one for the team

Friday was exciting, which is never really a good thing if you're a
doctor. I had been covering maternity while one of our docs was on
vacation and had gotten a phone call from the charge nurse that a
patient had arrived who was pregnant, had a goiter and had been coughing
for a couple of days. I was busy on another ward and promised to get to
see the patient, but it didn't sound very urgent to me and I went home
to grab a bite to eat. While I was at home eating my left-over soya
pieces I got a second phone call asking me to come in and see a patient
who might be having a miscarriage.
I grabbed my black bag (yes, I really have a black bag, although it's
now seen better days, with the stuffing from my shoulder strap hanging
out and the zipper broken) and head for maternity, when no sooner do I
get into see the second patient when the first patient starts coughing
up blood. A lot. She has a massive goiter the size of a medium to
large orange on her neck, and she's managed to fill an entire kidney
basin with her lung blood, and is now working on her second kidney basin
in about 5 minutes. The blood was bright red and shiny, frothing with
bubbles and gleaming in an eerily beautiful way against the silver of
the basin.
I call the nurse, who works on putting in an IV, and go to our OR, where
there's an ultrasound machine. Our visiting surgeon is there with the
bowels of the electrocautery machine spilled out on the back table while
he's trying to fix it. I mention that there's a case that's a surgeon's
dream, between the pregnancy, goiter, and now coughing up blood, and he
comes along.
In the time that we take to bring the ultrasound machine she's filled a
third kidney basin. I put the ultrasound on and get a quick estimate
that the baby is term, the heartbeat is okay, and I put in a second IV
while the surgeon notifies the theater team and we decide to head to
X-Ray to see if we can figure out why she's coughing up so much blood.
We trundle her into the wheelchair and set off, kidney basin in hand,
trailing blood, people moving anxiously out of the way on the walkway
when they see us coming. This is a shuffle I am familiar with from my
ER experience: we leave behind a trail of detritus and blood from head
lacerations, disconnected IV's, and chest tubes when our patients make
their way to radiology. Here we set off right at the beginning of
visiting hours, so there's a sea of women wrapped in brightly colored
cloth chatting and walking past as we head to the X-ray machine.
Warren, our surgeon, and I struggle to hold her up against the X-ray
tube as he tries to figure out how to develop the X-ray once it is
taken. She has collapsed at this point and is doing nothing to support
her own weight; I now have an X-ray with her lungs and Warren and my
fingers on the sides as we hold her up during the film. We decide to
head back to the OR to decide what to do at that point.
On arrival to the OR she's managed to fill this last basin and her
oxygen level is 40%. Warren and David, our resident surgeon, do a crash
C-section under ketamine while I help the RN intubate her and suck out
her lungs. Her oxygen level has improved to 60%. The surgeons get the
baby out in under a minute after the ketamine, and our pediatric nurse
begins to resuscitate the baby, while the fourth doc, John, helps to
plug in the warmer and check with lab to make sure we can get a blood
transfusion for her. The lab (we can now only transfuse 8 more people
until more blood bags become available in the country of Zambia -- right
now we can't purchase or appropriate any) gets us two units, which we
give quickly, and watch her oxygen levels climb to 70%. Curiously,
there's no blood coming from the endotracheal tube but there is
occasional blood coming from her mouth. The surgeons finish their
C-section, we send the child off to maternity, and now sit back and take
stock. Her bleeding is decreased but her lungs sound awful, especially
the right lung, and her oxygen levels still suck. We take a look with
the gastroscope at her esophagus (we actually don't have a gastroscope
but we have a sigmoidoscope that we use for the same thing) and don't
find any bleeding. I look in her nose, but nothing. We try to extubate
her and her oxygen levels drop to 50%, so we re-intubate.
Many times in Africa you feel like you're making decisions on your own,
with little information, and the stressful part is having to make these
decisions on your own. Making decisions is what I do in the ER -- ER
docs make about 10-20x more decisions/day than other doctors -- but at
home I have a lot more information to help guide me, and it takes some
of the stress out of the process. Here, there's no threat of litigation
but there's the pressure to not get it wrong for some very sick
patients, and the knowledge that there's no-one looking over your
shoulder to catch things you might have missed. It was a good
experience, however, to get together and make decisions as a team,
scratch our collective heads. It makes the process easier and helps you
live with what you decide.
Surprisingly, we were able to extubate her and watch her on the wards
with a oxygen level of 70% after she woke up from the anesthesia. Today
she's up to 90% on oxygen and the baby's doing okay. Unfortunately, we
didn't know before the surgery that she has had 13 children and wanted
her tubes tied. This one nearly killed her, but if she makes it we'll
have to tie her tubes later. Hopefully that will go more smoothly.