Numb

I stare blankly at the small hand and arm. I sit on a stool in front of a delivery bed. My hands hang at my side. My whole body feels heavy. My eyes would close if they could to banish the sight forever from my consciousness. Before me, on the floor sits a large, green plastic basin. In the basin are some bloody pieces of gauze, a few blood clots and disembodied arm and hand. The arm is perfect. The nails, the tiny fingers, the palm creases, the forearm and elbow are all perfect...except for being a deep purple and totally detached at the upper arm. There is no accompanying body. I sit here numb in front of its mother waiting for the rest of "it" to come out. My mind drifts as the minutes drag by...

I am pulled to the door by a rattling banging of fist on metal. My wife, Sarah, has left for N'Djaména. The monsoon rains pound the tin roof mercilessly. David, the night watchman, stands outside all but swallowed up in a bright yellow rain slicker.

"Bon soir, David."

He doesn't reply, just reaches solemnly into his jacket and pulls out a worn half of a paper notebook we call a "carnet" or portable medical record.

I read inside. Young woman. First pregnancy. Dates unknown. Bleeding since 4pm, 2 hours ago. Cervix dilated at 3-4cm. IV started with normal saline. Refer to Doctor.

I give the carnet back to David. "J'arrive."

I pull on my scrubs. So much for a quiet, rainy evening reading in my favorite chair. I go next door and quickly down some cold spaghetti and eggplant sauce and tell the medical students, Carol and Sara, what's going on.

I slip on my sandals, pull my hooded sweatshirt low and step into the downpour. The ground has disappeared. I slosh through water up to my ankles following the moonlight splayed across a million tiny circles splashing on the surface. It is a lovely dream about to become a nightmare.

I reach the shelter of the overhang beside the operating room and enter the hospital ward turning right into labor and delivery. The first surprise is that I see Rahama there. I think how nice of her to come help at night. She never does that. David, the nurse, is with a small frightened girl. She is completely naked her legs sprawled at weird angles on the table. Pools of blood stretch along each side of the bed. Clots with a few pieces of gauze are on top in between her legs. She writhes but doesn't really speak.

I ask how far along she is. Rahama replies that she's about 4 months. I then realize that this is Rahama's daughter. David is just finishing putting in the IV. The IV fluids drip in. I ask for gloves. Normally there are always gloves in L&D. There are none. I inexplicably start to become very nasty. I start to talk coldly to Rahama and David asking how come there are no gloves when I left a ton before I went on vacation. I tell them cruelly how they always just use stuff up. I feel very out of control and realize it but somehow don't care. I am bothered, frustrated, and in over my head.

David rushes off to the Garde room and brings me some gloves. I try to examine inside the girl. She won't move into the right position. She doesn't understand French. Then, she doesn't seem to understand the translation. She fights, squirms and I can't even begin to examine her. I start to yell how we're trying to help you but we need some cooperation. Rahama starts to yell at her, too. Nothing. We struggle. Rahama starts to slap her. Finally, I can examine her. There are clots but no real active bleeding. Must be an incomplete abortion.

I run out to get the instruments to do a curettage under spinal anesthesia. The rain intensifies. I give David a urinary catheter to put in her. He can't get it in. I try to help without gloves getting blood all over my hand. I call for gloves. There are none. There is no gauze. I wash my hands off. David continues to struggle with the catheter. I start to rain down deprecations on the entire lack of adequate staff and materials and how can we work under these conditions. David has no luck. Carol brings me some gloves. I finally get the catheter in. The girl has continued to struggle and get hit in the face by Rahama.

She is turned on her side and the spinal needle doesn't want to go in. The puncture starts to bleed. We have no gauze. Sara runs to surgery. I wait, seething. I wipe off the blood and am able to get the anesthesia in at last. The girl quickly relaxes and actually falls asleep during the rest of the procedure...exhausted.

I am able to examine her easily now and after dilating the cervix discover that the fetus is more like 7 months than 4. I can't do a D&C. We listen for fetal heart tones. There are none. On exam it feels like a breech presentation. I try to deliver the first leg and after pulling it out, find it's really the arm. Now I'm stuck. This position will never allow the dead fetus to come out. I don't want to do a c-section since the baby's already dead. I try to push the arm back in. The humerus cracks, but it goes in. I try to turn the infant inside. No luck. I feel sick at the thought that enters my head. I might have to pull it out piece by piece. I reach inside...

The arm is out again. It is a deep bluish purple and perfect. I grab some scissors and cut through the skin. Three cuts and I'm through. I drop the arm and I gaze in a weird slow motion sequence as it slowly spins through the air to bounce in the bottom of the basin splashing up a few drops of dark blood. I reach inside and able to pull the head down which has been doubled almost completely backwards over its little back. What now? The cervix is still only 5cm dilated...I place my hand on her uterus through the abdominal wall and feel only rare uterine contractions. I stop, dejected, and stare blankly at the small, detached arm and hand in the green basin on the floor in the pool of blood, clots and gauze...

We send David, the night watchman, to find Anatole to get Oxytocin from the lab fridge. The girl still sleeps. Rahama sits quietly. She looks at me and says, "I don't know what I'm going to do. The expense for all this falls on me and I don't know what I'll do..." Rahama always lives in debt, barely scraping by, getting advances on her salary to try and feed her husband, kids and relatives who depend on her. With the famine, the increased prices and her own crops from last year being burned up, she lives in constant anxiety about how to make ends meet. This is the straw that may break the proverbial camel's back. I sense her desperation.

The oxytocin arrives. The girl awakes. She is shivering only covered by a thin sheet. I grab my sweatshirt and lay it on her. Rahama tries to protest saying it'll get all bloody. I say not to worry about it. The girl snuggles under and goes back to sleep. I stay for 45 minutes with my hand on the uterus monitoring the contractions and adjusting the oxytocin till she has regular contractions and I'm sure she won't have tetany that could lead to a rupture of her uterus. Rahama has washed the instruments. The blood still lies pooled on the floor and table but has started to dry. Rahama says she'll monitor her closely now to make sure the contractions don't get out of hand. I head back home. The rain has stopped. My feet have been pickled in my soggy shoes. The puddles are still there. My forearm and hands are cramping from reaching trying to pull and tug and turn a dead baby...my mind has effectively walled it off so that I'm still in dream land as I slosh home, wash up and crash into an empty bed with a feeling of emptiness so complete that I can't even think of anything to worry about but fall into a deep, troubled sleep...