Saturday, July 7, 2012

Matters of the Heart



She came because she desired another child. Rich or poor, university educated or not, monogamous or polygamous, Christian or animist, it doesn’t matter, a woman finds her value through the children she bears. It may not seem fair and it can be downright cruel if one cannot conceive, but the fact remains that wherever you are in Cameroon, you must have a child be worth anything as a woman. After her name, a woman will always introduce herself by stating the number of children, and grandchildren if applicable, that she has. Children are the common thread that bonds women together and distinguishes them as adults and contributing members to society. It sets them apart from girlhood.

I studied Madam B who sat opposite me at the consult table. Several old medical booklets were stacked neatly in front of her on my desk. She was not thin or slender yet the flabby obesity that plagues those who eat too much and exercise too little was not applicable either. She was a solid, stout woman. Underneath a generous layer of insulating adipose that softened her features and gave her silky, smooth, chocolate skin were layers of strong muscle cultivated over many years of labor.

Although she was a secretary and worked a sedentary job in the office, the rest of her life was not so relaxed. Every morning she walked a considerable distance from the house to the main road where she caught a taxi to work. Every evening she walked the same route back. At home she cooked the food for the family. These meals required strong arms to grind the traditional spices and to stir large pots of garri and fufu. And then there was the cleaning. Daily sweeping, scrubbing floors, washing laundry by hand, and the many other household duties a Cameroonian woman executes. It was little wonder she was so strong!

Amidst the strength of her features, it was only her facial expression that revealed her vulnerability. She looked up at me with dark brown eyes filled with a mixture of sadness and desperation. Her smart business suit with matching makeup and heeled dress shoes hid her underlying fears and disappointments masked with an outward display financial success. Despite her envious employment she was still unfulfilled.

Outside her sad eyes and shoulders that sagged like one who has suffered too many disappointments in life, she appeared calm and complacent.

Making mental note in the back of my mind, I began to delve into her history.  The question uppermost in my mind was “What brought her to the clinic today?”

“How many times have you been pregnant?” I began our conversation.

She paused several minutes before replying. “Five,” she answered without conviction.

“Do you have any children?”

“Yes, I have one. A four-year-old boy. He’s not here.”

I nodded, encouraging her to continue as I jotted some details down in her medical book. “What about your other pregnancies?”

“The baby came out.”

“How old was the baby when he came out?” I prompted.

“The first time was three months. Now just a few weeks.”

“Ok.” I said, trying to understand here exact meaning. “So the second time you got pregnant you had a miscarriage at three months?”

“Yes.”

“And the third time?”

“It came out too. At six weeks.”

“And the fourth one?”

“The same,” she continued.

“And the fifth?”

“The fifth just happened, doctor.” She dropped her eyes and looked down at her hands. I could barely hear her. “It came out last week. I’m still bleeding.”

I looked at her sympathetically.

“I did a pregnancy test that was positive when my period was late. Then I just started having cramps and bleeding.”

“So you were only about five weeks pregnant?” I clarified.

“Yes.”

I hadn’t realized she had just had a miscarriage. This must have been what finally prompted her to come to the doctor.

She narrated her obstetric history with relatively little emotion. It struck me as the typical flat, hopeless acceptance of fate that I’ve seen in other sufferers.

Not wanting to sound callous but needing to know, I asked, “How did you know you were pregnant all these times?”

“See.” She shoved her other medical books toward me. She opened them up to the appropriate pages, pointing out documented positive pregnancy tests and an ultrasound report.

I asked a few more details in an attempt to elicit a reason behind her early, recurrent miscarriages. She answered each query with patience and thoughtfulness. Despite my numerous questions and thorough history, nothing popped out to suggest a diagnosis.


“Climb up on the exam table for exam.” I pointed to the sturdy medical exam table in the corner. The mackintosh cover had a little dog-eared tear that I had stitched closed while teaching my nurse how to suture last week.

Setting her purse down, she clamored up onto the table.

I finished my writing, got up, and walked over to perform my standard physical. Although she was here for issues with recurrent miscarriage, I still felt it was important to do a complete head to toe assessment.

“Look straight ahead. Open your mouth. Take deep breaths in and out.” She acquiesced as I inspected her head, eyes, mouth, neck and lungs.

“Ok. Lie back.”

After she was settled into a supine position on the table, I placed my stethoscope on her chest. (Yes, still the flimsy black substitute!).  A regular ‘lub dub’ throbbed familiarly in my ears. But then I began to notice additional sounds. Heart sounds that should not be present. Murmurs. A higher pitch systolic murmur and a low pitch rumbling, diastolic one.

“Have you ever been told that you have a heart murmur or that anything is wrong with your heart?” I asked.

“No.” She shook her head.

Making a mental note of the murmurs, I finished examining abdomen and limbs.  “Come with me.” I helped Madam B get up from the exam. “I want to take a little look at your heart with my ultrasound.”

I turned on my machine and had her lay down again on the ultrasound exam table. I am not trained in cardiac echoes. Nor do I have a cardiac ultrasound machine or a special probe that is designed to look at the heart. But, in a pinch, I can use the abdominal hand probe to peek between the ribs at the heart. It is less than ideal and doesn’t give a very clear picture. It is difficult to see the entire heart. But, I was curious about this abnormal heart murmur.  Maybe I could recognize some pathology. “It’s worth a try,” I concluded inwardly.

The quiet darkness of the ultrasound room was rudely interrupted by the melodious ring tones of Madam B’s mobile phone. It was in her purse that rested in a corner of the room. Mobile phones ringing at the most awkward moments seem to be the norm in my clinic! There’s nothing the patient can do. This time, she was lying on the exam table, half exposed with gel smeared all over her chest. I, on the other hand, held the machine’s probe in one hand and operated the dials of the machine with the other. We looked at each other; I gave a helpless shrug while we listened to Canon in D until the caller finally hung up.

A shadowy black and white picture appeared on the screen of my machine. A pulsating, fist-shaped hollow, muscle, contracting and relaxing, was revealed by my ultrasonic beams. Hypnotizing, tiny flaps of tissue waved back and forth allowing blood to enter and exit through the four valves of her heart. I couldn’t see the actual blood flow but I could see the tiny flap of mitral valve halt abruptly, like it was tied to a short string, as it attempted to open. The left ventricle tried valiantly to suck more blood through this narrowed valve with a little extra “umph” without success. The fuzzy picture that I saw certainly looked like the textbook cases of mitral valve stenosis (rheumatic heart disease) that I’d seen. Given her classic heart murmurs, I had a strong suspicion for this diagnosis.

“My dear, are you sure no one has ever told you that you have a heart problem?” She had been to numerous doctors in the past few years due to her recurrent miscarriages.

“No, doctor.” She insisted.

“Ok. Well get dressed.” I helped wipe off the gel from her chest. “When you’re dressed, we’ll talk more.”

She put on her blouse and buttoned her suit jacket. She straightened out her outfit and smoothed her skirt. Finally she picked up her purse, turned off her phone, and sat down.

“My dear, I know you came here because you are worried about your womb. You want me to figure out why you keep having miscarriages and to help you prevent them in the future.” I studied her face to see if she was listening and understanding.

She nodded.

“I want to help you. I am more worried about your heart though. You need your heart in order to live. You can’t have children if you have a bad heart.”

She sat quietly in her chair. There was a glimmer of comprehension in her eyes.

“We have to first solve the problem of your heart. Only after you have a full heart check up and see the heart specialist can we think about your other problem. Heart first then baby.” I emphasized the order of things.

“Do you understand?”

“Yes, doctor.” There was a hint of comprehension in her answer at least.

“Maybe your body was protecting you when you had those miscarriages, you know that?” I tried to cast the news in a more positive light.

“When you have a problem in your heart, pregnancy can make it worse. With your heart murmur, it could have been dangerous to have a baby.”

“What should I do now?” She asked.

“You need to go to the cardiac specialty hospital to have a full heart check up. After you get your heart checked and any problems taken care of, then we can think about having a baby. You get me?” I paused.

“Heart first then baby.” At the risk of sounding like a broken record, I repeated the point of heart before baby several times.

Finally, after a few more similar questions and answers, we came to the close of our visit. “I’m glad you came today,” I told her gently. “Now we know about your heart and you can get it checked before anything worse happens. I hope I will see you back after you finish at the cardiac hospital.”

“Oh yes, I will come back!” She heartily assured me. Her voice was full of conviction.

We’ll see,” I think. Follow up is still a difficult concept here. I do hope she comes back. From a medical point of view, I am curious to see if my diagnosis holds true. From a more personal perspective, I would really like to investigate her recurrent miscarriages and see if she might be able to have at least one more child. Only God sees the future. We both rest in His capable hands.

Aren’t two sparrows sold for only a penny? But your Father knows when any one of them falls to the ground. Even the hairs on your head are counted. So don’t be afraid! You are worth much more than many sparrows.”  Matthew 10: 29-31