from an American charity also died on us due to some problem with its power inverter. Argh!

Anyway, I left to get to clinic after she was (seemingly) stabilised. However, an hour or so later I could see a crowd of people gathered around the operating theatre and hear wailing from inside. Apparently she had become apnoeic again, was intubated but then went into cardiac arrest. So in the space of four hours, the poor patient's husband had lost both his twin newborns and also his wife. In retrospect, would an emergency hysterectomy have saved her life? It's hard to tell. Apparently her uterus was still uncontracted at the end of the repair and we don't have prostaglandins or the ability to perform embolisation. Another possibility was arterial ligation. In either case, none of the staff members have ever done any of these procedures so the outcome may have been exactly the same.

2. Severe dehydration
I can't emphasise enough the importance of knowing a patient's electrolytes. We do have a biochemistry machine but we lack the trained staff to use it. A very young boy presented to us that same day in severe dehydration (the first time I've seen markedly reduced skin turgor!) secondary to vomiting and reduced oral intake (combination of severe malaria and malnutrition). As expected, none of us could get IV access. This round, having learned from the previous case where we couldn't get access as well prior to the little one's untimely death, we didn't waste any more time and took him to theatre to put in an intraosseous line. Well, things seemed to be on the mend and he survived the next two nights appearing euvolaemic. Unfortunately, on the third night, we could hear wailing coming from the hospital's direction and a quick phone call proved that he too had passed away.

Was it hypokalaemia? Hypernatraemia? Acute renal failure? Something else altogether? I guess we'll never know now.

3. Why I would never choose obstetrics as a long-term career
It's all a bit muddled in my mind now but I believe we had either an emergency Caesarean section or a complicated labouring woman (pre-eclampsia, breech presentation, floppy neonate requiring chest compressions etc) every night that week. I don't particularly find the prospect of facing yet another placenta attractive in the least, no offence to all my O&G friends.

Anyway, at the end of the week during our Pioneers (the American-Australian missions organisation that sends us) get-together, one of my nursing colleagues shared this passage with the rest of us, which was truly a timely word of encouragement from God Himself:

Isaiah 65:17-25 "For behold, I create new heavens and a new earth; and the former shall not be remembered or come to mind. But be glad and rejoice forever in what I create; for behold, I create Jerusalem as a rejoicing, and her people a joy. I will rejoice in Jerusalem, and joy in My people; the voice of weeping shall no longer be heard in her, nor the voice of crying. No more shall an infant from there live but a few days, nor an old man who has not fulfilled his days; for the child shall die one hundred years old, but the sinner being one hundred years old shall be accursed. They shall build houses and inhabit them; they shall plant vineyards and eat their fruit. They shall not build and another inhabit; they shall not plant and another eat; for as the days of a tree, so shall be the days of My people, and My elect shall long enjoy the work of their hands. They shall not labour in vain, nor bring forth children for trouble; for they shall be the descendants of the blessed of the Lord, and their offspring with them. It shall come to pass that before they call, I will answer; and while they are still speaking, I will hear. The wolf and the lamb shall feed together, the lion shall eat straw like the ox, and dust shall be the serpent's food. They shall not hurt nor destroy in all My holy mountain," says the Lord.

Amen and amen. Lord, come quickly!

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