Wednesday, January 2, 2013

Blood on Table

People speak of a ‘pools of blood’ at a murder scene. A body on the ground, blood slowly trickling out at the site of the fatal wound. This - this puddle on the examination table in my office - was not a small pool from a trickling wound. It was a heap of lumpy, coagulated, blood-goo.

Under the brilliant jabs of light from the flashing of fluorescent overhead tubes that couldn’t manage to fully flick on, I surveyed the scene before me. I’d just completed an emergency ultrasound for a pregnant woman. It was a sad and desperate ultrasound. She had been referred to our health centre because of dire circumstances. Her doctor back at the general government hospital knew that we had the only accessible machine for the next forty-eight hours -- until New Year’s Day holiday festivities were past.

Madam was thirty-one weeks pregnant. Up until today, everything was normal. Now her world was flipped upside down and turned inside out. Despite an ingrained cultural ability to keep a platonic expression on the face during emotional turmoil - even I could discern her distress.

“Are you bleeding a little or a lot?” I asked her as she climbed up onto the examination table for the ultrasound.

“A lot,” she admitted.

I believed her. Her sanitary napkin was soaked and leaked through her panties to her dress, leaving a circular, rusty-red stain.

“And you have pain? Where?”

“Here, doctor,” she rubbed her palm across her entire belly.

“Is the pain sharp and constant or is it like a menstrual cramp, a contraction?”

“It’s paining me, doctor, all over my belly,” she reemphasised her abdominal pain with her hand.

I nodded and flipped on the ultrasound machine. As I waited for the inner circuitry of the computer to go through it’s self-diagnostic checks, I had Madame lie down and covered her with a sheet.  Ultrasound machine booted up and ready, I spread the cold gel on the curvilinear probe and took a deep breath.  It was the moment of revelation.

A black and white pixelated image popped up on the screen. I frowned. It was a terrible picture. Indistinct borders and vague shapes. At first I figured my nebulous images were due to a lack of water in her bladder.

“Did you drink all the water?” She’d been given a litre and a half of water to ingest prior to my scan in order to facilitate ultrasonic beam penetration of the tissues and clear visualization of important aspects on this obstetric ultrasound.

She nodded yes.

I shrugged. I’d have to go ahead with things. The bleeding and pain were intensifying. Some answers were needed, urgently.

I spun the knobs and did my best to decipher the grainy images. It was complicated since the shapes blended into one another.  At first I thought I saw a placenta. Further survey proved me wrong. It was all blood. Lots of blood inside the womb. It was no wonder I couldn’t visualize things clearly.

Madam shifted uncomfortably. “Almost finished,” I mumbled to halt her from moving and interrupting my measurements. I confirmed the age of the baby. With more difficulty than usual, I found the foetal heart. It was beating. A pathetic, weak lub-dub. I measured the rate at 81 beats per minute. (The normal is between 120-160). Not good. The premature infant was bleeding to death inside the womb.

To be honest, I’ve never diagnosed placental abruption on ultrasound but one couldn’t miss this. Although I had enough of a reason to explain her bleeding, in an effort to be thorough, I decided to try to rule out placenta previa (A condition where the placenta covers the cervix and blocks the exit of the baby during delivery). Previa is another common reason for bleeding in the third trimester.

In retrospect…it was a waste of time! No water in the bladder. Blood clots filling the cervical canal. I couldn’t discriminate anything among all that shapeless grey with either the transabdominal curvilinear probe or the endovaginal probe.

Plan B emerged in my head quite quickly. Get Madame with massive haemorrhaging back to her hospital and doctor as soon as possible!

I switched off the machines and turned to write up my findings on the report form. “You can get dressed.” I gingerly helped Madame off the table, trying to avoid the slippery wet blood that she lay within and upon.

As I finished scribbling to the rhythm of the flashes of the illumination, Madame, like all my patients, seemed to have an innate sense of responsibility to clean up any mess she made on my exam table.  Holding up her dripping, red sanitary pad between thumb and forefinger she pointed with it toward my small trash bin. “Can I…?”

“Yes, please,” I answered her unfinished question. “You can throw it in the trash bin there.” She dropped it with an unceremonious splat into the pink bin that thankfully had a plastic liner today.

While I was curling up the electrical cord and rolling the one machine back into its corner of the room, she began sopping up the crimson stain on my exam table. Her eyes were wide. Her face covered in an expression of alarm and apprehension.

“It’s ok. Leave it.” I handed her a large wad of toilet tissue to pad herself. She wrung out her panties in my sink, flushing down a red tide. Mercifully, the dim light veiled the full extent of the haemorrhaged blood. Utilizing more toilet tissue, she dressed and arranged herself.

I put together her medical booklet with my ultrasound report and handed it to her. “Don’t worry about cleaning.” She was starting to unroll more tissue in a valiant attempt to wipe down exam table. “You need to get back to the doctor.”

She gratefully dropped the tissue in the trash bin and took her medical book. “You’re bleeding from inside the womb, you need to go back to the hospital as quickly as you can. Your baby is still alive. He or she is not very happy though. Just take your book and give it to the doctor. If he has any questions, he will call me.”

She hastily headed out the door leaving me alone in an empty clinic with poor lighting. One exhausted doctor, two dirty echo machines, and a plethora of “hazardous waste material” that needed to be cleaned.  The flashing and useless bursts from the fluorescent lights did not improve the mood.

I watched her go. I felt drained, sad, vulnerable, and disheartened. The events of the day blew up in a swirling storm of pessimistic clouds that circled and taunted me. It was a tempest triggered by the events of the past hour and composed of all the other recent tragic medical cases. Each cloud another unfortunate case.  The HIV positive patient. The painful miscarriage. The child with irreversible brain damage from complications at birth. The hysteric girl from unheard of abuses. The woman with desperate cries to give her a medication to make her conceive.  The worried university girl asking for a pill to make her pregnancy go away. The unknown diagnosis on that very ill patient. The screams of the child that endures a finger stick with every fever because it might be malaria. The loss of a finger from a poorly dressed wound that became infected. The list is endless.  The clouds never ending. They creep inside and stifle every feeling I have. I have nothing left to give. It is just emptiness. I am a shell -- functioning on the outside -- past crying on the inside.

As Madame and her family drive back to the government hospital, I survey the exam room. The appearance of the table reminds me of the fresh meat section in the open-air market.  (If you want to become vegetarian, google a few pictures of these meat markets). Doctor’s exam tables are not butcher blocks. They are meant to facilitate a proper assessment of patient that includes auscultation of the lungs and palpation of the abdomen.  They are not designed to be flooded with copious amounts of human bodily fluids. The entire scene, broken, flashing lights included, was a silent testimony to the struggle between life and death that occurs on a raw and primal level every day here. “Thank you God for letting me see a new day,” is not just a meaningless prayer.

Sighing, I put on some flimsy exam gloves and find a small washcloth. I get a pan and add copious amounts of eau d’javel to some water. I begin the long process of cleaning.

And God is faithful; he will not let you be tested beyond what you can bear. But when you are tested, he will also provide a way out so that you can endure it.” 1 Corinthians 10:13