1am. 17/1/2021
I had just finished repairing the bleeding from the left chest of a young man stabbed in the chest by herdsmen who had made an attempt to kidnap him and his colleague, a lady, from their shop earlier on. I was far spent.
The relief that greeted me could be compared to quenching a taste with a chilled bottle of coke.
I quickly made for my quarters, had a warm shower and picked my phone (a drudgery routine) to reply messages and update our pages. I slept off later.
5.08pm. 17/1/2021
I felt as though I was being pulled by the shirt from this beautiful world I was in to a reality I obviously didn't wish for at the moment. The phone ringtone was holding me by the shirt in my dreams and pulling me to its reality. When I opened my eyes, it felt like fine peppery stones in them. I had to grovel a while to find the direction from where the tone emanated. I found the damn thing! "Hello Emma". I groaned. Sensing the discomfort in my tone, he replied, "Sir they have just brought in a PPH(postpartum hemorrhage)", he said anyway. "What's her vitals?" I shruggingly asked. "BP 100/60, PR 130, rr 40, temp 35", he recited. Start NS 1L fast. I am coming.
I wasn't still fully awake then. It was dark. I put on my phone's light, the rays broke through the darkness easily. I said, "that's the level, darkness. Light fucks you from behind any day any time" in my mind's voice. I sat up, delayed to gain orientation, grabbed my joggers and a t-shirt. "Nahh, I thought, let's grab a scrub instead. We could end up playing with blood. " I picked the scrub I had earlier worn, jumped off and grabbed the headlight and darted out.
I worked briskly. In the hospital the place was a sight of chaos. I slipped through this unnoticed to the nursing station. "Emma where is the patient?" I asked under my breath as though Emma was the one who caused the woman to bleed. "sir she is in the A&E". He replied. I walked there and met the woman and asked what the problem was. Her husband was distraught. A certain lady was cuddling a baby wrapped up in a blanket next to the bed of the patient. She took over the question from the man. "She is bleeding. She had delivered around 1am and didn't stop bleeding since then", she recounted. I urged her on while examining the woman. She was paper white. A phrase we use in medicine when a patient has lost a lot of blood. I ordered she be taken to the ante theatre for proper examination. There, I shouted for the lab tech to run some investigations. Ordered the relatives to help out by calling for donors so they could donate some units. "We would need 4 units,'' I screamed." Saline!, let's go! Get me suture. Chromic 1. I need surgical gloves". Within a short time my hands were working. The uterus, abdominally, was well contracted. On vaginal examination, the cervix was open and the blood kept gushing out like an opened tap. I used the Sims to examine. She was struggling. Gave some pain killers, nahhh those didn't work.
I sedated her. I needed to do an EUA. Checked the cervix, it wasn't torn to warrant this bleeding. Went into the womb and evacuated lots of blood clots and some retain products. Bleeding still didn't stop. Commenced oxytocics in fluid while applying fundal massage. The uterus was already contracted. Well, we still had to massage, more contraction will kill us now, will it? Passed misoprostol, high dose. Sutured the little cuts around the vagina. For a minute everything was calm.
Cleaned her up and made her comfy. Pcv came back to be 15%, bedside clotting time was 3min. Blood came while I was at it. One was running. The other was waiting in the queue. She was stabilizing. Gave some more instructions as I left to document. It was 7am already. 7.30am. The nurse sent one of the relatives to get me. I rushed there to discover my patient restless. "What's the vitals? BP?", I asked. "Unrecordable sir", she retorted. "Pulse?", I returned. "Unrecordable sir?!", she riposted. "What?!", I barked. She was not bleeding?! I checked for the peripherals, nothing. I immediately picked her from the couch and dropped her on the ground. YES, bare floor. She was gasping now, eyes rolling upwards. Foamy mouth and tongue stuffing the mouth. She gasped and drew air in with one of the most shrilling sound I have ever heard of a dying person.
You see, in 2016 I had flown to PH to acquire the CPR and ACLS skill as I had earlier searched for a training center around the north then and didn't find any. This was towards the end of the year. Good enough Dr. Victor Ofoegbu of Shield clinic, had made an advertorial in that regard. I am a bona-fide trained provider, though my license has expired. It's a 2 year thing.
We switched to emergency mode. Compressions while oxygen at high dose went in via a concentrator. Saline on one hand, and another line gave blood. We continued for another 30min before life was restored back to her by God's mercies. She was getting stable. We were getting calm. I ordered for a catheter to be passed. Started monitoring urine while all fluid kept going. "Blood!" A relative called out. I look in the direction she pointed at and lo and behold, she was bleeding again per vagina! The blood drew a thick map as it left its source. A blanket of gloom fell upon me. "Wasn't it this place I just repaired and cleaned?" I asked myself soberly. Obviously after I had earlier cleaned her uterus and repaired the cervix, she had lost almost all her blood and there was very little to drain again. This was why she went into shock and almost died. The magic of CPR and resuscitation fluid had normalized her system and blood once more could flow and bleed consequently. I asked that she be brought to the theatre. I thought of other causes of primary PPH. Could it be a ruptured uterus? This one would come with a flabby uterus. Or could there have been a little tear on the uterus? How about bleeding diathesis? In severe bleeding this can occur as a new cause. But then, Bedside clotting time was normal. My mind was racing just as her life was too. I called the husband to explain the new problem. "God has helped us to bring your wife back from the dead, however, we have a new problem. She is still bleeding. The more we gave blood the more we lost it.", I bluntly posited. "I may have to open her up to check the uterus from inside. If she had lacerated within, we may be able to repair and stop the bleeding. This is our current line of thought. But there was another problem. She had been pumped with oxytocin where she came from.", I continued. "Here we had given her 30iu and misoprostol. There is the risk of uterine atony that will lead to more loss of blood. I am not skilled in total hysterectomy yet. I would be stuck if I encountered it.", I confessed.
He appeared stunned.
I gave options. 1. I can risk all and go in to inspect the uterus for tears and hopefully repair. 2. If I am met with atony, I wouldn't be able to do anything than to cover up and continue hoping she would contract, I am not promising you that she will survive. 3. Refer you right now, if you have the wherewithal, to JUTH where the best decision can be taken. The young man thought deep. He probably thought about his children without their mother. 4 of them, this last one came after she had had an ectopic 3years ago. At this point, she had had 3 units of whole blood. 4L of saline. He gave the go. I declined. I bidded him to take the third. She was still on oxygen, spo2 98%, pr 120bpm, BP 120/80mmhg. I thought she could make the 2-3hrs journey to Juth. He agreed, made arrangements while I drafted a small referral letter. I called my colleague Victor and Obikili in Juth to help with the process. They were gracious enough to put machinery in motion and get the team on call to be on standby. They left after a brief clearing of logistics. The main reason I am bringing this long read and itemizing the steps taken is to lay bare to the public the need for a doctor in every community. These are decisions only a doctor can make and take. At every point of her management, crucial life changing decisions were made. These would have either killed or kept her alive. In this case, it did keep her alive. A good doctor knows how to operate. A better doctor knows when to operate and the best doctor knows his boundary and when NOT to operate. The rural doctor initiative will continue to do its best as long as it can and as long as it is caught up in the rural areas to provide solutions to the dearth of health personnel, especially doctors, in the rural areas. This is because EVERYONE DESERVES GOOD HEALTH. Ps: 4.33pm. Called JUTH and she is stable but still pale. I am told they arrived safely and the senior doctor received her and examined her. She is not bleeding as I write this. She will be transfused again and monitored. I can't thank my colleague, Dr. Chinedu Obikili, consultant O&G, enough, who wasn't on duty but had to rush in to check on things for himself and kept me in the loop. God bless you all for keeping a date with us.
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