Too late

I squat on the ground outside the operating room. A thin Muslim man squats in front of me, his green Arabic robe pulled tightly across his knees as he hugs them with his arms. He is staring at the blue basin between us. The insides of the basin is covered with a blood-soaked, brightly-patterned yellow wrap around skirt. I lift up the cloth with a gloved hand covered with dried blood. Underneath is a dead infant with a huge head (hydrocephalos). His blank eyes stare up at us as his neck bends back at an impossible angle. Underneath is the placenta still attached to the child by the umbilical cord. All is cold, lifeless and bloody.

I do my best to explain to him in Arabic what happened.

"The child, dead, when arrived, dead already. The head, big, not come out. The house of the child broken, the child come out here (point to my stomach). Blood come out, a lot, here also. The woman there, she not have much blood when she arrive not have. Si there is not much blood, she found death."

"Both of them, the two of them, both dead?" The man asks in disbelief.

"Yes, both dead, all dead," I repeat a million images of the last two hours flashing through my head...

"Doctor, doctor!"

I slowly stumble out of a deep sleep and a pleasant dream. "Yeah, what is it?"

"It's me, Augustin, I have a case to present to you."

"Ok, I'm coming." I pull on a pair of scrub bottoms and feel my way through the dark to the door and out onto the porch. Augustin is standing outside the screen door with a headlamp and a "carnet" or portable medical record.

"There's a woman, referred, in labor for two days..." Augustin stumbles through presenting the woman. He is one of our laziest nurses and often does as little as possible. I'm a little irritated.

"Whoa, whoa! Start over, give me that!" I take the labor and delivery sheet. I glance quickly over it and it's incomplete. I see the vital signs, heart rate 60 bpm, blood pressure 100/70, temperature 37 degrees Celsius. I'll regret later not noticing how generically normal they were.

"What? What's going on?" A voice comes from the room next to us where Jacques, our newly arrived doc fresh from medical school in Mali, has been sleeping.

"I'm talking to Dr. James," replies Augustin. Jacques quickly appears outside just as I'm telling Augustin to go get more information and come back to see me with the chart completely filled out.

As Augustin and Jacques walk off together I almost yell after him to check a hemoglobin. I catch myself, thinking I'll be over to see her shortly anyway. The second thing I later regret not doing.

I go back to my room and decide to lie down, after all it's been a long week filled with tons of surgeries and the training seminar I've been doing for the village health care workers on HIV and tuberculosis. I'll just close my eyes for a few minutes until Augustin and Jacques get back. The third thing I later regret.

"Docteur? Docteur?" The soft voice of Jacques floats across my subconscious. I go to the door. I glance up at the clock. It reads 4:25 am. I didn't look at the clock when Augustin first came, but I did hear the fridge running which it's programmed to do 4 times a day for an hour at a time: at 6am, noon, 6pm and midnight. It's been 3-4 hours since I saw Augustin and Jacques walking off together. A strange sense of foreboding falls over me.

"I've examined the woman and I think she has a ruptureed uterus."

"Go call Abel and Dr. Franklin and I'll be right there."

I pull on a scrub top, grab my keys and I'm out the door. I stop by the other house real quick to make sure Franklin's awake and then make my way across the compound to the labor and delivery room just past the OR.

As I walk in the room and glance at the patient, my heart skips a beat. A tiny Arabic woman lies stretched out on the table with one knee bent in the air. Blood has pooled between her legs. An IV with Glucose and I quickly assume Oxytocin is dripping into her left arm. Her thin abdomen is grossly distorted with several large, not normal pregnancy looking lumps. But what arrests my attention is when I look at her face.

Her head is flopped to one side and her eyes are rolled back in her head. She is pale and her only breaths are occasional sighs. She is on death's door and I see it instantly. I quickly feel for her heartbeat which is present but slow. I flip down her eyelids with my finger and my blood freezes. Her conjonctiva is white. She has practically bled to death in our hospital.

"Augustin, quick call the lab, we need blood! Abre, run and get me some Ringers!" Franklin arrives and quickly starts looking for a better IV. Then she stops breathing and I start chest compressions. Franklin has found an IV in her neck and we get fluids running. Abel has arrived and we take turns with chest compressions.

"Franklin, what about the monitor from the OR?" He runs quickly and arrives. We get no blood pressure and a weak O2 sat.

Finally, after what seems like hours the lab guy arrives.

"Abre, what blood type are you?"

"O positive."

"Mathieu, just check to see if she's positive or negative and if she's positive Abre will give."

She is B positive and Jacques and Abre run off to donate a bag of blood each. Augustin is B positive and refuses to give.

Abel and I keep up the chest compressions while Franklin guards her airway.

We get the first bag which is only a third full of Abre's blood. We hang it up.

"Abel, you and Abre get the stretcher and lets take her to the OR."

We flop her bloodied body onto the stretcher and Abel and Augustin carry her quickly to the OR while I continue chest compressions and Franklin carries the blood and IVs.

We get her all set up on the OR table with blood splashed everywhere. Still no heartbeat so we continue our ressucitation hoping that if we can keep her oxygen circulating until we replace her blood loss maybe we can save her.

We try some Atropine to start her heart. We try shocking her. Nothing. We have no Adrenaline. Then I remember we have some spinal kits. I open up two kits so we can use the adrenaline inside. Nothing works so we continue CPR.

Finally, a third bag of blood is running and I decide to take out the baby. We slosh Betadine on the belly, I quickly open up a C-section kit and put on a gown and sterile gloves. One slash and I'm in the belly. I cut the baby's face but he's dead already. His head is 5 times normal size with hydrocephalus. That's why he couldn't come out. Her uterus is in tatters. I pull out the baby and placenta. Place some clamps across what's left of the uterus and cut it out. I tie off the clamps, dump some Celox in the pelvis and hold pressure for 5 minutes. The whole thing takes about 15 minutes. All the donated blood is in, we've been working on her for almost 2 hours and she still is flatlined. I tell the guys to stop CPR, I sew up the belly and I go out to tell the husband.

As I'm kneeling in front of the Muslim husband, having just told him his wife and the unborn child between us are dead, I'm not sure how he'll react. A brief image flashes through my mind of the violence of two weeks ago with Arabs stabbing and killing Africans and vice versa and the chaos in the hospital trying to save as many as possible. But there is no revenge taken on me today. Instead, a gentle chanting in classic Arabic rises from the depths of his sorrowed heart.

"Illallah le Allah wa rassulloh Mahamat." The Muslim creed repeated over and over seems to soothe the sorrow. "Al hamdullilah" (Allah be praised) breaks in occasionally. A fellow Muslim from Lai comes and kneels down beside him reciting some Koranic verses in a low voice.

"Find me some brothers of Islam here. All the believers here in the hospital." The other Muslim goes off and soon a small group of robed and turbaned men surround us.

I ask him if he'd like to see his wife. He nods and we go into the OR where Abel and Jacques have been cleaning and covering the body. A portly Arab with a beige robe and white turban accompanies us. The woman is lying on the stretcher covered with a black, Muslim woman's cloth with intricate Arabic designs in gold woven into the fabric. The husband uncovers the wife's face and asks for water.

I get some water from the faucet and bring it to him in a small basin.

"Put a little over my hands," he asks me in Arabic.

I pour water over his right hand and he uses it to gently wash and wipe down his dead wife's face closing the eyes. The other Arab also moves his hand down the face to close the eyes and then they cover her back up. As we take her out to the morgue I hear some low sobs coming back from the OR.

15 minutes later, the brothers from the Mosque have arrived and I carefully explain in broken Arabic again what has happened.

"Xalas, inshallah, mashallah, al hamdullilah" come out in intervals from all resent. The accept and comfort and then take the body off to be appropriately buried as soon as possible in the Muslim fashion.

I go home.