Wednesday, February 12, 2014

Making Babies and Saving Mamas


It was nine-thirty PM on a Sunday night in Illula, a small drought-ridden town in Central Tanzania.  I had just finished doing pre-bedtime pest surveillance and slaughter inside my mosquito net.  I'd never had Malaria and wanted to keep it that way (although I would fail and get a mild case at the end of this mission). My mattress was a nearly rectangular shard of six inch thick foam. It did not fit snugly in the wooden bed frame and left plenty of open space for insect and spider attacks from below.  Working with what was available I developed a pest control protocol:  First was the copious perimeter spraying around the bed with DEET (if I ever get Cancer I'll blame my nights in Tanzania sucking down DEET in my sleep).  Secondly, I'd work my way inside the mosquito net with an electric fly swatter.  I meticulously killed each flying straggler inside the net  waiting for an easy ambush.  I scattered their carcasses under the bed as a warning to their friends. Lastly I systematically tucked each part of the net under the misshaped foam mattress.  This was a lengthy, exhausting process, but worth every minute for a good night's sleep.  When I had to urinate in the middle of the night hard decisions had to be made.  As I turned off my flashlight that night there was a knock at the door.

"Daktari!  Daktari! Are you yet asleep?"  It was Dr. M, the local Chief Medical Officer of the hospital where I lived, work and ate for six months.
"No, not yet, Daktari.  I'll be right there."  I pushed open the meticulously tucked mosquito net and got out.  I was destined to be the Sisyphus of mosquito nets, tucking and untucking to no avail, only to return and do it the next time.  I let Dr. M. into the house.

"How are you, Daktari?"  he asked, "Did you have a restful Sunday."
The identifier word "Daktari" would be formally and informally used in nearly every spoken sentence between us.  It's just how it was done.
"I did indeed, Daktari. Very restful.  I was just going to sleep."
"Very good, Daktari.  That is good to hear.  I was watching the African Cup of Nations football all day.  The Nigerian squad is very tough."
"Yes, Daktari.  So I hear although I'm a fan of the Black Stars from Ghana."

Obviously Dr. M was not at my door in the middle of a Sunday night to see how my day went and to talk football. Culturally, though, this was the way most conversations  started in Tanzania.  Always with pleasantries to start and to set the mood and in no great hurry to get to the point---which was actually kind of pleasant--even if there was an emergency notification coming. As a pragmatic get-to-business American, this bothered me when I first got in country.  With time and frustration  I'd learned to chill and wait for it.  I knew he'd get around to the reason for his visit eventually.

"Daktari, have you ever done a Cesarean Section birth?"
"Sure, Daktari.  As a much younger man during my Residency training. Long time ago. I don't think I was even shaving yet."
"I see, I see, Daktari.  Because we have a small problem." he said.  "We have a pregnant woman in the ER.  She is already three weeks past her due date and I fear for the baby. She must have a Cesarean Section tonight.  Unfortunately I was fixing my car today and I've badly sprained my wrist.  I cannot even hold a spoon with it.  I am going to need help.”
I’ve seen a lot of talented surgeons do some incredible work with one hand, but a C-Section was out of the question.

It would be a special Tanzanian meal tonight!
Dr. M was the only surgeon within eighty kilometers in every direction.  He was also the only Gynecologist, Pediatric surgeon, District Health Inspector and Head Safety Officer.  He had a staff of clinicians who were essentially physician assistants.  None were capable of performing surgery.  Tanzania has a difficult time training and maintaining its key medical staff.  Dr. M’s government salary was the equivalent of one hundred fifty US dollars per month.  Most doctors at his level eventually leave the country for much higher wages in nearby South Africa.

“Daktari,” I said, “as long as the parts haven’t changed since my residency twenty years ago I think I can help.  Just coach me along the way and we should be fine.”
“Ah good news, Daktari.  We should go now.”

And off we went.  I was already out of my mosquito net anyway.

We walked across the dark hospital courtyard with a flashlight.  We surprised a few chickens and goats along the way.  I considered this payback for the nights they croon outside my window at four AM.  When we arrived the staff was preparing the operating room table and equipment.  There was a loud whir of the generator in the background.  Without it we would be working with flashlights.  That would not present ideal conditions for my first C-section in twenty years.  We had no General Anesthesia for patients in this hospital.  It  didn't exist.  We had an anesthesia machine donated by an American religious group years before, but it just served as a shiny new towel rack as nobody knew how to use it.  The only anesthesia possible was by epidural injection. One of the nurses know how to do it.  Everyone here stayed awake for their surgeries. In the corner of the room, the patient was curled up on her side in a ball with the assistance of our nurse.  Her big belly was making it hard to get into position for the spinal injection.  Dr. M. and I put on our masks and scrubbed our hands with Betadine.  There was no running water so the nurse poured a pitcher of cold well water over our hands when we finished.

The patient was lying on the table.  She was awake and stared at the ceiling.  Tanzanian women define stoic. Even when in great pain you will  rarely hear any yelling, crying or complaining. It was as though their hard lives conditioned them for pain. The nurse slathered Betadine  over the abdomen to sterilize the skin.  I pinched her skin slightly with a pair of hemostats to see if the anesthesia was working.  She felt nothing.  It was on.  Dr. M. and his one good hand began to coach me. Before starting  I noticed a series of healing small cuts in a wishbone pattern across her belly.  She had been to the traditional healer of her village for treatment at least a week before coming to see Dr. M. The rhythmic series of cuts and herbs had not pushed the pregnancy forward.  It was common for us to get these referrals when the traditional healers gave up.

We had to work quickly.  The baby was at risk for several medical problems from being inside the uterus for several weeks past the due date.  I started to cut. The incision needed to be long enough to get the baby out and to see what we were doing.  So far, so good.  I made it through the skin, then the fascia and down to the muscle.  I used my fingers to bluntly separate the muscles so as not to cut through too many of them—this makes the post-op recovery more difficult.  Within a few minutes I was down to the exposed, bulbous uterus.  I could see the baby’s limbs moving beneath the red, muscular surface like a caterpillar in a huge cocoon.  This baby was ready to come out.  Next would be the tricky part for an amateur like me.  I had to open up the uterus safely with my scalpel, but avoid cutting the baby who rested just millimeters beneath the surface.

At this moment the surrealness of my situation struck me.  I was thousands of miles from home (where my wife was 5 months pregnant with our first child) in the middle of the Tanzania drought zone doing surgery in a small remote Lutheran hospital.  My hands were wrist-deep in the belly of a woman I’d never met. We were in the midst of a high-risk delivery seven hours of hard road from the nearest center of medical excellence.  I was doing my first Cesarean Section surgery in twenty years under the guidance of a one armed mentor. These are the MASH TV moments you dream about in medical school.  There was one opportunity.  There was no safety net. 

I gently nicked the surface of the uterus with the scalpel and worked my fingers in to reach the baby.  The initial gush of yellow amniotic fluid and blood poured out of the incision.  The nurse was ready with suction to remove the fluid and keep our operating field visible.  I slipped my fingers into the uterus and while protecting the baby with my hand, I cut across the uterus to make the hole big enough to get him out.  There was a lot of bleeding because the uterus was under so much pressure.  Dr. M looked at the anesthetist and said something to him in Kiswahili.  He reached under the sterile blankets and shoved the top of the uterus hard.  The baby’s head popped out of hole in the uterus and we quickly suctioned his mouth and nose to keep any fluids from getting into his mouth and lungs.  The rest was easy.  One shoulder out, then the other, then the legs. Clip the umbilical cord and Presto:  We made a baby.  It was a boy.  Despite the lengthy labor he appeared healthy and vital and crying loudly.  A nurse took him away and rubbed his body with towels to warm him up.  Now it was all just gravy.  Close up the mother, dwell for a few minutes on the miracle of birth and get back to bed.

Welcome to Tanzania!

Dr. M and I talked while we worked.  He complimented my surgical technique with such scant experience in the last few years.  I knew he was just being nice, but I appreciated it.  I was giddy from the experience.  I hadn't delivered a baby in so many years.  While I wouldn't  voluntarily do it on a regular basis, it was exhilarating to be back behind the knife. 

I glanced up at the anesthetist and asked him how the mother was doing.  He had his finger against his forehead and stared at her in deep thought.  He said, “Hmmmmm.”  Then he switched fingers on his forehead and took a deep breath.  He was formulating his response.

“Daktari,” he said calmly, “ I don’t believe she is breathing.”
“WHAT? Say that again.”
“Yes, now I am certain.  I do not believe she is breathing.”
“Do something!” I said, “What is her oxygen level.”
We had a device called a Pulse Oxymeter.  It is an ingenious handheld device which, when attached to the patient's finger, gives an instant level of oxygenation in the body.  I noticed it was unattached and still sitting in his top pocket. 
“Daktari, I’m going to break scrub and head up top.” I said.
“Yes, Daktari.  That is a good idea.  I can control the bleeding here.”

I went to the head of the table, pulled the Oxymeter out of his pocket and put it on the mother’s finger.  She was unconscious and, indeed, not breathing.  I directed him to get the Ambu bag and start breathing for her.  He found it under the table and put the mask over her face.  Backwards.  As he pumped the bag all the air was going out the side of the mask instead of in her lungs.  I turned it around and placed it properly.  Next I put my finger over her Carotid artery to check the pulse.  As expected, no pulse.  We were officially in the middle of a cardiac arrest, deep in central Tanzania in a room lit by a single generator seven hours hard road away from a medical center of reasonable excellence.  This was not how I saw this evening going.  I was thinking only:  This is bad.  This is really bad.  

“Daktari, there’s no pulse.  I’m starting CPR!”
“Yes Daktari.  I will continue to work here.”  He calmly continued cutting and sewing in the belly with his one good hand. The nurse assisted him.
“Give her one amp of Epinephrine!  Right now!” I said to the anesthetist, “What is her Oxymetry?”
“It is eighty-five percent, Daktari.  Epinephrine going in now, Daktari.”
Shit, I thought to myself.  Anything about ninety-two percent is normal.  Once that number stays in the eighties you are looking at potential brain damage.
“Start bagging her faster!” I said. “Hyperventilate her!  Get that number over ninety!”
“Yes, Daktari.”

I started doing chest compressions, counting loudly as I did.  I felt the distinct, disturbing, sickening CRACK of a ribs breaking away from her sternum.  This is an anticipated  hazard of doing CPR.  I've felt it before.  You never get used to it.
“ONE AND TWO AND THREE AND FOUR AND FIVE!  How are we doing down below, Daktari?”
“Going well, Daktari.  Just continue.”

After a cycle of thirty compressions I stopped and put my finger on her carotid artery to check for a pulse.  Just as I thought I felt something her eyes burst open and she gasped.  She started screaming something in the local language.  The anesthetist patted her on the head and calmed her down.

“Oh my God,” I said to no one in particular, “Shit.  That was intense!”
I knew what had happened.  Sometimes epidural anesthesia can creep up the spine to areas it is not supposed to reach.  When it does it can stop a patient’s lungs and heart from working until the Novacaine wears off.  This was just a perfect storm of medical bad luck. We had weathered it.

I changed my gloves to new sterile ones and joined Dr. M. in the belly.  He had finished with the uterus and was working on closing the layers of the abdomen.  He is a cold steel professional.  He didn't miss a stitch through the whole event.

“It is lucky that you were here, Daktari.  Usually I have to do that alone.”
“I can’t imagine.  Does this happen often?”
“No, Daktari, not often, but many people in this community die young.  There is not much medical care. We cannot do everything here, you know.  It is not unexpected when it happens.”

I finished up the skin incision with a nice subcuticular plastic surgery closure.  I figured it was the least I could do for her after this near disaster.

Dr. M and I left the patient with the nurses in the recovery room.  He told me he would stay with her.  I should go home and get some sleep.  I was far too amped to think about sleep, but Monday was coming and there would be work to do.  My mission there was to set up a government HIV treatment center in this Lutheran hospital in the middle of Tanzania.  There was training to do, supply chain issues and laboratory protocols to develop.  It was good work for sure. Just not as exciting as surgery.

I walked extra- slowly back through the courtyard to my house.  The cool Tanzanian night air felt good on my face. Simple and nice.  I was careful not to kick any sleeping chickens or goats.  No more surprises or intensities tonight.  I was done.

People who know this story have told me I should feel like a hero.  But all I felt then was damaged and numb  from the experience. Like I’d lost a few good years in the process. I still do.  In that brief moment when her heart  stopped I felt like I was in everybody’s shoes.  Like her husband who would have to hear that he gained a boy and lost a wife at the same time. Or her children with the excitement and anticipation of having their mother come home with a new baby. And my own shoes as I considered my wife who was pregnant with our first child.  How would I cope if this happened to her?  When I considered this later I figured I was simply in the right place at the right time to do the right thing.  Period.  And because I was there life could just go on for everybody involved like it was supposed to. Without skipping a very dramatic beat.   If I was happy it was for one thing:  five children never needed to know that for nearly a minute they had no mother.

I needed to chill.  I had one Seregheti Beer left in the house.  I had no refrigerator so I left it in the livingroom in a bucket of tepid water to keep it reasonably cool.  I was ready for it.  The adrenalin was starting to fade.  There was still a few hours of night left and I had a mosquito net to tuck in.

Dr. M and Dr. E:  Game Faces
Postscript- I had written this blog a couple of years ago, but subsequently received an official letter from the organization I was working for telling me to remove it as they were identified in the blog.  They were concerned that there would be "liability" if people knew that we were working in more than a "Technical Advisory" role in Tanzania--which is what we were contracted for.  I've omitted their name from the blog. I remain a bit baffled that they would see this work as a negative reflection of their services as opposed to one of their doctors stepping up to do the right thing, but such is the nature of politics I suppose.  In my world people bleed the same color in every country.  Any reasonable doctor would, and should, step up in these situations.



  1. I do not know you, but I just read your story, and I was on pins and needles, gripping the side of my chair, trying not to spill my coffee. God is with you, and you are obviously not just a great doctor, but a talented writer as well. I can only imagine the adrenaline rush you experienced in those precious few seconds.....but the visual you proposed was an excellent delivery. Thanks for sharing!

  2. I love reading your always makes me want to do more in life!