This morning we began our day’s training with a Clinical Case Review session in the hospital. We selected one of the 5 known maternal deaths in the past 3 months and examined what information was available in the admission documents. Perhaps we need not have gone to the trouble of obtaining the notes – a young woman admitted two days ago with infected retained placenta died during the night and the mood was sombre as we gathered in the office next to her empty bed.
The case we had chosen was that of a 26-year-old delivered at midnight on 24th December. I recall that once it was usual for the hospitals in our area to compete for the first birth of Christmas Day. The Press would be keen for a photograph, the parents would enjoy the publicity and the staff would feel a sense of achievement but I fear that it is no longer popular or PC.
This baby was a 3kg boy, the first baby of a young married woman, and it did not survive the Caesarean section. She had transferred from another hospital apparently with eclampsia although there was little documentation to indicate this. Afterwards she did not pass urine until she died 3 days later. It’s possible the catheter was not in the bladder. With FGM it can be difficult to locate the right orifice. Maybe the catheter was blocked. Perhaps both ureters were ligated during the operation. Perhaps she had acute renal failure but none of these possible explanations can be verified without a proper examination, investigation and documentation and all were seriously lacking. In addition she probably had DIC and suffered a cerebrovascular catastrophe after cerebral oedema, severe hypertension with vasoconstriction and intravascular coagulation. Encouraging a proper process of investigation and reporting of these cases is the mission of a number of agencies in the health sector. Post-mortem examination is another important means of reaching the correct diagnosis but we are far from that type of resource here even if it were culturally acceptable.
The woman who died in the night was a mother of four. The current pregnancy had ended in premature birth somewhere outside the hospital and on admission the placenta was still inside and there was a foul-smelling discharge. Despite removal of the offensive material, administration of iv antibiotics and fluids, she developed severe septicaemia and DIC and died with 48 hours. DIC is a process of intravascular coagulation which depletes the blood of clotting factors and can lead to uncontrolled blood loss. In this lady’s case it apparently caused thrombotic damage to her brain and lungs although we have no objective means of confirming this as the mode of death. When we saw her on the previous day the interns were present and they implemented the suggestions we made although I’m unsure that the medical opinion we requested was actually obtained. At lunchtime we called in to see the blood results and found the ward in the care of the cleaner. The qualified staff were somewhere else sleeping. The cleaner removed the drip when it was through. Twelve hours later she was dead. There was no doctor available to attend at 2am so the nurse on duty recorded the fact of her demise in the notes, and that was that.
All is not as bleak as it sounds however. Our second group of trainees were joined by a young doctor and a medical student from Hargeisa, both very bright, well-informed and enthusiastic to learn. On the final day as we said our goodbyes, Abdi the student who will qualify as a doctor in a few months time asked for what good advice I would give him to become a good doctor as he embarked on his new career. I first told him what I had been told when I first started, ‘take a systematic and full history and make a proper examination in each case’. That way few mistakes are made and we can justify and defend the actions that we subsequently take. Then I added a piece of advice that has arisen spontaneously in our discussions in the last couple of days – in a land where God, most Merciful and Compassionate is fervently worshipped, we who are so much in need of that mercy and compassion and are eternally grateful for it, should exhibit the same to our fellows. After all, if we do not display mercy and compassion to our patients and their families, who will?
Tomorrow we set out for our new location in Berbera where we are told it is extremely hot at this time of year. We plan to spend our remaining days doing clinical teaching with all the trainees who are based there, health and heat permitting. If we don’t melt I hope to blog again from there…