Thursday, March 20, 2014

Priority of Life

It started like any other morning in Hiche; cereal, coffee, some quiet banter about what everyone was going to do for the day. Tara and I were not supposed to be headed to the hospital until the PM shift-2 to 8pm. We took our time in the morning, getting some relaxation and ultimately looking for something to do to pass the time.

We found out they needed cord ties made. Once 100 were made, they would autoclave them to sterilize them. These cord ties consisted of 3 pieces of string, each 7-8 inches long, rolled up into a ball, then wrapped in paper. Tedious work, but it was keeping us occupied for a few hours.

Suddenly, Nadene comes down with an urgent phone call from Wendy. There was an ectopic on the unit and she was headed to surgery soon and the Haitian OB wanted my help. I took about 2 seconds for me to hop up, gather my gear for the day and head out. My only mistake was forgetting to fill up my water bottle. In this heat, that wasn't a good mistake to make.

The moto ride is usually a casual, leisurely ride from the house. This ride was no different, although I was imagining this mom having a ruptured ectopic and bleeding out as I was taking a gentle stroll though town. I need to go faster!!!

I get to the unit and things seem relatively calm. The OR is on hold because of a general surgery case. I learn later that it is a radical mastectomy being done. Recurrent breast cancer, apparently. I'm shocked to see such a surgery done here. But, I digress. The mom with the ectopic is stable, thankfully. She is obviously in pain, but vitals seem normal and no immediate distress. And due to the delay, it's a good thing she is stable.

I sit and wait for the OR to come get this mom for surgery. I turn my head toward the door because there seems to be some commotion. A mom was being helped in to L&D by two men. She's in pain and sounds like she is in labor. She takes a few steps and blood is pouring from her onto the floor. Flowing from her, steadily running down her legs and onto the already filthy floor...it is truly a horrifying sight to see. Regardless of the cause, she most likely needs to be delivered quickly. First, I find heart tones...baby was alive. Next, I use the crude ultrasound and rule out a previa. I her IV fluids that she walked over with- two IVs hanging- LR and magnesium. Her blood pressure was 170/120. Imagine that...another preeclamptic. Another complication from preeclampsia. There was no doubt she was abrupting and urgently needed to be delivered. But...so did the ectopic. And there was still that pesky mastectomy going on.

I looked at Wendy and said, “This might be very bad. With the delay, we could easily lose all three (meaning the ectopic mom, the pregnant mom and the baby.)” And it could be quickly.

I thought of this were my decision to make, who would be the first priority? The ectopic could go bad quickly, but it also would be a relatively quick surgery. The abruption, though stable at the current moment, had both the lives of mother and baby at stake. There is a prioritization of life being contemplated...and the Haitian OB makes the call that the ectopic gets to go first.

A bubbly, Hispanic guy named 'Romero' came bounding into L&D and introduced himself. It turns our Romero is our anesthesiologist. He has come to see the ectopic. I assumed at this point that the general surgery case is done. I was wrong! Romero left the OR, came to see the ectopic, got her back to the OR and placed her spinal, all while the mastectomy was taking place. As crazy as it sounds, that is exactly what needed to happen here. Time was ticking and there was none to be spared if a life was not to be lost.

I am doing the ectopic with Jean Baptiste, the only other Haitian OB that I had not yet met. He is a very nice man. You can tell he cares about his work and his patients. As we prepare to begin the case, he reaches over and firmly grabs my hands...holding hands with a man I have just met and whom I do not understand his language, he says a prayer in Creole. This work and situations such as these, transcend the expertise and skill of any surgeon. We need all the help we can get.

We start and as soon as we open her belly we know that it is a ruptured ectopic, blood fills her belly. The right tube was distended and ruptured. We take it out. The left tube was severely damaged and we both agree she may never have kids. My guess is that she had an STD at some point that has ruined her tubes. Sad, but it is the reality.

Ruptured right fallopian tube.



Headed back to L&D I'm hopeful that the abruption mom is still stable. She is, only now we still wait for her turn. This time we do wait for the mastectomy to finish, probably another hour at this point. All together it was nearly 4 hours between when she came in with an 'emergent' reason for delivery and when she actually delivered. Lucky for her, she maintained stabilty for the duration.

Surgery was uneventful. Dr. Celestin let me do the case and it was like any other c-section. Baby did great and mom did great. Her placenta didn't exactly look like an abruption, but her uterus had ecchymosis (bruising) that appeared to be a classic Couvelaire uterus with bleeding into the uterus. A good call to deliver by section. And a tubal after this her 10th baby was also done.

By this time, Tara and Kerri (a doula from Connecticut) had arrived to work the PM shift. Things were oddly quiet for a while. As it usually happens, more commotion. This time it is several men and one tiny woman carrying in a mom on a stretcher. It was her first baby. She was 30 weeks by their discussion, but looked more close to term. She had been in labor and had been under the care of a Matron (a local, traditional birth attendant) and she had apparently seized several times prior to being brought to the hospital.

Matrons are traditional birth attendants. These are both men and women that have grown up watching others in their village attend births. They have learned their skills by observation, being taught be matrons before them, folk lore, and probably a bit of voo doo thrown in for good measure. Matrons often have had no formal training in birth at all. Yet, because of the long history of using matrons, these women are very much a trusted part of the community. (Midwives for Haiti has begun a series of classes to teach the basic medical skills needed to provide safer care to the women in these remote village without access to midwives.)

On first evaluation, her blood pressure was 140/120, baby's heart beat was 120 and she was complete and plus 2. All in all, she was pretty stable. She continues to labor as the midwives work to start her IV, hang magnesium, and wait for her to deliver. Over the next hour or so, it becomes clear that her seizures have left her exhausted and her pushing efforts are non-existent. Tara wonders and questions o the Haitian midwife whether a section would be in order at this point. She unobtrusively asks how long they will wait before making that decision. In her mind, I can see the reasoning. A first time mom who has knowingly seized several times and while now arguably relatively stable, she is not coherent and hardly conscious. I can tell she feels this should be happening. One of the Haitian OB doctors checks the patient and says that he will give her a bit more time before ordering pitocin.

I can't say that listening to heart tones is a regular thing here. There doesn't seem to be a protocol. We tried as best as possible to listen consistently every 20-30 minutes, but in an environment of chaos and a lack of staff, it is difficult. In this case, we listen and find the heart rate in the 70s! It stays in the 70s. We set in motion the means to get a section done. I notify the anesthesiologist, the midwives call the Haitian OB. The heart tones have come up a bit to the 100s, but are still low. I was very surprised, pleasantly surprised, that things went very quickly towards section. Within minutes of my notification the OR was in the room to get her. Within a few more minutes she was off to the OR. In the OR, she had a spinal placed mostly on her side, but I'm fairly certain that he nearly put it in with her on her belly. For those that know OB anesthesia, you'll know this is no easy task when they can't sit straight up or lie still on their side.

The only thing missing was the Haitian OB. Once her spinal was in, the anesthesiologist and scrub tech yell at me and motion for me to just start. “You...go!!!' Hesitantly, not wanting to break any rules we agreed on at the beginning of the week, I decide to scrub. It is either that, or we might lose this baby. Just as I'm prepping the belly, the Haitian OB walks in and motions for me to continue. It looks like I'm on my own. He doesn't scrub.

I quickly get to the uterus and open it. Mec...lots and lots of thick meconium. Not terribly unexpected, but also not a great indicator of what I'll find. The baby was limp and apparently lifeless. I knew, however, that there was a set up for resucitation handy, just in another room. I quickly hand the baby off and finish the section. All is well with the mom. I find out that the baby has actually done well. Initial heart rate was 130 and only needed bag mask to get started.

All in all, a busy day. I have found that the willingness to call for a pediatric nurse and have them called for every birth has truly been a life saver. There is no doubt in my mind that without a skilled pediatric nurse for this last baby, that she would have died. For that one change since we were here last, I am grateful, as well as proud of this program. There is change being made.

Until tomorrow.

Glen

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