30 May 2020

So familiar. So unwelcome. Not again!
Maybe this time we can fix this. Maybe this time will be different.

We sat relaxing in the potluck pavilion, 1.5-year old Adelaide bringing mangoes to each of us at the table, then enthusiastically running back toward the mango tree cheering Andrew on as he helped her pick another ripe mango. We heard an engine noise. "Is that a plane?" The fan overhead slowed. "Ah, that was the generator dying." We watched the fan blades slow to a stop. "Maybe Lazare is switching the generator early today," someone suggested hopefully. Each evening he switches the source of electrical power for the compound from the large daytime generator to the small overnight generator. The fan blades remained still, silence in the background beyond the sounds of the birds and sheep and bats and flies. We soon learned that Lazare was not switching the generators, because only one generator had been working all week. The small generator had a leak. One large generator could turn but did not produce electricity. Now the one remaining large generator had stopped working, too. Lazare thought he knew the small part that had gone bad--a part that he could replace but that had to be bought in Moundou. A part that had just recently been replaced before the mechanic from Moundou assured us that all three generators were working great and wouldn't need any repairs for a long time. Lazare was able to patch together the one large generator using parts from the other non-working generator, and by late evening we had electricity.

"Bonsoir, doctor. On a reçu une femme . . ." This has to be one of my least favorite beginnings to a phone conversation with a nurse from the hospital. Good evening, doctor. We have received a woman with . . .
But this call didn't start with "C'est la maternité." So it wasn't maternity, it was urgence, the ER. It turned out the patient had arrived last night. She had malaria and typhoid, so they'd started treatment, but then she was "agitated" so they gave diazepam. She was still agitated so they gave more diazepam. Now she was in a coma. Was it the malaria? Was it the diazepam? Was it something else. Oh by the way, the family mentioned today that she had had vaginal bleeding. After not having her regular period for awhile. Didn't seem relevant last night, apparently. "Can we do an ultrasound, doctor? But . . . there is no electricity." Right, no electricity. She could have had an ultrasound last night if anyone had called then, or this morning, or this afternoon. But, yes, once the power comes back we'll do an ultrasound. For now get a blood type and hemoglobin and pregnancy test.
The handheld ultrasound that would plug into our phones was supposed to come with the visiting hand surgeon, but the visiting hand surgeon is still in the U.S., thanks to closed airports and coronavirus travel bans. Our awesome new ultrasound--which was purchased to replace the old ultrasound whose motherboard died--is still in Loma Linda, waiting for a day when volunteers from Loma Linda are again cleared to travel internationally and a day when Tchad has an airport again. For the moment, we get by with an ancient machine that has no battery. No electricity, no ultrasound.

When Lazare got the generator to start limping along again, I went to the office to restart the hospital EMR, then I went to urgence. "I'm going to do the ultrasound now. Where is the patient?"
"The pregnancy test was positive, so we moved her to maternity."
I wheeled the ultrasound to maternity. A crowd of about 15 people followed her as several men carried her into the delivery room (which has electrical outlets where I could plug in the machine). I kicked out all but "two" people, which soon became more like a rotating group of 3-5. As the screen came to life, I placed the ultrasound probe on the lower abdomen. Uterus full of debris. I also noticed that her pagne (fabric women wear wrapped around like a skirt) was soaked with blood. Ok, a curettage has to happen, and it has to happen tonight. At least it's not an ectopic, I thought. I brought the gurney and took her to the operating room. By curettage, I removed the infected, awful-smelling debris.

She barely bled. Maybe that's good. Hemoglobin 15. Dehydrated, but not bleeding out.

Comatose, smelly infected debris, vomiting. Not good.

I encouraged the family to buy all of the IV antibiotics prescribed. We removed the infected debris, I explained, but she's still really really sick. Septic. Dying from infection.
Really not good.

My phone lit up at 2 am. Ok, that earlier call definitely wasn't my least favorite beginning to a phone call. This is my least favorite: "Bonsoir doctor, la femme qui vous avez fait le curettage, elle ne respire pas bien." Doctor, the woman for whom you did the curettage, she's not breathing well. Too often, "Doctor, the patient isn't breathing well," can be interpreted, "Doctor, the patient stopped breathing," or "She's taking occasional gasping breaths that don't count as breathing." I passed wailing family members and sniffling visitors outside the maternity ward, then arrived to find the nurse squeezing a bag to breathe for the patient. No breathing, no heartbeat. Nothing. Not again.

Our last death on this ward, just a few feet away, also was sepsis related, also waited at home for weeks before coming in for treatment, also received a weekend emergent minor surgical intervention and a day or two later died from the sepsis that was already too advanced. That time it had been a dental abscess and infection that had tracked into the chest and a lung full of pus. She had initially improved with a chest tube, but never recovered.

How do we convince people that pulling a tooth is better than waiting until the infection tracks all the way into the chest? Or that a curettage right after the miscarriage is better than waiting until it becomes septic?
How do we start giving preventative maintenance instead of desperate interventions only after the problem becomes catastrophic?