MAR-A-4
TRAGEDY AT MIDNIGHT:
THE EXPECTED OUTCOME OF THE INFARCTED GUT
AND THE LOSS OF A YOUNG MOTHER
A BRIGHT SATURDAY MORNING RUN PRECEDES ELIZABETH’S DEPARTURE WITH KENNEDYS TO LILONGWE,
BEARING A DISC OF MY “MESSAGES FROM MALAWI”
TO DATE, AS I CONTINUE WITH ROUNDS AND THEN “C-SECTION CITY”
Mar. 2, 2002
What do I say? Other than “we did the best we could”…without an ICU, a Swan Ganz catheter monitor, and pressor drips with a ventilator—none of which exist here, or anywhere near here. And, if we had them, or if we were to magically transport this patient by some form of time machine from here to the best equipped and staffed ICU in the First World with the same dead gut I had encountered on opening her at the first view in theatre yesterday, the outcome would have been the same, albeit with a conscience-soothing futile layout of an additional two-thirds of a million dollars.
I WILL CALL “ELIZABETH”, NOW AN UNFED ORPHAN
As it is now, the oxcart is coming to bear away the body of an 18-year-old mother for burial in her village about fourteen kilometers away, and we are scrambling to find some form of infant formula (Steri-Milk, Lactogen or powdered milk) in an environment where any from of bottle feeding is anathema. They have not adopted the imminently practical method of wet-nursing here, and despite a whole compound full of women with a baby attached to a nipple, the hungry three-week-old cute tiny girl is squawking as I am desperately searching around for some form of nutrient for a newborn. The NRU has soy, nsima, goats milk in a method for feeding children six times per day and adults three times per day to rescue them from the horrors of Kwashiorkor and marasmus—a starvation into apathy and stunted stature and retarded growth milestones and condemning them to a life of imbecility, with hardly trainable skill patterns—if they make the one in four cut in the survival to age five. But, in the front of the hospital there is a sign, which says in pictorial graphics “This is a no bottle formula zone.” Even the former PCV and present wife of the MK who built most of the houses occupied by the Wazunga along Mc Gill Avenue, Jodie McGill, must have a tube from a flask taped to her boobs in order to go around publicly breast feeding her small adopted orphan girl, since coming from the Granola set, she could never be so traitorous as to NOT breast feed her adopted orphan. Appearing in public with a bottle with a nipple on it would be akin to an endurance runner lighting up a chain of smokes at the finish line of an ultra marathon, and every effort and subterfuge must be enlisted to maintain the party line.
Even before I turned off the IV drips and stopped the blood transfusion and the Oxygen concentrator support of the non-breathing young woman with fixed and dilated pupils, I had gone over and had taken the baby from one of the in-laws who was holding her, and tried to find a way to get this child fed. She had gone over four hours from the last feeding, since as soon as we came out of the Theatre after closing the patient over a plicating bowel tube with dead gut and thrombosed veins in the mesentery for a futile hope for a second look to resect less than all the bowel a day later if she could be stabilized, I had attached the baby to a nipple of the unconscious mother. That did not work, but with difficulty, we had expressed a few milliliters of milk from the mother before she made no more. I even tired to see if the post-mortem feeding might be possible, but a cold lifeless breast produced nothing but pathos. We found no way to quiet the squalling hungry little baby with mouth gaping like a carp sucking bubbles from the surface of a stagnant pond. She was not concerned with the attentions we were all paying to other organs of her now dying mother, she had a unifocal concentration on a single urgency, necessary to her for life itself, as it was for me to get her mother to the Theatre—and within the same timeframe, about three hours max.
Elizabeth went looking for Steri-Milk somewhere in the compound, and we promised to buy Lactogen in a large container in the morning if we could keep the little girl going until then with whatever other fluid we could get into her. That was not easy, since we had to identify a surrogate mother to care for her and instruct her in the very foreign concept of bottle-feeding. We also struck out in finding any Lactogen in the “Trade Center.” The “La Leche League-equivalent” have done a god job here of MauMauing the Nestles—there is no infant formula or bottle-feeding to be had anywhere. Even Jodie Mc Gill with her “pseudobreast” is back in Mizima, several hours away by a vehicle that would cost 40,000 Kwachas to rent to get up there—which has otherwise dimmed the enthusiasm of John Sutter (who tired to look into this for the possibility that he and I could rent a vehicle for a Martyr’s Day long weekend excursion to the wilderness game park called Nikya (=”wilderness” in Tumbuka as “Hlane” meant the same in SuSwati).
Then I turned off the oxygen concnetrator and sat between the young woman identified as an “in-law” and an older woman I had thought was the Ngongo, but turns out to be the aunt. When I sat with my hand on their shoulders, they got the picture very clearly, which had only been feared before. I had taken a picture of the little orphan in the making in the arms of the aunt before we pronounced the mother, and they then set up the ululating cries and shrieks of grief as the idea sank in that here they were, away from their village, and they now had not only a small dependent with no resources even to feed her at this very preemptory moment, but now also had to carry back a body prepared for a funeral the very next day. There are losses multiplying on top of losses here that were being realized as I sat with them in the finality of death in youth. The crying lit up the night just before 11:00 PM, as we had all returned for a very agreeable dinner party hosted by Kathryn, the very competent Matron who had put on such a feast for us. Between rain showers, and with the idea of putting together a cover note and copying the disc of the chapters of this story so far produced to send along with Elizabeth to be emailed from Lilongwe at the overnight stop at the Rodehavers where she will be with the Kennedys tomorrow before they all leave for Heathrow the following day, I had wandered over to see how our young mother was doing. All of us appeared in the ward between the rain showers by night, and we all saw the hopeless finality of the dying woman. She had rallied right after the operation, even though the awful smell of necrotic gut had permeated right through the wall of the distended bowel. She made 300 cc of urine, and responded to eight liters of fluid at first, but now it was all going into the third space of her abdomen now distending again after its earlier decompression from the untwisting and aspiration of the homemade placating Baker Tube. She was not breathing, and the blood pressure was not even palpable. A unit of blood was brought over from the laboratory—a rare commodity in this area--, as her Hemoglobin had been recorded as 15.2 g before the operation, but was probably doubled by her severe dehydration. Now, without appreciable blood loss, her Hbg was more like 6, so the transfusion was ordered. Now with the life support withdrawn, we should get that unit back into the refrigerator as soon as possible so this critically important unit would be useful for someone else. The lab was locked, and the only one with the specific key was the laboratory fellow (the one who had scored such a coups on the India Ink cryptococcal meningitis stain) had asked if he could go home and we had agreed he could. Now, the only way we could get in to the lab was to see if the night watchman might have a master key, but we did not want to pursue him. As John Sutter and George went to the lab, they came to the locked door, and found no satisfactory way to break in to return something, even something so precious and perishable as a unit of whole blood. While they stood at the door, John pulled out his room key and shoved it into the lock. Hey Presto! The door opened as though he had a master key—and they figured there were probably only about a dozen lock and key combinations in all of Malawi! I may return here, then, with a great future as a cat burglar, but I have only limited potential as a nourisher of newborn infant orphans.
This, then, is the denouement of the story I had ended last chapter (Mar-A-2) by telling you to stay tuned, before I packaged it up with the cover letter (Mar-A-3) to be sent forward to you from Lilongwe by Elizabeth Yellen, on her return with the Kennedys to overnight at the Coordinators (the Rodehavers) and catch tomorrow’s BA flight to Heathrow. As inevitable as it was—apparent from the first opening of the abdomen and encountering the putrid black dead bowel, when Elizabeth, being asked by Betty Poehlman How bad is it?” responded from her freshman clinician perspective with the perfectly astute “Ten out of ten non-survivors”) I had to act in hope. A young patient, especially and eighteen year old mother, with a mewling 3-week-old, just alive enough to follow me with its eyes and demand that I consider its peremptory claims first, was the reason for doing as much as we could. It was, as Mister Tembo pointed out, necessary surgery, but it was not sufficient to save her life and secure her future and that of an infant for whom she is a life-support system. We must now move on to what else we can do, as the oxcart plods toward the mortuary, and the ambulance that carries Elizabeth and Kennedys to Lilongwe will be returning with he Lactogen they will find in the markets of the Capital.
I had teased Elizabeth initially, when she picked up the baby from the cot on which its mother was delivered to us, saying that if she did not do an adequate job, she would be returning home to start a residency “with child” and her name shall be Elizabeth. That will mean you are obligated not just for the infant feeding formula, but school fees and all the way through the day of the lobola, when the wedding will free you at last from this totalitarian role of new motherhood. This little “joke” has almost come to pass, although she objected to naming the orphan Elizabeth, and we may yet find out what the future holds for our survivor of the two that came to us in desperate straits.
As I had come back over to my room after the initial operation yesterday afternoon, I had sat outside my door to use what fading daylight there might be to type up the last chapter (for some reason, the light in my room does not work, so sitting outside gives me daylight for the last of the circadian rhythm, but the light of the laptop screen also draws the first of the night’s mosquitoes, as I am sitting just as far from the door as the extension cord allows, since I still have electricity in the wall outlet but no functioning light overhead. I should quit complaining about such trivial inconveniences, since I spent most of my time in Assa, diligently trying to get some little bit of energy into the Think Pad batteries, and if I had a choice between overhead light and the charged up laptop, I would take it as I have it now since I have completed the last series of chapters using my Petzel Head Light.
I heard a commotion on the same corner of the compound where I had seen something happen last Friday at the same time. I had wandered over somewhat late to check it out last week, since I had discovered the outdoor butchery on the Embangweni compound. Before the light had faded, I picked up the cameras and walked over to see a thick knot of people, haggling over price and options as a large ox was being butchered. It looked amazingly like my sessions in the swamps of Zala, when I would be disassembling a waterbuck I had shot. The hide was spread out on the grass to constitute the “sterile field” and the head was detached to stare back at the proceedings, as the viscera were first removed—which seemed to be the most highly coveted parts. There was a good deal of bidding and interest from a group of people I recognized from other settings in which I had just worked with them, but now they were out of uniform and in a combat shoppers competitive mode. The flash of the Nikon made them aware of my presence, as Mama Chima turned to see me and laugh after here serious engagement in a competitive bidding process, as the tripe, the mucosal lining of the stomach rumen, was being divided and hung on a small spring scale suspended from the tree which was the ox’s last hitching post.
I estimated the weight of the intact animal at about 700 kg, and when I asked, I was told “Oh, no—more like 100 kg.” When that did not seem right, I found out that they were quoting the price of the meat, at 100 Kwacha per kg. This would mean that the intact animal was worth 7,000 Kwacha, or $100 on the hoof. I watched as the indiscriminate butchery proceeded with a lot of hacking and hatchet work parceling out the less desirable parts, at least the parts I would consider rather “high on the (no hogs here) hind”—as, for example, the tenderloin or rib steaks which all became part of a bit of ragged flesh chopped to include some bone on the spring scale. I could have taken out the prior experience in my earlier life as a butcher/meat cutter in high school to precede the time spent in surgery to make some prime beef out of the rather amalgamated skeletal beef, but since that seemed to be of secondary importance to prize gut and offal, it would not have mattered a lot to them. As I have often said, the difference between surgery on people and meat-cutting beef, is that with the latter, you have to be so careful, given the price of beef. Turning the knife one way or another makes sirloin of hamburger out of the same muscle, with a very large differential in price. Not here. After the really precious guts are gone, the rest is just so much dead weight at 100 K per kg. It looked like a cape buffalo of my series chopped up and ready for smoking/drying over wet leaves—which, I found out later, is exactly what happens to much of what is bought here. In fact, having dinner at Geoffrey Malwa’s house that evening, we had, inter alia, the beef cubes of dried smoked beef from some prior cow slain on the same spot and processed not differently from my Assa Cape Buffalo skeletal beef. This is a very good preservation method in a place without refrigeration, and for most of the citizens gathered around the carcass, that would include this place in Malawi.
The whole cow was gone—head, hooves and guts included—by the time we went back to go for the dinner we had been invited to by Geoffrey Malwa, who is head of PHC and a leading figure around here. I knew this from another connection, since I operated on his wife. She never had a name, except for Mrs. Malwa, Malwa’s wife, and, as such, she got prime treatment, including a private room off the female ward, which she did not even occupy the pre-op night, choosing instead to go to her home in the “starved” (i. e. “NPO”) state as a pre-op after I had seen her in clinic. That led to some consternation on the part of Mister Tembo on morning report, since he had gone to see the patient in the morning of the operation and neither she nor her chart were anywhere evident, since she had not been “clerked” (pronounced, of course, in fine UK tradition “Clarked”) as a very private patient who might refuse her role as a teaching case for the staff. Just her luck that she ran into me. I had certainly told her all about the procedure and its complications and got her “informed consent” but that did not mean she is not in a “teaching hospital”—which is wherever I happen to be. I helped Dr. Ngere do his first thyroidectomy ever seen, and also showed how it should be done to Mister Tembo who does not ever remember such a “high risk “ elective procedure being done here, despite an abundance of goiters. The neck, Ishmael said, is a very scary place to be, so he watched attentively to see the steps of the rather instructive anatomic thyroid dissection. Her post-op status was rather benign, but, in contrast to the Mindanao patients I had just done who could not be found a few hours after their thryoidectomies because they were on their way back home, she took to her b ed and asked for pain medicine, stating she could not swallow food or liquid, even though she was in good voice. I believe she suffered a bit from status consciousness, as a VIP by marriage, and had to play the role. I pulled here drain the following morning and told her she could go home now, with a normal diet and activity and no dressing needed, with a subcuticular closure that would not have to be removed. All of this was re-stated later when we had heard that she was our hostess on Saturday evening when Malwa had invited us to dinner, with perhaps the second agenda that the entire medical staff would be available as a very public “house call” on the patient six days post-op. She looked fine when she was “brought out” later in the evening, although she did not eat with us, but is eating quite satisfactorily in private. She has received maximum benefit from an elective operation quite in addition to being relieved of a goiter.
THE KENNEDYS DEPART ON SCHEDULE WITH ELIZABETH,
WE MAKE ROUNDS ON THE WARDS AND FIND MERCY, OB NURSE ADMITTING TWO
PROBLEM PATIENTS—WHO, TOGETHER, DEFINE THE REST OF OUR CLINICAL ACTIVITY FOR
THIS WEEKEND “DAY OFF”
To return from the evening activities of our social schedule to the day-long clinical activities of our day off, we entered this three-day holiday weekend, which includes a Martyr’s Day celebration as a bank and hospital holiday Monday.
. I had begun the day with a good morning run, going the direction opposite the turn that would have me in a loop around the compound I had learned in the heavy rain three days previously. I came into real savannah bush with no farms, but had seen a lot of school age girls out early as the warm bright sun was rising, and they carried hoes into the field for a lot of stoop labor. “Come on over and help us!” one pair shouted to me as I shot a photo of them from the hip as the dawn sun illumined their labors.
We saw off Elizabeth and the Kennedy family on their return trip via Lilongwe. Elizabeth is carrying the disc of my journal through the events up to last night, with a cover note appended to be emailed. I gave the disc to her as we were both attending the death of the young woman last evening. As the ululation and wailing shrieks filled our ears, and the concerns for the unfed baby busied our nocturnal search for formula, I also gave her the names and phone numbers of my sister Milly and Virginia whom she may call to leave an answering service message upon her return to Washington pointing out the email and address connections at the Rodehavers for any messages I might need before departure. We got a final “GW Photo” of our group at the ambulance, loaded with the Kennedys’ four-year collection of “Africana” and sang them on their way.
And, now, to work. We made thorough rounds, beginning on the Male Ward. The patient whose discussion had included the differentiation of an obtunded sensorium and persistent hiccups after treatment of 1) cerebral malaria, 2) meningitis, leaving us with 3) the cerebritis of AIDS had refused the VCT of an HIV serology. But, then, he was non compos mentis, and could hardly have been said to have given informed consent to either performing or not doing the test. What does “Voluntary Counseling and Testing “ mean when a patient enters with the primary CNS manifestations of AIDS? We had a brief discussion before deciding that we should probably go ahead and test him anyway, not because we were interested in overriding his autonomy nor because we were curious about this status (although a testing refusal in someone who is mentally competent is probably based on a significant degree of positivity risk, also) but because we have run out of things to treat that would account for his mental status. If the test were truly HIV negative, then we would have to persist in looking for a reason for his continued failure and his annoying and unstoppable hiccups. He is rousable today, but still not capable of careful thought for the VCT. One of the agents that might help treat his hiccups, high dose chlorpromazine, might also render him into a “Zombioid “ status, so it is a difficult thing to treat, and we have elected to consider his hiccups as trivial while continuing to search for treatable problems we must fix.
We came to a new admission who has an anemia of unknown origin, and also has a fever. One source of anemia is the hemolysis of malaria and he was started on Fancidar as malaria treatment. But, he had had a similar course of treatment already two months ago, and it is unlikely he would have recurrent malaria and anemia from such a source, given some degree of partial immunity with each new malaria exposure. He was treated with a single dose of albendazole, as treatment for the presumptive diagnosis of hookworm, a reasonable source of his anemia. This disease has the unique distinction of afflicting more people with a morbid illness from its anemia world wide and still being relegated to an “orphan illness” since it kills very few people, just sapping their strength, productive energy and the ability of children to concentrate and learn. Since treatment occurs among people who are nearly sure to get re-infested, it is a somewhat futile Rx, which is why the Bill and Melinda Gates Foundation has funded the research and development of a hookworm vaccine in the laboratories around my seventh floor Ross Hall office of the “other department” in which I have an appointment—Microbiology and Tropical Medicine. I will be feeding back to Peter Hotez on my findings here and the possibility of opening a research affiliate here as an African counterpart to the similar sites I have proposed for Manali in Himachal India, CME at Nyankunde in the Congo, and his own sites in China.
Of the leading causes of anemia in the developed world from either blood loss or failure of production, what definitely falls off the list of our differential here is the leading cause in children—leukemia—or young men—ulcers—or old people—colon cancer, none of which make the map in this area. So, once again, to come to the Osler aphorism, “Ask not what kind of disease does this patient have, but ask what kind of patient has this disease.”
On that score, Humphrey has pain in both knees from our stretching them to make him “plantigrade” to get him up and mobile rather than bedridden as an invalid. He has not enjoyed this prospect, even though he had aspirations toward getting up and out, even if it meant waddling like a duck. He complains of a burning and series of swellings along his inner thighs, and I checked to see he has a virtual explosion of his K. S.—Kaposi’s Sarcoma. His grafts are doing well, but I fear the disease is gaining on him and by the time we get his superficial wounds closed, and our limited attempt at physical therapy to get him up and out, Humphrey may be too sick to leave, and may be terminal before long.
And, on that subject, I swung open the door to Stanley’s room—and it was empty. “Where is Stanley?” I asked. He had been afebrile since the operation and had even been up and out of bed since his thoracic drainage had been improved by our rib resection and decortications. He had one worrisome episode of what had sounded like an ulcer—the first evidence of any I have seen here—with epigastric pain and a single episode of vomiting up blood, but with cimetidine, that had resolved.
“Oh, he died this morning.”
That was it. No fanfare, no explanations. Just a very much expected event that took place today rather than a few days earlier, and no particular event that precipitated it. He did not have an abrupt GI hemorrhage, or a septic event, he was just getting weaker. He had been in good spirits since we had showed him enough attention to think that he was being attended for his incurable ailment, and was getting up and around, sitting up when last seen—and still sitting in that posture when seen later when it became evident that he had slipped away. RIP Stanley.
“Yea, though I walk through the
Valley of the Shadow of Death,” I was thinking. I have been in Malawi for ten
days in a 134 bed hospital averaging about sox births and two deaths each
night. This is a telling ratio, which
may be true for the nation as a whole, with the real danger coming more from
the imbalance in the greater number of births than the high number of deaths. I
began to think about all the deaths that have occurred and made an astounding
discovery—the young woman with the dead bowel was tragic, not only for her
youth, her maternity, and her three-week orphan, but because she was the only patient who has died during my working
here that has not had the known and HIV-serologically proven diagnosis of
AIDS. They are not just
seropositve and dying of something else, dying with and not because of
HIV. They are not just dying of something else while sero-positive, they are dying of AIDS. I am working in the center of the “Hot Zone.”
A young man came in with hepatitis. Our job was to keep him hydrated, fed, give him some vitamins and rest and let it run its course. This he could do at home, since there is no specific therapy for this disease, here, or elsewhere in the world. There is no Hep B vaccine given here as it often is used in other endemic areas like China and the Far East states such as Taiwan. There is 40% hepatitis seropositivity—so that a good reason for hand washing is that there are many infectious agents running through Malawi, and HIV is but one of these, and others may not be any more curable, either, although the mortality may not be as high with several of the others.
I saw the young man with the eyelid repair after the barbed wire avulsion injury. He is doing well and the lid looks like it will be a very good repair. That did not mean the patient was happy with the result, and in fact seemed quite sullen, perhaps do to the sociology of this injury and how it was sustained. The surgery would have been no different whatever the social circumstances that brought him in but the satisfaction rate seems to have been impaired.
We have discharged most all of our patients from the female ward. The dignified older woman with the African melanoma excision is home, having been carried out by her husband, both of whom were delighted with her result. The young bride who was returned has a healed looking leg on one side and a raw open wound on the opposite leg with an exposed Achilles tendon, we plan a split thickness skin graft for her, but the Martyr’s Day Holiday goofs up my Theatre List, so that she is postponed from Monday to Tuesday, my last full theatre day, being added after the prostatectomy on the fellow from the Male Ward with the ill-advised circumcision that caused necrosis of half his glans, but who could not void after his catheter was removed, revealing that he had had a primary BPH urinary tract obstruction to begin with.
The post-op hysterectomy (TAH & BSO) is doing well, on oral feedings, so we stopped the IV and encouraged her to walk around. Elizabeth’s last surgical case (ever?) is the D & C that was done last night after all the other activities had been resolved with our patient and her orphan. The post-partum hemorrhage was stopped by the D & C and she was discharged, almost on a par with US HMO hospitalization durations.
Now, here comes trouble. Mercy, the OB nurse who was our hostess for the “birthday party” for her absentee juvenile son Robert the night before last, has drawn the duty for the holiday weekend as Mama Chima is off duty, as I learned when I had met her at the cattle butchery in front of my Guest House room. As we made rounds on the post-op C-sections, one of whom had a superficial wound infection and the others were all doing well. I f I just check the ward to see how many post-op C-sections there are here, and still a 15% rate of abdominal delivery, imagine the carnage among womankind, if this service were not available here! Remember, there is a specialized hospital in Ethiopia which does nothing but repairs of VVF’s and RVF’s—fistulae from vesico-vaginal and recto-vaginal in the smelly outcast patients who are leaking as from a cloaca, having had too prolonged a labor and necrosis of their perineum.
As we made rounds of the C-sections, Mercy had no one in labor—a nice, quiet holiday weekend. I teased her and learned the proper name of the slogan over the painting in her home I had described from the evening at her home “Ifa Sith Thawika” which turns out to be in the Chiwa language for “You cannot escape death!” I suggested that such a painting should hang in every consultation room and should be made a part of every Op Permit. The lawyers and government officials who seem to imply a risk-free life being guaranteed to each one of us by citizenry of some group that is responsible for our fates, when in fact the common citizenry in humanity guarantees the sentiment in the portrait. Since no one had come into Delivery at the Maternity Ward, I wandered around and inspected the charts and flow charts on the walls, to show the “Syndromic management” of the maternity process. I made a lot of photos on today’s ward rounds, particularly when we came over to the Children’s Ward, where a colorful procession of women came out from under the shade of trees on the campus, each with a baby on the back of each, most holding on to a breast, either pendulous enough to be pulled around to the side, or, in the event that the woman was so lucky or still young, slinging the baby around on one hip to get at least the head up front in nuzzling position. I was told that almost no Malawian women have any sense of where their head is when lying in a standard hospital bed, and will invariably clunk their heads on the headboard of the hospital bed having had no previous experience with a bed, which has a headboard. This is not a “pillow culture!”
All the women in the Children’s Ward did not have to worry about that, since they all had the patients’ hospital beds on their backs, and would come in and sit in a thick cluster of communal observation and await their turn while seated in a crouch on the cement floor. One by one they would come forward and present their infant charges with the reports on what their diarrhea or fever, or drainage, or whatever had done for the day. I would be frightened of sitting in the midst of this contagious mass, in the same way that Alex Mac Lean is a very intimidated reluctant surgeon in the Theatre, but feels more comfortable on Children’s’ Rounds, since much more of it is devoted to the Well-Baby kinds of checks and standard treatments for what he calls a “Full House”: Diarrhea, Pneumonia, Malaria, Malnutrition—at least the first four sixths of DAMMM—the top five causes of death in the world, 1) Diarrhea, 2) Acute Respiratory, 3) Malaria, 4) Measles, 5) Malnutrition—each of which take their highest toll in the “under fives.” In this area the mortality before age five is a quarter—a woman must have four children that survive delivery to be half sure she might have three by school age.
I had been talking with Mercy about this when I had showed her pictures in response to her request “How many children and grandchildren do you have?”
“What?” she responded? “You have only two, and they each have only two?”
“That seems to be enough,” I responded, “Given lots of love and straight teeth and college tuitions!”
“But, what if God takes one of each?” said Mercy. Remember, this is an educated Malawian, who is very tuned in on matters of birth and family. I had seen from the number of the kids at her home that she was taking no chances, and child survival was likely to be much higher than among the over three thousand women she herself had delivered, let alone the twice that number Mama Chima has done right here at Embangweni Hospital—with 10 births and two C-sections on the Monday night of my arrival here. De-programming that instinct for perpetuation will take more than a generation even among the educated and elites, and there will not be the luxury of time nor another doubling of Malawi’s hungry population. And there is a ticking bomb among the ovaries of those that are here already since the majority of the Malawi population in this bottom heavy pyramid is under age 14. The WHO report on the “Current HIV/AIDS Status in Malawi and its Response” identifies Malawi as the nation hardest hit, with the third highest population density in the continent, and the highest percentage of orphans and a steady increase in the HIV rate of the population with a 13.8-year median for the start of sexual activity. It is in the younger less biologically mature girls who are engaging in sexual practices for which they are not ready that the highest incidence of HIV positivity exists, with a rate of SIX TIMES higher HIV + in girls of that age than of the boys. If the other factors that increase the HIV transmission rate besides too early youth are factored in, STD’s and a phenomenon I had not been familiar with, the “vaginal drying agents,”[1] this makes for a serious AIDS risk. But, there is an even more serious risk—an unsustainable fertility rate, that even the deadly virus cannot contravene.
I had been musing on these and other thoughts about the population bomb in Malawi, and the role of the Embangweni Maternity service in enhancing this survival rate into unsurvivability, when abruptly I got sucked into the activity to become an agent of child preservation in a big way myself. Right after we had congratulated Mercy for being on duty with no line-up of laboring women, two young women appeared who each had had previous C-sections and each was in active labor. In the US, with NICU’s and sophisticated fetal monitoring obstetric services, a woman can have up to seven, or perhaps even more, consecutive C-sections, but, it is a conservative e policy to say “Once a section, always a section” and no more than three C-sections are allowed her in total. On the third C-section, a woman gets a BTL (bilateral tubal ligation) with her consent, to prevent the horror of a ruptured uterus on the prolonged laboring on a scar. So, here were two women who were already in labor, and would be given a short trial of continuing labor to see if they could progress. What was the problem for which the first patient had been sectioned the first time? She seemed to have had a hard labor but there was no progress after the head was well down the birth canal. The section was then done to deliver a dead infant. This did not sound promising, but we said we would check on her later. We took the other one over to see what her status was on ultrasound. As amateur sonographers, we first had to “go to school” on the machine, after waiting for the electricity to be restored. She had a small, but term infant, and we elected to see what she could do in labor. Another woman entered, and patiently sat on the cement floor until Mercy had finished with the first two patients and had time to do a vaginal exam on her, at which point she quietly and simply delivered her, with the usual and customary and accepted practice of no anesthesia, for delivery or for any repairs necessary afterwards.
We went to lunch and at the time of lunch Jon Poehlman, his wife Mary Bennett, and Betty Poehlman all decided that they would like to see a C-section, so that if we had to do it in the afternoon, they might stop by. After all, we had the dinner invitation from Malwa for the evening, and we would all be gathering there to dine at 6:30 PM. We went back over to find that the patient had pushed the head of the infant down to within two centimeters of the perineum and got stopped, just as she had apparently done the previous pregnancy, without ability to “negotiate the turn.” It was time to act.
This one was on me. The Theatre Team was notified, but we got there ahead of them and I found an Abdominal Pack and Gown Packs and put them out, being delighted to see Mister Tembo arrive. But, Ellen, the anesthesiologist did not “pitch” (as the Briticism has it, so George, who was eager to do a C-section, since he had not done one in a year since his last Malawi stay, was suddenly the anesthesiologist. I prepped and the Poehlmans who were hanging out behind the glass window at the scrub sink were invited forward where they could see what was happening.
After the first dose of Ketamine, I had John Sutter, who had asked me if I might be able to help him do a C-section (he has since changed his mind about this based in this case) excise the skin scar from the previous C-section “tracks.” I made the abdominal incision, and then the lower uterine incision, and encountered the backside of an infant and a cord. I reached down and down and down, as far as my hand would go and there still was no end of the elongated head. I switched hands and tried with my left to go down and found the neck of the infant but the head was impacted. I remembered vaguely (it comes back to me from forty years ago) that occasionally a Simpson forceps can be used for up top to “shoe horn” an infant head back up into the wound, but we had none here so I used my fingers to “break the suction” and rock the head back when I could get my hand around the crown of the very elongated “chignon” of the head. If there were any "Simpson" to be referred to hear, it would likely be more like Bart's relatives, or the "cone heads" than an obstetric forceps here at this table. I pulled back with care not to put traction on the neck or the extremities, and hoisted the limp infant out of the uterus and held it upside down sucking its nasopharynx vigorously to induce some gasping first respirations. I clamped the cord, which was cut, and we tossed the child into the waiting blanketed hands of Mercy as the midwife standing by to carry the infant over to the bassinet to work on it there with suction and O2. The Apgar at the start was between 2 and 3.
“This baby was trying so hard to get out the way it was going that it could not turn around ad get backed up,” said the awed John Sutter, who was not quite prepared for the “accouchement force’” and the observing Poehlmans said that this might be a way of discouraging the production of grandchildren. Betty said it did her heart good because she had seen George struggle to deliver an impacted head once, and she did not know if it was because he was inept, not strong enough or not tall enough to manage the delivery. But all of us were relived when the infant began both breathing and sqawling, with a rising Apgar, as I was involved with a two layer uterine closure. The rapid and decisive delivery of this infant abdominally probably prevented a repeat of the last episode in which an even more experienced obstetrician had delivered a dead infant. Presenting this woman a second dead infant in the total of three c-sections would hardly have been a good outcome.
As I felt the anterior pelvis, it seemed that the bladder area was boggy and edematous. The following day, she was found to have bloody urine, so she has come very close to having a necrotic bladder wall and a VVF on the basis of her hard and unproductive delivery—unable to make the “curve of Karris” sacral turn, before—with lethal results—or, this time, with morbid results. But, at least, now, despite the inexperience of the operating obstetrician, we have a live mother who is happy with a live baby. Since I will probably not be responsible for school fees on this baby girl, and she is not given my name, I do not yet know if she will not be able to get into Harvard on the basis of her childbirth experience. The chignon is already resolving, and although she was not enthusiastic about sucking right afterwards, some expressed breast milk was poured in with a cup and she seemed to get the idea
This C-section certainly woke John up from what had been a lethargic afternoon for him, and we walked over to the shop that is supposed to be getting in the chitengas and the iron that I had seen and let Elizabeth take for the first samples since she would be going home first. For the third time, his shop is closed. With a holiday weekend (I am not sure it is a big “shopping day” as was the similarly unexpected Monday holiday on the day of my departure for Malawi, our “Presidents’ Day.”) My shopkeeper may be missing his biggest sale order this year!
We heard the sound of a lot of chanting dancing kids and made our way around the Loudon Campus to the football field and watched half of the match between the Robert Laws secondary school and the neighboring government secondary school who were the visitors. The “cheering squad” of dancing kids would run circles around the field in a dancing shuffling rhythmic dance, almost ignoring the game, which I found to be quite skillfully pursued, with a lot of heading the ball and even some “bicycle shots.” The score was 1:1 in the second half, as I was thinking we probably should go back to check on the second non-progressive labor on a prior C-section scar before we went to our dinner engagement, and said so to Mister Tembo who was sitting on the same side, watching the game. I walked back over to the hospital as the sunset made an orange blaze in the west, and as I came to the grounds, a watchman in army boots came passing me on his way to the football field, say9ing “You are wanted in theatre.”
C-SECTION FRONT
Sure enough, the “FTP” =”failure to progress” had stopped labor on a very small infant, and an exhausted mother. The head was not even engaged, despite dilations and what was said to be broken waters. This would be a simple section without the need for the heroic back retrieval of the descended head back out of the pelvis. This was George’s section—just to make me look bad, and to make us late for dinner. It was easy and over in a short time with a tiny but crying infant. We arrived at dinner an hour after the other Poehlmans and in time to sit down and join them in a full court press of Malawian cuisine.
[1] . [The ulcerative STD’s are means of blood-to-mucosa transmission, as are the practices of vaginal drying agents, said to enhance male pleasure in “dry sex” through the use by young women of herbs, stones or alum. Almost all these routes of viral transmission imply a barrier breach to intact mucosa.][1]