Spoke too soon....

The last post I did was about the successes that we had in the OB ward.  I’m sad to say, I spoke too soon.  One of the success stories I mentioned, the woman who’s baby was breech and had a c-section, died yesterday.

She was discharged.  She’d stayed her 7 days and was ready to go home.  But the bill wasn’t paid in full yet.  Her husband came to visit her almost daily, always promising to come with the money and always drunk.  On the patient’s last admission he threatened to beat one of the nurses because he was upset about the bill.  He is a policeman.  Yup.

So she was ready to go.  She had been having vague complaints throughout her stay.  Every day it was something different.  Her head hurt. Her back hurt, etc.  She spent a lot of time in bed and we had to keep encouraging her to walk.  Those of us in health care have had these kinds of patients before.  The best thing for them is to get out of the hospital, get back into their routine and they start feeling better. They forget to be sick. 

Such was this patient.  Needless to say, when we were doing rounds on this patient on her 3^rd or 4^th day after being officially discharged, I wasn’t overly impressed when she said, “I torment, I torment.”  What does that mean?  “I just don’t feel well.”  Well, we all said.  You need to get home, get back to your routine, etc.  Your blood pressure is fine, your incision looks good.  You’re on the mend. 

About an hour after this conversation, she said she was feeling cold so we took her temp.  102.6.  Huh. That’s weird.  Something really is going on.  I called the doc and we ordered some labs.  While the labs were cooking, she started becoming delirious, talking but not making any sense.  The family also said that she wasn’t moving her right hand very much. 

While we were waiting for the labs, we called another doc to come look at her and see if this was a complication from her surgery.  I’d listened to the abdomen and didn’t hear a whole lot in there, so it was possible.  The doc came, looked her over but decided that this wasn’t a surgical problem.  Darnit. Back to square one.

The labs came back and she was malaria positive.  Upon admission, she’d been negative but had been given the treatment anyway (we can only test for one strain of malaria so if they complain of symptoms we often treat even if the test is negative).  Ok, now it was starting to come into focus.  Cerebral malaria.  I’ve never really been with someone it came on so while it seemed pretty fast to me…maybe that’s what happens?

Now our dilemma.  We use quinine as our injectable anti-malarial for adults when patients aren’t conscious.  It’s not the best medicine because the malaria in this area has developed a resistance to it. It also has some pretty nasty side effects.  But it didn’t matter because we don’t have any.  We have recently discovered injectable artesunate.  This is the drug we use as first-line treatment for malaria.  Unfortunately our supply is limited so we’ve been using the artesunate in the kids, the quinine in adults.  But we don’t have any quinine. We have 30 vials of artesunate.  Kids, depending on their weight will use 1-2 vials. She would need 4 vials for every dose.  It would burn up our supply pretty quickly. 

We stood there…two doctors, three nurses, trying to figure out what to do…what decision to make.  We have plenty of oral anti-malarials.  Can we give that rectally?  Will it still work as well?  We have no idea.  No study to help us decide.  What if we gave a lower dose, didn’t use as much?  But then what’s the point if it’s not a therapeutic dosage?  Does she really need the injectable artesunate?  Her family said she seemed to be getting a little better, moving her right hand now.  Could we get away with saving it for the kids?  Finally one of the other nurses suggested putting in an NG tube (tube going through her nose into her stomach) and giving it orally.  Perfect.  The oral anti-malarial we have works really well…and this way she doesn’t have to be awake to take it.  Seemed like a good solution.  I had high hopes she’d turn around.

When I came in the next morning and asked the night nurse how the night had been, she told me it was very rough because the woman was “tormenting” all night.  She hadn’t come out of it.  When the doc came by for rounds she listened to her lungs and said she was full of fluid.  They were now suspecting that she threw a pulmonary embolus (little blood clot into the lung) and this put her into pulmonary edema.  We threw a whole slew of medicines at her…..although it was frustrating because we just don’t have the testing capabilities or monitoring capabilities to do everything we would in the states.  We continued on like this for the day.  When the doctor came by in the afternoon she was hopeful that if we just gave this lady one more day, she would probably turn around.

Over the next 2 days there was no improvement.  This woman lived nearby and was well liked so the family and friends started coming by.  The crying began.  She has three children.  Two girls, age 10 and 6, and this new little baby boy.  The older girl began to see that her mama wasn’t getting better and became hysterical.  Some other family members took her home.

Yesterday she started seizing.  The family had once again begun complaining that she wasn’t moving her right hand, so we thought she must have had a stroke. Again, no way to confirm.  We got the seizures under control but now her oxygen saturation was dropping. We put her on oxygen.  We tried to suction her lungs, but there was nothing to come out. 

The ward was full of people! The rumors had started that she’d died and the nursing assistant working with me was fielding the calls to find out if it was true.  Her family came and asked me if they could take her.  They wanted to take her to her home town about 6 hours away.  This town is the center of all things “magical” “occultic” whatever you want to call it.  They said that her sickness wasn’t a hospital sickness and that her twin brother had taken something from her that they needed to go to this town to get back. 

I didn’t see any reason to keep her.  She began doing the “guppy breathing” that people often do at the end of their life, and I knew there wasn’t anything else we could do for her.  It was heartbreaking to see her two daughters sitting by her bedside.  The older one knew that something was going on, but the little six year old had no idea that her life was about to change forever. 

I couldn’t do anything to stop this woman from dying.  For some reason, her little daughter just got to me. I wondered if she would remember her mom. I wondered if she would remember the week and a half that she spent in the hospital, only to leave with a new brother and no mother.  I wondered who she would live with.  What was her life going to be like?  I mentioned above that she and Kadiatu had become quite good little friends.  They often played with Kadi’s “baby” (a black baby doll that was sent over on the container).  People freak out over this doll because it’s pretty life-like. I’ve had tons of people stop to see if it was real, touch it, etc.   And I had another one.  The dolls came as a set of twins. I’d given the first one to Kadi on her first night with me but the other one was sitting in my closet. I’d been saving it for….something.  I ran up to the house to get it and had Kadi give it to this little girl.  She was so excited.  I felt like crap.  A baby doll?  Really? It was such a small thing to give when I knew what this girl was about to lose.  I knew, but she had no idea what was coming. 

I left that afternoon and she was still alive. I found out the next day that they had taken her that evening and she died three hours after leaving the hospital.  Leaving three beautiful children behind.

I wanted to remember the feeling I had, remember her, so I snapped she and Kadi with their babies.

 The faces are real. It is so common here to meet people who have lost their mother, their father or both parents.  While I always feel bad, I generally meet these people as adults and the wounds have had time to heal, at least a little bit.  This was the first time I watched it happen.  It sucked.