It was another busy morning at the rural mission hospital where I was working. The hospital has a 112 bed capacity and there are only two doctors working, myself and a colleague. My colleague had gone for a three months attachment out of the province and I was on my own. I went home for lunch at around 2:00pm and was eating when I heard a rattle on the gate. It was the matron.
“Doctor, we have a mother who has been in labour for more than 24 hours and now there is no more contractions and her abdomen is distending and she is in distress”. That was the message I got. I knew straight away that she most likely had a ruptured uterus with bleeding into the abdominal cavity.
I tried to remember the last time I assisted in an hysterectomy, let alone an emergency hysterectomy due to ruptured uterus. It was more than 5 years ago and the last emergency hysterectomy we had at our hospital was 12 months ago, which was done by my colleague. He has more surgical experience than me by the way. I told the matron, “Let’s go examine the patient”.
The mother was lying on the labour ward bed. She had a very distended abdomen, was in and out of consciousness and I could not feel any pulse. I knew I had to operate. But I told the matron, “sister, we will refer her to the provincial hospital, you know I have not done an emergency hysterectomy on my own here yet”. “But doctor, she will die on the road. You know that. See her condition,” was her reply. I had no choice. I had to go in, experienced or not!
After discussing the risks of what we were to do with the anaesthetic scientific officer, we took her to the theatre after giving her a bag of whole blood. One last check in the operation theatre – her blood pressure was very low but her oxygen saturation was good. Her pulse had a very low volume and was very fast. Signs that she had already lost too much blood and was in shock. After the patient was draped, I told my team – “you all know I have never done an emergency hysterectomy on my own, but I will do my best”.
I opened her abdomen, it was full of blood. Her uterus was ruptured. I opened the uterus and removed the dead foetus. As her blood pressure picked up she continued to pour more blood. I tried to close the uterus while the blood was being sucked at the same time. I was very nervous but tried to be confident. The abdomina cavity was full of blood and bleeing seem to came from everywhere!
Thirty minutes into the surgery, and the anaesthetic officer said, “doctor there is no blood pressure and no pulse”. “Give her ephedrine” I said between sweats. After 3 minutes her systolic blood pressure was 80mmHg. Diastolic blood pressure was un-recordable. “Give her another ephedrine” I ordered with palpitations. Now, I didn’t care whether I was closing the uterus as a surgeon or a gynaecologist. I closed it the best I could. My aim was to control the bleeding and keep her alive. I closed her up and had to wait for another agonising hour before she came out of anaesthesia.
She was transferred to our “ICU” which has no monitoring equipment. Just another ward but where we keep the sicker patients. After thanking everybody and having a cup of juice I went to the ward to check the patient. She was gasping! Her blood pressure was still very low and she was cold.. Her blood bag was running at full speed. There was no urine in the urine bag. I knew from this signs that she was in shock and her kidneys were shutting down and if I don’t open up her kidneys to allow blood flow to produce urine, she will die from actue renal failure. I gave her 40mg of Lasix (drug used for making kidneys produce urine) to produce urine and ran in 1 litre of Hartman’s solution very fast. Then I inserted another IV line and put up an ephedrine (drug similar to adrenaline) infusion and kept her on oxygen.
I went home at 2am and discussed with my wife what I had done and prayed that she will be awake the next morning. I told myself I had done the best I could and could not have done more than what I have, given our location, resources and my limited surgical skills.
I woke up very early next morning and hurried to check the ward after a hasty breakfast. There she was, sitting up!
I reviewed her two months ago in our outpatient clinic. She now has a catheter in place due to vescico-vaginal fistula that will be corrected by a specialist soon in one of the major provincial hospital.
Miracles do happen!!