Stretched

One of the things I both fear and love about working in a place like Kibuye is that you are constantly stretched beyond your skill level.  Stretched because of lack of resources, lack of specialists, language barriers and a million other reasons. 

Friday morning, Joseph, our Burundian anesthetist, came to tell me that there was an urgent Cesarean section.  This is not unusual.  It seems that people in Burundi do not travel at night, even when experiencing life threatening emergencies.  Therefore, women in obstructed labor often present for C section first thing in the morning, once the sun rises.  Joseph then told me that the woman’s blood pressure was 190/120.  Well, yes that is a problem.  He then explained to me that she was also alternating between seizing and unconscious.  She had full blown eclampsia.  

Now, as a practicing anesthesiologist in the US, I have read about eclampsia many times, such as during medical school and while studying for my board exams 10 years ago.  But I have never actually seen a patient with full blown eclampsia.  That is because patients with PRE eclampsia are identified early with good prenatal care and if things show even a hint of progressing to eclampsia, they are transferred to a center which specializes in this life threatening problem, such as the University of Washington, where they are managed by a team of specialized anesthesiologists, intensive care doctors and OB/GYNs.  

So, as my mind is racing trying to retrieve any bit of memory about management of eclampsia, I follow Joseph to the Maternity ward.  When we find her she is unconscious, and within 2 minutes starts convulsing.  They cannot find any fetal heart tones (they use a small wooden tube which they place on her belly and hold the other end to their own ear).  Their best guess, she might be 20 weeks pregnant.  I remember that we need to give magnesium.  But first we need an IV.  We spend about 7 or 8 minutes trying to find a vein, but find nothing.  I decide we can’t wait.  I ask them to take her to the OR as fast as they can.  I run to Jason’s office to retrieve his ultrasound machine.  When she gets to the OR I ask them to hold her head still while I put an 18 gauge IV catheter in her internal jugular vein under ultrasound guidance.  It works, we have IV access.  Now, how much magnesium do I give?  I can’t remember if it is 2 or 4 grams.  No one else seems to know.  There is no high speed internet to look this one up, and since we seem to only have a few vials left, we give 2 (it turns out the correct answer was 4, but thankfully 2 seemed to work).  

On weeks when I am not here, there are 2 options for anesthesia for cesarean.  Spinal or Ketamine.  Problem is, her platelet count is dangerously low (26K), so spinal could cause bleeding around the spinal cord which could paralyze her.  Ketamine will make her blood pressure even higher, which could cause heart failure or a stroke.  But thankfully, this week, we have compressed oxygen and so we can do a real general anesthetic.  We get her off to sleep, the national doctor performs the C section, while Jason is performing another urgent C section in the other OR.  As we suspect, the baby is stillborn.  

During the surgery we continue to give more magnesium and clonidine to lower her blood pressure.  We find another peripheral IV (much easier while she is not having seizures).  She wakes up and we remove the endotracheal tube.  Now after most C sections the women return immediately to maternity where they are checked on by a nurse once in the morning and once at night.  I suspected she would not survive without more intensive monitoring.  So, we brought her to our “recovery room” right next to the OR, so that we (Joseph and I) could continue to watch her vital signs and continue to give her magnesium for the next 24 hours.  Now that we are post-op, I finally look at her pre-op labs.  She has both renal failure and liver failure.  Her urine catheter is putting out what looks like mostly blood.  And there are still a line-up of scheduled surgeries to get through, including our next patient a 6 month old with cleft lip who has been waiting for me to arrive so he could have this done.  

Joseph goes to maternity and finds a nursing student who can sit with the patient.  I take a blank piece of paper and make a graph where she can chart vital signs and urine output every hour.  I don’t have the experience to know what this woman’s chances of surviving at this point are, but I suspect they are low.  I pray for her.  

Throughout the day, by God’s grace, her blood pressure remained stable.  She had one more seizure a couple hours after the C section which we treated successfully with more magnesium and valium.  

This morning I found her wide awake. The family tells me she had no seizures overnight.  Her blood pressure is normal.  Her urine now looks like urine. The nursing student had stayed with her all night and completed my vital sign chart, filling in every hour except 3 AM.  I am shocked with delight.  I now believe that this woman is actually going to survive.  

This case stretched me.  This is not the only case that stretched me yesterday, but this is the one that stretched me the most.  I am grateful for the intensive and compassionate care that was given to this woman, especially by Joseph and this nursing student.  I have heard health care professionals in the US say they could not come and work in a place like Burundi because they are not “good enough”.  Many of them are much better than me.  They are smarter than me, more skilled at performing procedures, and better looking than me.  All that you really need to come and work in a place like this is the willingness to be uncomfortable and the willingness to be stretched.