Spring up, oh blood...

Tout le monde,

As I walk into the wards I hope I won't throw up. I've been down with Typhoid Fever and just got up because I can't help worrying about this one patient and if I've made the right diagnosis. She'd come in with pelvic pain, no period for 2 1/2 months, and no bleeding. Since our ultrasound is down I just had my exam and intuition to go on. I decided it was an infection and started her on antibiotics while ordering tests for today.

But this morning, I was feeling nauseated and had diarrhea so I didn't to into work. However, I couldn't get out of my head I should go check on her.

I enter the female ward and turn to my right where I see the young woman sitting comfortably on the edge of her bed, smiling. I breathe a sigh of relief and walk up to her.

"Lapia"

"Lapia ei"

I reach for her carnet where I see a lab slip sticking out with red writing on it indicating results are in. I peruse quickly the tests... all negative for infection, but the pregnancy test is positive and her hemoglobin is 4.66 g/dL. My heart sinks. I ask her to like down and I palpate her abdomen. I think it's more swollen than yesterday and is tender in both lower quadrants but is still soft. I think about doing a culdocentesis to confirm that it's an ectopic pregnancy but deep down I won't feel at ease even if it's negative. She needs an operation.

She is soon prepared and lying on her side for the spinal anesthesia on the OR table. The Ampicilline has been given. The blood transfusion is running in. She has two good IVs. We can start. I easily find the spinal fluid and inject the lidocaine. Samedi, Josue, and I flip her over on her back and tilt her head down slightly. Josue attaches the pulse oximeter and automatic blood pressure cuff while Samedi and I prep the patient, then scrub, gown, and glove, and drape the patient. I grab the scalpel, Samedi says a prayer and I'm about to start when...

I turn my head and look at the pulse oximeter. It reads 85% oxygen saturation (normal is >92%). Her pulse is 65/min. I look across the drape at the patient and my eyes are drawn to the skin on her shoulders. She is covered with hives. Her eyes look blank and I'm not sure she's breathing.

I glance at the blood pressure and it's 84/36. I start to bark orders at Josue to start bagging her. He panics. He can't find the bag-valve-mask. Then he has no idea how to use it. I stand there helplessly scrubbed and sterile holding my impotent scalpel for a few frustrating moments before I give up, break scrub and grab the BVM from Josue, and start breathing for the patient as the pulse oximeter starts to beep slower and slower and the alarm sounds as the red numbers keep going down and down just to the 40s before my bagging starts to bring it back up.

Meanwhile, I'm ordering Josue to give Dexamethazone and Adrenaline. The IV fluids and blood are running full speed. I think we have some IV Benadryl somewhere. Fortunately, Anatole pokes his head in just then and I yell for him to go get Sarah. Anatole is by far the most nervous of nurses (since he's really a lab tech functioning as one) and so takes off like a scared rabbit.

The patient's pulse starts to pick up. Her O2 sat is still in the 80s but holding. Sarah comes in and then goes off in search of IV Benadryl. The blood is almost all in. She is fighting the bagging so I have Josue give her Diazepam and Ketamine to put her under. Sarah comes back. She can't find the Benadryl. I give the bagging over to her and go to look myself. I can't find it, either. I come back. The blood pressure has come up some as has the pulse (now 115/min) thanks to the Adrenaline. The O2 sat keeps going up and down. Samedi says he thinks the IV Benadryl might be in that little blue pouch down on the shelf behind the Anesthesia machine. Sure enough, I find it just in time to hear the patient start to retch. Foul, yellow-green, thick vomitus is coming out her nose and from in and around the oral airway.

I demand suction while Josue gives the Benadryl and her O2 sat starts to fall. She needs to be intubated. I grab the kit and a size 8 ET tube. I check the Laryngoscope and it works. I put a stylet down the ET tube, tilt her head back, insert the Laryngoscope and pull up. I suction out the airway and have a clear view of the vocal cords opening and closing. I position the ET tube and than quickly jam it through the cords as they open.

It slides in. I forgot to attach a syringe so Sarah quickly grabs one and blows up the cuff. I attach the bagging apparatus as her O2 sat has hit zero but her pulse is still strong at 136/min. Her O2 sat slowly climbs up to the high 80s but doesn't seem to want to get normal.

Sarah takes over bagging. Feeling like we need to get this surgery done as quickly as possible, I don't take the time to rescrub but just put on new sterile gloves. I grab the scalpel again and swiftly slice through skin, fat, fascia, and muscle to the peritoneum where I see the ominous dark look of intra-abdominal blood. I make a small nick in the peritoneum and dark purple blood shoots out. As I make the incision bigger Sarah gives her a deep breath and the blood literally wells out of her belly in a tidal wave crashing to the floor. I grab suction but it's like trying to drink from a fire hydrant.

I attach the autotransfuser and slowly suck up as much blood as I can to be regiven to the patient while the rest continues to surge every few seconds with each breath given and splash onto the floor which soon looks like a killing spree has just occurred as pools collect and seep into all corners of the room. Samedi takes over the suction as I start to insert lap pad after lap pad into the never ending reservoir of blood that is her abdomen.

The only bright spot is that with the release of abdominal tension, her breathing becomes easier and her O2 sat shoots up to 96%.

After taking off 1200cc into the autotransfuser, another 1-2 liters on the floor and another 1/2-1 L soaked up in a mound of lap sponges and gauze piled on her legs, we can start to make out the anatomy of the abdomen.

After handing off the autotransfuser to Jacob (who has just entered to see if we need help), I see the tell-tale smooth, purple mottled mass of placenta on the right side of her uterus where the ectopic pregnancy is. I reach in my hand to dissect it off the posterior peritoneum and a four-month-old, perfectly formed fetus shoots up and out. I grab him (as will be verified later with a close look between his legs) and toss him onto the mayo stand. The placenta part pulls up and out easily and I place one clamp across the tube where it is bleeding and the bleeding stops.

We suck and mop up the rest of the blood hiding out in the various pockets of the abdominal cavity, I tie off and remove the right tube and ovary, and we close her up.

Her hives have disappeared, her blood pressure is normal and, with bagging, her oxygen saturation remains normal. The auto transfused blood won't flow through the right IV so it's switched to the left where it runs for 5-10 minutes and then stops there too. Both Sarah and Josue are unable to find another IV so I grab a central line kit, betadine her groin, palpate her femoral artery, stick a large needle into her femoral vein, slide in a guide wire, pull out the needle, nick the skin with a scalpel, slide a dilator over the guide wire and slip the central line in before finally pulling out the guide wire and attaching the blood line.

After 800cc of the 1200cc of her own blood has run back into her there are two many small clots clogging up the filters and we have to give up on the blood. Sarah, Josue, and I have now been artificially breathing for her for almost over four hours. While Samedi, Jacob, and Josue clean up the substantial mess in the OR, the girl starts to wake up and I extubate her. We then bag her for a while more, and then wean her off oxygen. When she's breathing on her own, we wheel her out to the ward.

When I go home, I feel tired but energized. I drink some cold water, grab a bite to eat, and sit down with my guitar. The joy flows out of me as my heart and soul are poured out into the music and songs. I know I have just experienced a miracle. I know God has just used me and the chills run up my spine as the tears run down my face.

The next day, the girl is asking for something to eat. Three days later, she goes home.

James