We'll see, but we don't know if we'll have internet in Tsavo and the Mara, so this may be the last post for a week (and then we'll be home so you can see pictures from the safari at that point). Either way, we drive out of Kijabe at 5am tomorrow morning, so this will be the last post from Kijabe. I'm typing this on Susan's computer, so it will just be text, but I have a few photos from today.
As you will recall, our call last night started in a more eventful fashion than we were hoping. Well, everything stayed calm after we came home until about 6am, when I got a call from the family medicine attending covering labor and delivery that there was a young woman with a history of congestive heart failure who was 30 weeks pregnant and desaturating. I did a quick clinical consult with Joe and headed in to the hospital. I got to the labor and delivery unit to find an obtunded mother with sats in the high 80s-mid 90s on a facemask. The rest of the story was that she had originally presented with acute-on-chronic heart failure a few days before but had been stabilized, and they were trying to get her through the weekend for a c-section on Monday. Well, at about midnight, she probably had another heart failure decompensation and got hypoxic and agitated. Instead of calling for help intubating, she was given sedating medicines. She had been hypoventilating and hypoxic all night. The attending asked me what I thought we should do, and I answered that we should get her to the OR, get her intubated, and get the baby out. I called the nurse anesthetist on-call, but she said a new person would be in to take over in a few minutes. I went to set up the OR, make ready the ICU, and call home (this is when I talked to you, Kate). I then went back to labor and delivery to find her oxygen saturations in the 60s. I immediately began moving her to the Theatre and met the nurse anesthetist on the way. We masked her up to sats of 91% in the OR and intubated on next to no drugs. Now, a normal person's end-tidal CO2 is around 35, a person with bad lung disease can get their's to the 70s. Hers on the ventilator read 90s when we started. I vigorously bagged her to drive it down, but it stayed at 90 for about 8 minutes. After that it quickly fell to near normal, and I realized that the reason it was staying at 90 for so long was that it was actually quite a bit higher, but the anesthesia machine only recorded up to 90. I then ran between the OR and the newborn resuscitation area for a little bit, checking on mother and baby frequently. When the surgery was finished, we took her to the ICU (and the baby to the newborn nursery). On arrival, we discovered that 3 of the 5 ventilators were malfunctioning. We hand-ventilated for the next few hours while trying to fix them, and I only left the OR once for a stat I was called to in which I intubated the newborn. The patient was getting more and more pulmonary edema from the heart failure, and it became harder and harder to ventilate. By the time Joe arrived, she was getting hypotensive and he set about fixing her pressure. The newborn also arrived in the ICU, and her family began to accumulate outside of the unit. By noon, things were headed downhill very rapidly, and Dr. Newton, Joe, and myself stepped back and realized that we had two working ventilators for three intubated patients who needed mechanical ventilation. So we asked: which of these three patients is least likely to survive? Cardiogenic shock is difficult to treat in the US, and it is more-or-less a death sentence in Africa. So we stopped. The mother died. Her very pre-term baby has a bad prognosis as well, but it still alive currently. This was a six-hour ordeal that marked the beginning of my day and the end of our time in Kijabe. It is terribly sad story, but is fitting in a way. We have seen a lot of death here in Kijabe, and have made some difficult decisions. Maternal morbidity and mortality is unacceptably high in Africa, and today we experienced that.
We've spent the rest of the day debriefing and packing. We said goodbye to Dr. Newton (and he asked us to come back and promised us a trip to South Sudan to see really low-level healthcare if we did). Who knows? It may be a good time. Anyways, I'm calling it a night for now, see you all soon!
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