Harrowing stories from the OR

I am in the doc’s waiting room in the OR waiting to do a C-section. Reading my JOGC that I am planning on leaving here when I finish reading it (a medical journal--yes I'm a nerd!). Topic is peripartum hysterectomies in developing countries. Apparently the number one cause is uterine rupture, unlike at home where it’s PPH/placental abnormalities like accreta. Interesting. We get called that the OR, the patient is ready. I put down the journal. Little do I realize how topical it would be.

In the charting room

It’s a routine section, woman in labour with a previous section and failure to progress, and some signs the fetal distress. I open up and groan silently to myself. Nothing but thick, thick adhesions. The bladder is scarred halfway up the uterus. I can do it, I can do it, I tell myself. Slow and steady. Nice and methodical. Yes, here comes an adhesion down. And another one. Progress is slow. Painfully so. But it is still progress!

All of a sudden that changes. I see some strange filmy layer on the uterus, brownish in colour. I touch it gently to see if I can get a better idea of what it is. But even a light prod is enough to burst the sac, and fluid that looks ominously like stool starts to pour out. After a moment of deliberation, Dr Paul decides that it’s meconium (baby stool), and that this poor woman’s uterus has ruptured. We incise just above and pull out the baby, who is grey, oh so grey, and limp. I have no idea if it is alive or dead. But can’t focus on that. We need to figure out if we can save this woman’s uterus. We feel down to see if we can reach the bottom part of the tear, sew it together, make it possible for this woman to have another baby. But feeling down down down, all I can feel is friable tissue that would never hold together. Getting a better view of things, we can see that almost a quarter of the uterine circumference has been torn. It is not salvageable. So we have to take it out. “Please save the baby”, we announce to the nurse. “It is this woman’s last baby”. Miraculously, the baby survives. The mother barely does. We have no blood in the hospital for the last few days. We’ve asked someone to go to Kampala, at least an hour away, to get some blood. We get called to the patient's bedside later in the afternoon. She is still breathing, but has no palpable pulse and no readable blood pressure. Her breathing is slow and labored, her heart pounding at a pace I know is unsustainable. We’ve already given her a lot of fluid. In fact she probably has more saline flowing through her vessels than actual blood. I call for some epinephrine, the only pressor they have here. It doesn’t do much. Blood pressure still not readable. What she needs is blood. Dr Agnes has the same blood type. We are getting ready to take some whole blood from Agnes and transfuse it into this woman, when the ambulance arrives from Kampala with that precious blood. We run out and hang it. And wait. And hope. And pray. Miraculously, this woman has been brought back from the brink of death. Another few hours, and she would not have been so lucky. I saw them just yesterday, and they looked fine, both mother and babe. I wonder if the mother realizes how lucky she is to have a live baby, how incredibly fortunate she is to be alive herself. 

One day, I was reading a bit in the surgery textbook that sits in the OR charting room. It’s basically simplified surgery for non-surgeons who must operate. The typical scenario they open with strikes terror into my heart:

“you have just arrived at your new post. As you are unpacking your things, a nurse runs up to you and yells, ‘Doctor, Doctor! There is someone who has just arrived after a motorcycle accident. We fear his spleen has ruptured, he will need emergency surgery.’ You have never done one of these surgeries. You assisted on a few as an intern, but the senior you were working with never let you operate, except to sometimes close skin. You are the only doctor currently on site. The nearest referral center is 3 hours away and you know that if you refer this young man, he will die on the way.” 

YIKES!!!!! They have something in the textbook I think called “Bewes Rule” (or something). If you are really stuck, have an assistant press a gauze firmly against the source of bleeding. Unscrub, have a cup of tea, and look at this book. After 10 minutes you will be much refreshed and more confident.” I ask Dr Matov and Dr Agnes if they've ever used this "rule". "Many times!" they both chime in. While it has clearly been helpful in saving patients' lives here, I somehow doubt it would be acceptable for a Canadian surgeon to try that...

One of the OR sinks. The soap dispenser is out of soap. The remaining bit is in that blue plastic container. To scrub we just have to fish it out with our fingers. At least the water works.

Again, my reading proves to be somewhat topical. Later that evening, I get called to see if I want to see a splenectomy. Of course! Drs Matov and Agnes are doing it. I ask Matov how many he’s done. 3. One for each of the months that he’s been here. They have all been unsupervised. He had assisted on a few as an intern before being thrown into the situation of being the sole doctor on call in the whole hospital in a rural area, where patient transport is slow and prohibitively expensive. So the buck stops at him. Little matter if he’s inexperienced. Either he operates or the patient dies. Matov says a prayer before we start. Unexpected, but I like it. As soon as the peritoneum is incised, burgundy blood flows out. And keeps flowing out. With each breath of the patient, another gush. I wonder when it is going to stop. If it is going to stop. We fill up a suction canister and there is little sign of slowing. I am starting to get worried. Finally the flow slows enough (it never really stops) for Matov to reach a hand in. Out comes what looks like a giant clot. Oh, nevermind, it’s what remains of the spleen of this poor young many hit by a boda boda, a motorcycle taxi. The surgery goes well, and we are actually out pretty quickly with good hemostasis. Good job Matov. Maybe I should take to praying before my operations, too.

 Drs Paul, Matov and Agnes in the OR charting room

Another evening, unstable bleeding patients seem to be the theme. This time it’s a woman with an ectopic pregnancy. I get called to the OR. I get there and it’s locked. When I call Dr Paul, he says in a very frustrated voice that the woman is refusing to consent to surgery until she talks to her husband, who has been unreachable for the last hour while they have been negotiating. I walk back to the guesthouse, feeling sick. This woman is already very unstable with tanking blood pressures. But there is nothing we can do. What about when she goes unconscious? Is that implied consent? Or will we have to watch her die? 

Luckily we don’t get to that point. About 30 minutes later, Dr Paul calls me again and tells me they finally reached the husband and he talked his wife into consenting.  When we open her up, it’s blood again. So much blood. When we finally clear things enough to see the tube, it’s hard to believe this tiny little tube with the steadily oozing blood could be responsible for this much havoc. Blood is everywhere, clots soaking through the OR drapes, through my gown and into my plastic apron that we wear since the OR gowns are just cotton and not fluid resisitant.  The white rubber boots we wear are stained deep red, and I’m standing in a puddle. When I start to suction her belly clean, Dr Paul tells me to hold off and leave it. We leave the blood in her pelvis because there is no more blood in the hospital. They ran out yesterday. And this woman has lost at least 2L. Apparently it will reabsorb through her peritoneum, like peritoneal dialysis of sorts. A few days later, we get some blood from Kampala, and we give her one unit. But despite the fact that her hemoglobin was only 39 (!!) pre-transfusion and likely now only sitting at about 50, and her heart is racing and she’s dizzy, we dare not give her any more. She looks and feels better than when her hemoglobin was 39 (how can you not!)  and her heart rate, although still high, has come down. We dare not transfuse her, for we won’t get another shipment of blood for at least a week, and the weekend is coming up. If we give another unit to her, it could cost the life of another. She has enough to survive, for now.