Thursday, July 24, 2014

Csection gone bad

For the past 7 years, I have been doing Csections when a women is unable to have the baby naturally.  In that time, I have encountered various problems that were beyond what I knew how to do, but there was always a man who would pick up the phone when we dialed 665, who within 2 minutes was walking into the OR ready to help.

At times, Bill and I have been in difficult CSs, sometimes we have needed Jim to come in, other times, just the presence of another experienced doctor is enough to get through the tough cases.  As we have encountered these, I have said to Bill, "What would you do if you encountered a problem and Jim wasn't here?"  We formulated a plan - call in the most experienced doctor on station to help, and if that isn't enough,  pack the patient as best you can, put her in the ambulance and race to Mt. Hagen hospital, our referral hospital for help.

Thankfully, I have never had to execute that plan until Saturday morning.  Thankfully, when I did have to execute that plan, it worked.

I got a call around midnight or thereafter that a women had just come in who had 2 prior CSs and was having very minor labor pains.  Hearing the words 2 prior CSs, always puts a little fear into me.  Having one operation in the past often means you will encounter scar tissue and adhesions which can make the surgery difficult, have 2 operations, means there is a chance the adhesions and the scar tissue will be even worse.  If possible, you want to do these Csections in the daytime, with good help, lab staff around if you run into a problem.  Since she was having minor pains, I said we would plan to do it in the morning, unless something changed in her or the baby's condition before then.

Another women was having difficulty with her labor, so I had to do a Csection on her at 0530 in the am.  So while we were all there, I decided to go ahead and do the repeat Csection right after.  So after finishing the first section, I started my ward rounds as our OR crew got ready for the 2nd section.  When I got to the OR, I was happy to see that the prior to Csections had been done with an incision that went across the lower part of the abdomen.  I normally make a vertical incision, so since her prior incision were much lower, the chances of scar tissue and adhesions, where I was going to cut, should be much less.

I made my incision, and quickly found that the anatomy wasn't looking quite right.  I wasn't seeing the fascia like I normally do, and instead there was a red object that was just bleeding.  As I felt it, it was hard and firm, unusual.  I put my fingers in and started to poke around and quickly discovered that this red mass was the uterus.  The uterus was scarred/adhered to the whole abdominal wall.  As I moved my finger from side to side to try and make a plane to get around it to free it up, more bleeding would occur.  I cut further up in the abdomen to try and approach from that way, but that resulted in more bleeding and no progress.  I looked down at the window of uterus I had in front of me which was about 3x3cm.  I was far from getting the baby out, and the amount of bleeding that was occurring was more then I was comfortable with, because I knew it was only going to be worse.

In my mind, I was weighing my options - keep going with the nursing student who has assisted on a total of 3 other sections or call for help.  As I thought of my help - my first option wasn't available, as Jim had just had heart surgery the day before in the US.  Bill also wasn't an option as he was still back in the US finishing up his Home Assignment.  So we called Andy, who wasn't home at the time, so I called Imelda, who agreed to come.  In Jim's absence we have had a surgeon from Hagen who has helped to cover, but he is still training and has lots of limitations.  I tried to call him anyway, but he was in Hagen and wasn't back yet.

Imelda lives farther away than Jim from the hospital, so in the 5 minutes it took her to come, I had already decided we shouldn't keep going.  There was too much bleeding, and it would only get worse as I made room to actually get the baby out.  With all the bleeding that was just coming from the whole window of uterus I was seeing, I wondered how was I got to stop that.  I don't know how to do a hysterectomy on my own.  Both Mel and I have assisted Jim and Scot Pringle on hysterectomies, I have done part of them, but to do them myself, nope we weren't there, and doing a hysteretomy after a C/S is a little different than doing it on a nonpregnant person.  So the contingency plan that Bill and I formulated in years past, kicked in.

As I was packing the abdomen and sewing her up, we started making calls.  A former anesthesia officer for us now works at Hagen, so we called him and told him we needed to come.  He agreed to get a doctor there and he himself was on call to do the anesthesia.  We mobilized our ambulance, our lab to get us blood, as she had lost about 1 liter of blood just in our sponge count alone, and off we went.  Imelda, David Wan - our anesthesia officer, and myself accompanied the patient in our ambulance as Sailis, a man of many talents and jobs for us here, drove us.  Our ambulances aren't really equipped to do real patient transfers.  David is sitting on the chairs, I am crouched over the patient on the wheel well, and Imelda is in the front turned around holding IVs.  Throughout the trip, we were checking her blood pressure and pulse, we were giving her more blood and all the while, trying to negotiate the swerves and bumps that our Highlands Highway is famous for.  At one point, our patient was nauseous and wanted to throwup.  David got out his kit that he brought along, but we found we didn't have any syringe or needle to draw up the medicine.  We had IV fluid, we had the blood, we have the IV tubing, we had needles to restart an IV, we had gauze, but we had forgotten the syringes and needles to draw up the medicine.  We got a little laugh out of it, as we were thinking how we might get her the medicine.  We settled for just wiping her mouth after she vomited and trying to keep her calm.

Through most of the trip, she just rested, looking peaceful, her eyes closed.  When she wasn't talking, it got me concerned - have we lost her, has her BP dropped too much, but then I would touch her arm, and her eyes would open.  She is a christian and knows the Lord, so we prayed numerous times, asking God to be with us.  Sailis drove as fast as he safely could, siren blaring, weaving around cars and potholes as we went, and before we knew it we were at Mt. Hagen hospital.  Their OR crew was waiting for us, we gave a quick history, and off she went to their OR.  We finally took a deep breath knowing we did all we could and then started praying for their team and the job ahead of them.

Thankfully, a few hours later I heard from our anesthesia friend at Hagen, that the surgery was difficult, but they were able to get the baby out and the bleeding stopped and mom was doing well.  Baby was admitted to the nursery and we pray will be ok.

After things happened, I couldn't help but think of how fortunate we have been for the past 29 years to have Jim Radcliffe at Kudjip.  His presence on station, his surgical skills have saved thousands of lives.    All the doctors here have been bailed out by him, time and time again - whether it is 2pm in the afternoon or 2am in the middle of the night, when you call 665, he answers and he comes.  His witnessing of Jesus to his patients has resulted in 100s if not 1000s of changed lives in Christ.  We are so thankful that his heart surgery this past week has gone well, and we continue to pray for his recovery, hoping that he will be able to answer his phone again in January for those emergency cases that come up.