Today's post is the first time that Pete, my husband, has ever written on the blog. His story is moving as he describes what he experienced while working in the Kenyan hospital today where we are currently living.
I’ve been wondering for months, maybe even years, what my first delivery would be like when we arrived in Africa. A vaginal delivery? A cesarean section? Would there be instruments available? What about assistants? Would I even be in a hospital? You see, I’m used to the very best…
Most vaginal deliveries are attended by two or more physicians, an attending, a resident, and sometimes even another intern. By the time the patient is ready for a vaginal birth, she’s been monitored carefully for many hours, with baby’s every heartbeat recorded electronically (and on paper). We have a good idea of what to expect, and we also have everything we need in case something doesn’t happen the way it should. Sterile towels, gauze, masks and gloves, a vacuum device, even forceps for a difficult delivery, medications to stop bleeding and ease pain, sutures, scissors, scalpels…the list goes on. Most importantly, incredible OB nurses who are among the most calm and collected people in just about any hospital, certainly in Duluth.
For those vaginal deliveries that take an unexpected turn, we can change over for a cesarean section in about 10 minutes. By the time we arrive at the pristine operating room with the patient, awaiting us are perfect surgical tools sterilized and neatly wrapped, opened only by trained surgical technicians under sterile conditions who will later hand them to you when requested (most often even before, they know each surgery so well!). An anesthesia team is present to provide pain control with a spinal if there’s time, but they are ready with everything to intubate and breathe for a patient in case of a “crash section” (emergency surgery to save mom and/or baby). The Neonatal Intensive Care Unit (NICU) staff are already there with a resuscitation team and an incubator in addition to all the tubes, lines and cords needed for the worst of resuscitations. Oh…and those awesome OB nurses are there too.
I could go on, of course. But we’re not there. We’re in Africa. And it’s different here.
It didn’t start the way I expected, I guess. I was emergently paged to Casualty (the emergency department) to attend to an 18 year-old who was pregnant with her first child. She hadn’t reported any contractions, rupture of membranes, or vaginal bleeding. I didn’t have time to ask her if she felt her baby moving.
You see, there wasn’t any time for questions. When I arrived to the small room crowded with 7-8 beds and even more patients standing/sitting as they awaited care, the clinical officer (CO, similar to a Physician’s Assistant) helping the patient looked at me with panic. He pulled back a curtain to reveal a flurry of activity. The nurse was hurrying to start an IV while humming a hymn – I can’t remember which one right now. Another nurse had just arrived with an oxygen mask, freshly washed and ready for reuse. The CO rapidly explained that two girls had just dropped the patient off at the door and couldn’t be found.
I was at the foot of the bed while the CO spoke, partly listening, partly assessing. My hand felt her pedal pulse – weak and thready. I glanced up at her face just as the CO was finishing. She looked slightly ashen, and was gasping for air. Her uterus was at or below her belly button, meaning that the baby was either small or at about 20 weeks gestation or less. (A nurse confirmed she was 20 weeks pregnant shortly thereafter.)
Alright, Pete, don’t forget the ABCs. Airway, Breathing and Circulation. We have all sorts of these acronyms in medicine to help us remember a ridiculous amount of information (and recognize a whole lot more). There’s a pulse, she’s breathing (albeit with difficulty), but she’s losing her airway. As I moved to the head of the bed, a dark, liquid substance began spilling from the patient’s nose and mouth. We suctioned, intubated and started breathing for the her. Then we “dropped” (placed) a nasogastric tube and suctioned another 200 mL or so of the black substance from her stomach. We still don’t know what it was. By now the cardiac monitor was on and the patient’s heart rate was in the 130s (normal is 60-100 beats per minute). One of the nurses looked up a moment later and said the initial blood pressure was 70/50 (normal is 120/80 mmHg), but now she couldn’t get one. I felt the patient’s neck for a carotid pulse – there was none. “Start CPR,” I said.
I know all this sounds exciting, but really, teams of nurses and physicians all over the world do this often. It’s called a “code.” Someone’s heart or lungs stop and we basically have an algorithm (based on good science) that we follow to restart the patient’s heart or get them breathing again. It’s never fun, but it does become routine, at least when it’s performed by a well-trained team. This was a good team.
With the chest compressions came intermittent cracks (rib bones breaking from the pressure of compressions). At two minutes we checked for a pulse and gave epinephrine (adrenaline) to shunt blood back to the heart and encourage cardiac activity. There was not a rhythm that we could “shock her out of,” so we just kept doing CPR and using epinephrine every 3 minutes, checking for a pulse each time. After 40 minutes without a pulse, I called it. “Time of death: 10:24 am,” I said softly.
I helped the nurses clean up the patient, remove the lines, and apply fresh linens. Then I prepared for the hard part – talking with the family. They arrived later and I had a room prepared to tell them that the mother (and her baby) had died. They were inconsolable, of course. I spent a few moments there, but left them with the chaplain and returned to the emergency department where another patient needed care.
The mother was taken to the morgue in preparation for burial. Two days later, the family returned with one request: to have the opportunity to bury the mother and baby separately. I spoke with my supervising physicians who agreed this was reasonable.
I lead the family members, this time with the father of the baby, to the morgue and had them wait in the office. Then it was time for my first delivery in Africa, a postmortem cesarean section – another first. She laid there draped in a perfect, white sheet on a rusty, steel table. Even though the mother had died, I maintained very similar surgical technique as my attendings in Duluth had trained me to do. As I cut, the smell of formalin filled my nostrils. A moment later, I delivered a beautiful, tiny, lifeless, little girl. I carefully closed the mother’s tissues, even using a subcuticular stich to close the skin (a suture that is hidden from view). It wasn’t necessary, but it felt right.
I draped the mother again and then carefully attended to her little girl, only slightly larger than my hand. I washed her gently and placed her in a brand new swaddling blanket, her arms gently folded. One of the morgue attendants went for the father and the rest of the family. They arrived, not knowing what to expect, but when dad saw me holding his baby girl, he started tearing. I asked if she had a name. “Fancy…Fancy is her name,” he said, barely audible. “Well, Fancy is a beautiful little girl,” I said, handing the swaddled little girl to dad. “I’m sorry that her time with us was so short, but I believe that she is now with Jesus where there is no pain and no suffering…where we’ll all be together again.” I began to pray, my two fingers on the side of Fancy’s head as we invited God to be with us and bring His peace. Everyone, now with tears, gently filed out of the room. Dad stayed a moment, took one last look at Fancy, handed her to me, and said, “Asanti.” (Thank you.)
The refreshing African rain greeted us as we slowly walked back from the morgue to the hospital where we parted ways. It was early evening, and I was done for the day. I loosened my tie and draped my white coat over my arm to the let the rain wash me gently on the way home. I was greeted by a beautiful little girl who came dashing up to me yelling, “Daddy, Daddy, I have an umbrella for you.” I scooped Ella into my arms and kissed her. I walked toward apartment #7 and let my eyes meet Ang’s. She knew instantly. She just has a way of knowing that no one else could. I kissed and snuggled Sam for a moment before she quickly swept both children into their bedrooms for the night. I let the warm shower wash off the formalin, dressed and here I sit on our living room couch.
You might think now that I’m sad or depressed or maybe even upset about all of this, but I’m not. In fact, not at all. This young woman losing her life and her baby is tragic, yes. But in the end, I’ve never been able to stop someone from dying forever. Hester Lynch Piozzi, an 18 – century British author, once said, “A physician can sometimes parry the scythe of death, but has no power over the sand in the hourglass.” It’s true.
But I’ve also learned that one of the most compassionate acts we can do for one another is to relieve suffering and pain – to make room for healing. And tonight, when one dad looked back at another, there was a silent understanding that healing had begun, and then a quiet, “Asanti.”