Sunday, April 6, 2014

A long week

Some of you may know the maxim "All bleeding stops eventually". The phrase came to mind this week as we dealt with multiple difficult cases. (This may be too graphic of descriptions for some, so I'm giving you fair warning to stop reading now if this is the case. I'm also going to use medical terms and not explain everything. Suffice it to say, we had a difficult week with one emergency after another. Not many survived.)

Monday was a busy day. There are often cases that have been admitted during the weekend that aren't urgent enough to require us to come in during the weekend, but do need to be handled that day. We had several procedures already scheduled, plus the usual outpatients. Around 1pm we heard some vague rumors about a patient with hemoptysis and severe melena. But it wasn't clear where this patient was, and what exactly was happening with him. Then about 2:30 pm or so, we found there were several endoscopies which the medicine team wanted us to do. These patients had presented during the weekend with hemoptysis, but had been otherwise stable and could wait until monday for endoscopy (we look for esophageal varices, which are common here due to high incidence of infection of schistosomia, which causes peri-portal fibrosis, portal hypertension, etc). We did the endoscopies (I got to do two of them-and made it through the pylorus both times!), and even banded a few varices (which I did not do). Then we heard more about the patient with hemoptysis and melena, around 4pm. Turn out he was hypotensive and while blood transfusions had been ordered, donors had not yet been found. We got a line in him (he had had a 22G in the wrist), and about that time a friend of his and a passing nursing student were able to give blood. We did an endoscopy and found a large duodenal ulcer. We thought we could cauterize it, but when we did, then it started bleeding heavily. We rushed him back to the OR, and had him open and pressure on the site of bleeding in no time. Fortunately we had a case earlier in the day that we had cancelled, but the drapes, instruments, and gowns were all still in the room, which allowed us to start the case that much faster. He had lost so much blood that his organs were white, and nothing was bleeding. We managed to stop the bleeding, do a vagotomy, and close. He got two units of blood intra-operatively, and another post-operatively.
He remained stable overnight, but the next morning he developed tachycardia and hypotension and was transfused another two units. He was awake and talking to us, but you could tell he had this sense of doom about him. We tried to encourage him, to get him to fight, but I think he had lost hope. By thursday he had passed away.

Then tuesday we a fairly average day...two prostatectomies, removal of an ovarian cyst, etc. But Wednesday was another matter. We had a 2 year old present with hemoptysis. It is very unusual for such a young child to present with hemoptysis, even in an area with schistosomiasis. He was transfused and an endoscopy performed. It was found he had some form of vascular malformation in his duodenum, but no longer actively bleeding. It was decided to give fluids, blood, and observe him. He was doing fairly well the next morning when around 10am, he vomited again, copious amounts of blood. We rushed to the OR and found the site of bleeding and were able to stop it. However, his extremities remained cool and clammy throughout the procedure, and we weren't able to get a good oxygen saturation the whole time. After returning back to the ICU, we were called because he was noted to have dyspnea. He had an IV in his external jugular vein which infiltrated, and was causing respiratory compromise. It's unknown how long this had gone on before it was noticed. His breathing was rather Kussmaul-ish. We checked his pupils-fixed and dilated. My suspicion is he was hypoxic for a significant amount of time, whether during the OR case or after the IV infiltrated. He died not long after.

Thursday we had another man present with bleeding-this time a large amount of melena, but no hemoptysis. His hemoglobin was stable at 13, and no further melena, and his vitals were stable. In light of the long day of events on thursday and him being stable, we decided to wait until friday to do his endoscopy. But around midnight, he became agitated and was given tramadol and diclofenac by one of the other docs. Then at 7:30 am, he had acute onset of abdominal pain, tachycardia, hypoxia and hypotension. He was found to have free fluid in his abdomen. He did not follow the axiom that "Bleeders don't perforate and perforators don't bleed." We needed to resuscitate him with fluids before we could take him to the OR, so a central line was placed, we tanked him up with fluids, and blood was ordered. However, he remained too unstable to operate, and he passed away.

Not to mention the other cases we did this week: three cesarian sections added on to the schedule on either wednesday or thursday, I can't recall. Two with good indications, a third that was thought to be term by her last menstrual period with a hand presentation but was actually 28 weeks with twins (no ultrasound had been done, and apparently no one had figured it out by Leopold's maneuvers). The twins did not make it.  We also found out that another patient we had operated on a few weeks ago (menigocele repair) had died.  It seemed that death was all around us, despite our best intentions or best efforts. Perhaps we should have intervened sooner in some cases. Perhaps there are things we could have done differently, and the outcome would have been different. There are many what if's, but we have to live with what was. 

Then friday, I noticed one of the doctors had posted this to Facebook:
Dans un bon nombre de situation difficile,Dieu nous demande simplement d'avoir confiance en son plan et de continuer a avancer jour apres jour,sans baisser les bras.Alors quel que soit votre vie a un moment donne,prenez courage Dieu reste Dieu,il est assurement avec vous et il vous aidera quel que soit le defis devant vous. Philipien 4:6

Which means: "In many difficult situations, God asks us simply to have confidence in his plan and continue forward day after day, without giving up. When this comes to your life, take courage that God is always God, and he is surely with you and will help you no matter what the challenges before you. Philippians 4:6"

Philippians 4:6 says "Do not be anxious about anything, but in every situation, by prayer and petition, with thanksgiving, present your requests to God."

It gave me courage to read his post, and to remember that as he said, God is always God, no matter the circumstances. 


Anonymous said...

Thanks for sharing. Somehow, I'm actually a bit comforted. It's not like I'm wishing bad luck on medical outcomes -- just a bit nice such doesn't just happen to me.

mom said...

Amazing the things you are seeing and doing there. I breaks this mother's heart of mine that you see so much hurt and pain but that is the case with doctors and nurses no matter where you serve. Glad you know God is in charge of the ultimate outcome in all cases. Love you, Mom