"The measure of any society is how it treats its women and girls" - Michelle Obama
Today I performed my first perimortem cesarean section.
But we'll get back to that in a bit.
In the past few weeks, the greatest challenge I have faced in the hospital is not as much the lack of resources, but rather the complete apathy to intervene in critical and lifesaving moments such as postpartum hemorrhage and pre-eclampsia/eclampsia.
After the last physician educator post, the weekly maternal mortality review revealed that the physician on duty treated a patient for postpartum hemorrhage with blood, pitocin, and misoprostol, then walked away. No uterine balloon tamponade, no B-Lynch suture, no attempt at a hysterectomy. After bringing up these comments in the audit, I discovered that the consultant (attending) physicians at the meeting had read about these life saving measures, however had never themselves performed them. Another consultant physician later revealed that there are two Bakri balloons on the Labor unit, available for use. This was an incredible find.
A few weeks later a patient on the ward has massive secondary postpartum hemorrhage, and my students and I are able to stop the bleeding with the newly found Bakri balloon. She stabilizes and we resuscitate with blood transfusions. However, a medical student checking up on patients before heading home finds her again unstable due to profound hemorrhage while lying in her corner bed, no medical staff in sight. The student finds me in the main operating theatre assisting another surgeon to tell me the patient wasn't doing well, heart rate 160s and pulse oximeter showing 85%. I gave him instructions to get the medical officer, get blood, and get the patient to the theatre where I would quickly join. The response was that the student had already tried to get the medical officer, however was told that the patient was not his problem and that she was one of Dr. Sarah's patients.
With this I leave the theatre, and on arrival to the ward note two liters of blood that the patient has lost, the patient in shock, and neither the medical officer nor nurse on duty are anywhere near the bedside. The nurse is going through the all of the patients' charts, pretending that nothing is happening. The medical officer is in the examination/evacuation room, and when I ask for help the response is that he is too busy. I sternly tell him that this patient will die without his assistance in resuscitating and moving to the theatre. He again is too busy to help. I let him know that the division director and esteemed professor will hear about his refusal to help, with the next excuse left trailing behind me.
The medical students are advocating for their patient, extremely active in mobilizing the patient for theatre, giving normal saline, and getting blood.
At the blood bank, there is no one in sight. The husband is waiting for someone to return to hand him a unit of blood for his wife. When he does arrive with the blood, we call for another to attempt resuscitation given her massive blood loss, however the husband is refused a second unit as giving more than one unit at any one time is considered a waste of resources. Too true most of the time, except in cases of massive hemorrhage. It is not until I write that it is needed STAT for a postpartum hemorrhage that they release only a second unit.
In the theatre, the two anesthetic officers (training US equivalent of associates degree) are finishing cases and refuse to help. They have stayed past their required time and are ready to go home. After making phone calls to a consultant anesthetist at home, they are able to convince one officer to stay. While awaiting the operating room to be cleaned and the instruments sterilized (no other instruments are available at this time), a thunderstorm rages outside and the electricity goes out. Only my headlamp to operate by and no instruments until the electricity finally returns. The Busitema University FHS students are again active at bedside, placing lines and trying to get the blood running faster, moving the patient to the table and preparing for surgery.
At this point performing the hysterectomy becomes the easy part. A wonderful consultant stayed behind to be my assistant. One respite. Given her hemorrhage and shock, the internal organs are nearly white and devoid of color. The uterus is quickly out, and hemostasis ensured despite warning signs of impending DIC.
Throughout the procedure I am watching the blood drip, rather than pour, into this patient in shock. I am constantly watching and asking the anesthetic officer to ensure the blood runs more quickly. The blood continues to drip until the anesthetic assistant, a smart young man who was previously a cleaner until being promoted to assisting the anesthetic officers when he showed interest and aptitude, began using the pressure bag to infuse more rapidly. Two units of blood in for a cool 2+ liter blood loss. With vital signs of 140 and oxygen saturation of 90%, she is looking more "stable" than when she first entered the theatre. As soon as the surgery is finished and the patient extubated, the anesthetic officer has left. We are running the third unit of blood as quickly as we can when the patient heads back to the ward, where there is one nurse for 20+ patients. There is no recovery room. There is no ICU. There is no ventilator to continue respirations in a patient still unstable. 10 minutes after arrival to the ward, her heart can no longer keep up and she succumbs to shock and dies.
The next morning I wake up sobbing, destroyed by the fact that so many providers could say no in the face of helping a patient when death could be prevented. A phone call to Dr. Maureen Ries with SEED is a welcome sounding board. Despite the inability to change those already calloused, I have the opportunity to lead as an example to my students, to inspire them to be a physician that does not turn away from their patients.
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| Busitema students learning to make a condom-catheter uterine balloon tamponade |
Flash forward to today. The students are supposed to have a learning tutorial on pre-eclampsia, where we present a patient, discuss learning objectives, then students go home to read and present their findings at the report-back session.
When we arrive on the ward it is obvious there is a patient not doing well. She was 38 weeks pregnant and had arrived a few hours earlier after an eclamptic seizure, Glasgow Coma Score of 8. She is breathing heavily and rapidly, BP 181/115 (though on the right arm that she is leaning on in the "recovery position), pulse 173. The pulse oximeter is having a hard time reading the pulse, let alone the oxygen saturation. Within minutes at the bedside, she goes into cardiac arrest. We immediately call for help, start CPR and bag/mask ventilation, and I call for a scalpel. I receive the scalpel blade, no handle. It is me with 13 medical students and 20+ nursing and clinical officer students. In my office clothes I perform an emergent cesarean. As soon as the infant is out and somehow alive, I return to directing the CPR that the students had continued. Despite continuous CPR, bag/mask ventilation, and epinephrine (drawn up and given by one of my very own students), after 30 minutes we call time of death. The only provider to arrive for help was my counterpart, who helped to stitch up the uterus and skin while I talked with the family and gave them the bad news. No anesthesia arrived to assist. The one nurse had left to tend to the other 10 patients under her care.
What do you do when your students feel discouraged and upset after watching a patient die?
Talk to them. Tell them that no matter how you might look at that moment on the outside, that you are not okay. You are not okay to stand back and watch people die. That it bothers you.
And then listen to what they have to say. During our conversation this afternoon they each echoed many of my own frustrations that I have had over the past several weeks. They expressed anger and frustration that people could walk away and not care, relating stories from both patients with postpartum hemorrhage and eclampsia. They recognized several gaps in the system, with impossible nursing and physician to patient ratios (a ratio of 1:20 upwards to 1:55 nurses to patients is a fact of life), of physicians being absent from work on the ward or even from their own Busitema University so they can make larger pay at a private clinic in town or in Kampala, and providers taking out their exhaustion on the patients by telling them to go away, chastising them, or generally treating them badly. They expressed frustration when a woman who is HIV positive delivers a baby and there are no gloves available for providers to protect themselves in assistance, or when other needed equipment and medications simply don't exist on the unit.
Then we talked about how that can change. I let them know that by being bothered by the situations, they showed that they cared, and to hold on to that and use it to move them forward to make change. And then we talked about how things can be different. I let them know that seeing a provider say no or simply walk away when a patient is in need is one of the most difficult challenges and frustrations I have faced so far. That for several years they may not be able to make a difference amongst those that have already formed those habits. But that they can be the physician that does not walk away. That they are the ones who will stay and help. That they will be the ones to care for patients and not demean them. To treat every patient as if it was their own family member, mother, sister, or wife (thanks for those exact words of inspiration as an intern, Dr. Major!).
And one day, when they themselves are members of parliament, directors of an obstetrics and gynecology unit, or working as doctors taking care of their patients, to continue to be that physician who addresses issues and cares for their staff and patients, and becomes an inspiration for other providers.
Then we watched a youtube video of Michelle Obama's empowering speech. To explain, ward rounds often consist of 30+ participants, including medical students, clinical officer students, nursing students, as well as the doctors and nurses themselves. Especially for the soft spoken women, I encourage them to speak up. On Friday I encouraged them to use their Hillary Clinton voice. Today, I encouraged them to use their Michelle Obama voice to present their patient. This sparked an interest in the amazing speech given by the first lady.
For men, women, and the upcoming generation, her words were an inspiration for all. No matter the issue, be it women's rights, racial equality, or even the right to health care, her words encourage us to not ignore the issue, but rather role up our sleeves, exemplify and fight for the change we want to see in the world. First Lady Michelle Obama, thank you for rocking the world.
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| Students watching Michelle Obama's speech |
"We teach our kids the value of being a team player... We also teach our kids that you don't take shortcuts in life, and you strive for meaningful success in whatever job you do... And finally, we teach our kids that when you hit challenges in life, you don't give up, you stick with it."
The fourth year medical students at Busitema University Faculty of Health Science have made me so proud. They are striving to learn, taking care of their patients oftentimes alone on a ward too busy and with too little staff, following up on lab results, and doing anything they can to help. They care for their patients, and want others to care, too.
October 22, 2016 Updates:
The infant delivered via perimortem cesarean did well, and went home with family on Wednesday.
Yesterday marked the end of the rotation for this group of 13 students. Before sitting for tests, many students approached to say thank you for the teaching, and let me know that they will miss being on the OB/GYN rotation. This morning I received an amazing heartfelt message. "Hello Dr. On behalf of the team that has been in OBS & GYNE, allow me to extend my sincere gratefulness and heartfelt appreciation towards your selfless dedication and love you have shown us in the course of the rotation. Indeed you became like a mother and a friend to me. Words might not describe it all. Thanks."
Wishing this group the best of luck on their next rotation in internal medicine, and looking forward to meeting and teaching the next group of students on their OB/GYN clerkship!
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