I have been home from South Sudan for nearly 6 weeks. It has taken me all this time to write about my end of mission (EOM) primarily because it has taken all this time just to process those last hours. I was already suffering from pretty severe burnout and vicarious trauma but the last hours really upped it to a whole different level.
I really wanted a simple EOM day. I would wake up in the morning, have my coffee and then just spend the morning bidding farewell to staff, get in the truck around noon and go to the airstrip. I was still on call (by choice, never wanting to miss a thing!) and as luck would have it, at 3am the national staff midwife called me on the radio. He said there was a patient who had come in complete and birthed twins immediately upon arrival very quickly one right after the other. She then hemorrhaged but now it was controlled and they were just informing me, she was stable.
I was not asked to come to maternity but knowing I should have been called as soon as the patient arrived, regardless of how quickly she was birthing, and then should also have been called when she started bleeding, I felt a need to go down there and just make sure all was indeed well. This decision would prove very critical later.
When I arrived in maternity about 5 minutes later, I found the 2 staff midwives standing at the patients bedside. There was oxytocin in an IV running and the patient was resting on the delivery table. They again said she was stable. I checked her fundus, it was firm and there was no active bleeding at that time. I looked at the blood in the bucket and estimated there was about 2 liters. This was a very significant amount of blood. I asked what her vital signs were. Not only had they not taken them, they didn’t have either a BP cuff or pulse ox in the room! I checked the conjunctiva and saw it was white and asked what her hemoglobin level was – they had not taken it. At this point they jumped into action and took her vitals and tested her hemoglobin. She was found to be in compensated shocked based on her vitals – BP 70/40, pulse 142 and a hemoglobin of 3. She needed a transfusion immediately.
I asked the midwives to get the family to go to the lab so they could be screened for blood donation. This is the only way people can get transfusions, by having family donate. We have a bank but there are usually only a few units and we still need to replace it.
While that was happening, I asked them to put an IV line in her other arm as we would need a second one. I asked if she had been given misoprostol (a medication we use to help postpartum hemorrhage (PPH) and to prevent it as well. They had not so I asked them to do that. In the meantime, I was checking her fundus again to make sure it was staying contracted and several clots came out and then she started to bleed again. It was a fairly substantial amount. I kept massaging her fundus while I had the staff taking vitals and getting the oxygen tank. This was not going well. It went through my mind that I was leaving the project in about 8 hours and this patient was going to die.
I called the expat midwife that was to replace me, while I controlled the bleeding, we needed more hands. Once she arrived, we basically took over the care of the patient completely and the staff got blood from the lab and we hung it. The patient was going to need at least 3 liters and 2 immediately but we needed to get the donor blood and that would take time, so we started with one liter and hoped it would make a small dent. Shortly thereafter, she started bleeding again, it was terrifying. I got no distal pulses and she started gasping for air. Again, for the second time, I thought she was going to die. I called the MD on call and did bimanual compression to help stop the bleeding. I asked the staff to give 1 gram of tranexamic acid (a drug used to stop bleeding in traumas). The MD arrived and I briefed her. There was nothing I expected her to do other that what we were already doing and she was not an OB but because I thought the patient might die, I wanted as many expats there as was reasonable. I did not need to carry this alone and I didn’t want to be questioned later as to why I did not call for support.
The MD and I agree if the patient started bleeding a third time, we would call the surgeon and take her to OT, her uterus would need to come out. We would do absolutely everything we could to avoid this scenario. I had measured the blood we had in the bucket and it was 3 liters.
Eventually, about 3 hours into the whole ordeal and once the second unit of blood had been given, the patient stabilized. Her heart rate was a more reasonable 110bpm and her blood pressure had come up a bit as well. Her respirations were normal.
By 6am I was able to go back to my tukul and have coffee and pack the very last of my things. I was ready to leave on every possible level. I still needed to to carry my radio because it was how the radio room would reach me to let me know when the truck would take me to the airstrip. As luck would have it, I was called by the in-patient department (IPD). They had a 32 week pregnant patient admitted for GI bleeding and now she was bleeding vaginally and they wanted me to come and assess her. I called the national staff midwife and asked him to meet me in IPD with the ultrasound. I arrived at the patients bedside and while I waited for the ultrasound to arrive, I checked the patients labs. I noticed her hemoglobin was 5 and her platelets were 7! These labs were from the previous afternoon! I asked the nurse if anyone had pointed out these abnormal (life-threatening!) labs to the MD or anyone! They said they didn’t know – this was not my staff so I was unsure how this department ran. I called the MD on the radio and asked him to come.
In the meantime, I did the ultrasound and saw that all was well with the baby. There was no abruption of the placenta or any other reason for bleeding that I could see. I performed a vaginal exam and her cervix was closed and felt normal for 32 weeks gestation. Her vaginal bleeding was minimal but given the circumstances, we still needed to find out why she had bloody diarrhea, bloody nose and now vaginal bleeding. Hemotology is not my area of expertise and I was relying on the MD to figure that part out while I came up with a treatment plan for the patient from the obstetrical end in the last couple of hours I had before departure.
After looking over the labs and looking at the big picture, it was agreed that the patient probably had disseminated intravascular coagulation (DIC). DIC is a rare and serious condition that disrupts blood flow. It is a blood clotting disorder that can turn into uncontrollable bleeding. First, DIC creates many small blood clots that keeps blood from traveling through the body. When this happens, the blood is not able to bring oxygen and nutrients to the brain, heart and other organs. Then, having used up the proteins and platelets that make the blood clot, DIC causes uncontrollable internal and/or external bleeding. It is not exclusive to pregnancy, anyone can get DIC and although not common in pregnancy, it is a leading cause of maternal mortality.
DIC is usually diagnosed based on blood tests – PT, PTT, FDP – none of which we had but we did have her hemoglobin and hematocrit as well as her platelet count and they were all life-threateningly low. DIC was the only diagnosis that made sense. Its presence in a pregnant patient invariably means there is some other underlying illness. In the case of this patient, it was probably sepsis.
The patient develop a fever later and respiratory distress. The treatment and management for DIC depends on the cause and in low-resource settings, it differs somewhat from what would be done in a developed country where blood tests, medications and blood products were in full supply. She was given a transfusion, antibiotics and she was on oxygen. The last thing I told the MD was that he needed to have the IPD staff monitor the patient closely for contractions. They were not used to doing this since they are not usually caring for pregnant patients. I told him in all likelihood the condition of the patient would set off labor and it would be a good plan to give dexamethasone to help the baby’s lungs mature. Also, the staff needed to call maternity as soon as they saw any signs of labor. I left the project that day not knowing if she would live or die.
I spent 2 days in Juba debriefing. While there, I stayed in touch with one of the MDs to get periodic updates on the patient. She was still alive. As I had predicted, she gave birth in the middle of night the day I left. The MD was surprised. Not sure why since I told him this was going to happen but it was no longer my concern. In the days that followed, she would have a total of 6 blood transfusion before they decided they would give no more since they could not get her hemoglobin above 6. They would just provide palliative care.
After nearly a week at home, it was still difficult to let go of the last 8 hours of my assignment. I kept replaying all of the things that happened both with the hemorrhage and the DIC. Having 2 patients that I thought would die on the very last day of mission, was very traumatic. I had never had the experience of coming home from a mission and not being able to just detach. Because I felt I needed to know if the DIC patient survived or not, I kept in touch with the MD who was most closely managing her case. She kept me updated. It was through her that I learned they had put her in palliative care. Her baby was fine; small but fine.
About 10 days after leaving the project, I received a message that the DIC patient had a platelet count of over 200! She was doing much better and she would survive. Against all odds, in this low-resource setting with every stacked against her, this woman survived. She would not be a maternal mortality statistic. The relief flooded through me. Even though it had nothing to do with me anymore, I still cared about the outcome, how could I not?
After that message, after learning this patient was going to live, I was able let go of the mission, finally. I was able sleep better and to be home and be present for myself. Although I do carry a certain amount all the time, I had never had the experience of bringing so much home with me and it was exhausting. I am relieved to be on the other side.