Eclampsia

Angie had a brilliant idea the other day, hold an OB clinic to give the CHW students a chance to perform physical exams on pregnant ladies.  The day before, I opted to cut my interview day short and zig zag through the surrounding communities finding "fam sage" and "fi ansent".  I encouraged the pregnant ladies to come for a free check up and set up a meeting next week with the local midwives.  #Positives

The morning of the clinic started off normal enough.  A few sick people, and many more who were not too sick.  The CHW students were told to go round up some more pregnant ladies because they failed to do so the day before.  Eventually we had a clinic full of pregnant women.  Talk about a hormonal nightmare.

Some ladies had never had care before; others were at our clinic at the beginning of January.  One woman was at 38 weeks and one was just over 3 months.  Some mothers were teenagers while others were in their thirties. Seemed pretty similar to a clinic at Broadlawns, translators and all.  It was busy.  We treated some women for possible sexually transmitted infections because the outcomes of missing an infection are way worse than treating an infection that isn't present.  We provided pre-natal vitamins to every pregnant lady.  For those that were more then 32 weeks into their pregnancy, we started them on malaria prophylaxis.  Again, we are providing empiric treatment that is designed to save lives.

I noticed that one lady had a high blood pressure when she checked in.  It isn't anything new.  The CHW students just learned how to do vitals a couple weeks ago.  They don't have the best equipment.  And the lady just walked however many miles to get to our clinic.  So she waited till her turn.  First thing was first, I had a CHW recheck her blood pressure.  160/100.  Tansyon wo.  I looked at her hands while she sat there.  I couldn't see her knuckles #Swelling.  Her feet looked like they would break her shoes.  She had pitting edema above her knees.  "Have you ever been pregnant before?"  G2P0.  She lost her last child at 7 months because doctors gave her a shot.  She said she had 'eclampsya'.  Time for a urine test.

She came back and her urine had more bubbles than a carbonated beverage.  We didn't even need the dipstick to tell us that she had a ton of protein in it.  We lay her down and clear the rest of the clinic.  There is a nurse/midwife with us who we ask to put in an IV.  Unfortunately she had never used a safety needle, so she pushed through the vein.  I didn't notice until we'd already dumped 20 mL of fluid under her skin.  I grabbed a new needle and tried her other hand.  Flash.  Thread.  Nothing.  It must have rolled out.   I try again.  I pick what I think is a vein, aim and stab.  Flash.  Thread, slowly.  Boom, it's returning blood.  I apply pressure and attach the tubing.  Didn't need to tell the patient this, but I don't remember the last time I put an IV in someone #TheyDontTeachMedStudentsPracticalThings #NursesKnowMore.

We crank the fluids and give her blood pressure meds.  We have to get her blood pressure down or she risks some serious health complications.  One dose of labetolol.  Dr. Angie checks her blood pressure.  It's 210/1something.  Not good.  Remember when I said that the CHW students sometimes struggled with accurate blood pressures?  Well, looks like this time they actually underestimated it, by a lot.  Second dose of labetolol.  We're down to 180s.  She's not feeling well.  And she's beginning to look ill.

Someone calls for a tap-tap to come pick us up.  We decide to give her a dose of mag sulfate while we wait.  She didn't respond well.  One of the side effects of magnesium sulfate is anxiousness.  She felt hot, tachy, sweaty and scared all at once.  Her airway is starting to become a concern.  We have her rest and check her pressure periodically.  She's down to 160/110.  We decide to make our move.

We load her in the back of the tap-tap.  As previously described, a tap-tap is a converted pickup truck that basically has a roof welded over it.  Certainly not a luxurious ride.  Three CHW students accompany Dr. Angie, myself and our two translators to the local hospital.  The back is packed.  Dr. Angie hands me a syringe with another dose of magnesium in case she starts seizing en route.

We depart the compound.  It's a long, slow 10 miles to the hospital.  Somehow the patient's family had orchestrated a drop of clothes and food at a speed bump on the way.  I was quite impressed.  In the midst of chaos they had managed to give the patient what they thought she needed for a hospitalization.

It didn't take long for the patient to start freaking out.  I don't blame her.  She was surrounded by seven strangers, laying in the back of a pickup truck, and had a bunch of magnesium coursing through her veins.  Most people would not have responded favorably.

She fought us.  She tried to climb out the back of the tap-tap.  She continued to hyperventilate as she rolled around.  We cut her shirt to try and make her feel more comfortable with breathing.  The look in her eyes was that of sheer terror.  Her words said it all, "M pa v'le mouri."  "I don't want to die."  She was having a panic attack and at the worst possible time.  She was in the middle of a tap-tap and we had no medicine to treat her.  I could only imagine that her blood pressure was continuing to spike.  She pulled and crawled towards the open end of the truck bed.  The CHW students, God bless them, did not respond with calmness to the situation.  Everyone began talking at once and they got louder and louder.  They grabbed her arms to hold her down.  Their hands were all over her face and head.  It was a mad house.  I tried to listen to her lungs.  She was breathing fast, but amid all the noise from the truck and the chaos I couldn't appreciate any details.  She continued to squirm, and scream.

I looked at the liter bag of saline.  It wasn't dripping anymore.  Shit.  I just lost my access to administer the magnesium.  If she starts seizing in the truck we are defenseless.  It is now imperative that we get her to the hospital as quickly as possible.  I turn and see the CHW at the patient's head with her eyes clothes and praying.  I think she thought the patient was possessed.  It will be hard to tell them otherwise.

We arrive, somehow.  My translator rushes to get a wheelchair and we slowly lower her into it.  He pushes her forward while Dr. Angie and I go up to the Cuban physicians.  The place is empty, save for the doctors. Certainly makes getting their attention much easier.  I hand them a card I had made containing her history in as many medical abbreviates as possible and her most recent blood pressures: 36 yo f G2P0 @ 7mo w/ Hx of Eclampsia, BP160/110.  Labetolol 40 mg.  Magnesium 4 g IV @ 1410.  They got the message.  We summoned our translator to give a verbal report as they took the patient back into an exam room.

She was still panicking.  She was rolling in the bed crying out that she didn't want to die.  We were asked to step out of the room, and understandably so.  We did our job.  We got her to the hospital alive.  Now we are just in the way of the other doctors.  We watch on from outside the room.  I want to know what they do.  After about 30 minutes, I have my translator ask the Haitian doctor if they need us for anything else.  Do they have any questions about her presentation or our treatment?  No.  It's all written down.

I take one last look through the window.  She's certainly more subdued, but she may just be exhausted.  They have a catheter in.  I think they've been able to measure a blood pressure, now.

We got the patient to the hospital.  It wasn't easy, but nothing is in #Haiti.

As an update.  Found out today from the patient's sister that she had a c-section last night and that both the mother and the baby are doing great!  #Blessed