The Reward

This week was long & exhausting, but it was one of those weeks where I get to remember why I do what I do.

One of the patients I have been taking care of for 2 weeks was incredibly sick. She is 21 years old & came in at 34 weeks pregnant in respiratory distress. Her chest x-ray was horrible & we started treating her for pneumonia while awaiting her tuberculosis testing (I naively thought it would be negative since she is HIV negative). She was so sick & dehydrated we were concerned that the baby wasn’t doing well, so I spent half an hour doing an ultrasound to try to make sure it was safe to continue her pregnancy. She clearly was in no shape to go through labor as she couldn’t maintain her own oxygenation, and being intubated for a cesarean section (all of our C-sections are done under general anesthesia) wouldn’t be safe either.  The entire time I did the ultrasound she was having trouble breathing and coughing in the poorly ventilated room where I do ultrasound & fetal monitoring. She had low fluid but her baby was ok for the meantime. Later that day her TB test came back positive. She had been in a room with 5 other high-risk pregnant women, so they were quickly moved out and we began her TB treatment. But she didn’t get better. In fact, she became worse including being confused and pulling out her IV. We did a lumbar puncture and found she had meningeal tuberculosis as well. Over the next few days of treatment she began to improve but the fetal status deteriorated. On the next ultrasound there was no fluid around the baby and by the next day we decided we needed to deliver the baby as soon as possible by cesarean section. I left that day assuming she was “next in line” for the theatre, but came back the next day to find that the anesthesiologist didn’t think it was safe to put her under general anesthesia, and there were no beds in the ICU in case that she couldn’t be extubated. By the next day her respiratory and overall status had improved enough that they agreed and she underwent a cesarean section. I wasn’t there for it, but the following day I went looking for her to find out how she and the baby were. She looked better than before, no longer required oxygen, but said she hadn’t been able to see her baby yet. Can you imagine, after going through all of that & not even seeing your newborn baby?? She was still very weak so I supported her arm as we walked down the stairs from the postpartum ward, through the labour ward & into the newborn unit. She had to wear a mask, but they let us in for a moment to see him. I will never forget the look in her eyes when she first saw him, put her finger in his little hand, caressed his little foot & wondered at his five little toes. He was the most amazing thing she had ever seen. The nurses quickly shooed us out, and we walked upstairs in silence together.

Today I saw her smiling for the first time, practically running through labour ward on her way to the newborn unit to see him and my heart was bursting with pride that I had helped care for her and her baby, that she had gotten through her terrible illness, that they were both alive and healthy.

My other long-term sick patient was transferred from another hospital a week after delivering twins. They sent her overnight with preeclampsia and when she got here they gave her blood pressure medication that precipitously dropped her blood pressure. When I saw her that morning she was practically unconscious. We resuscitated her with IV fluids and quickly sent her for a CT scan of her head. She had had a large ischemic stroke. The next day she was still curled in bed in the fetal position, unable to say much. But over the next few days she began to improve and I realized she spoke English very well and had the greatest sense of humor. Trying to explain what had happened to her and her family was incredibly challenging. She said she didn't understand why the scar on her belly where she had had a c-section was healing, but the thing that was wrong in her head wasn't healing. I explained that it was healing, but that it would just take more time; that while she could see the scar on her belly healing she couldn't see this scar, but that her moving every day was showing us it was healing. 

The first thing I heard her say, and every day after that, was “when can I go home?” I would tell her when she can walk out the door she can go home. The laughs of her and her family egged me on, wanting to get more laughs out of them. I said, “you can leave when you can walk out the door, down the sidewalk and get in a matatu with your babies.” They all doubled over laughing, hearing this muzungu doctor talking about matatus (those dangerous taxi vans stuffed to the brim with passengers). She would grab both my hands in hers to lift herself up in bed (she weighs all of 100 pounds) and attempt to swing her legs to the side of the bed to show me she could walk out the door. At first this didn’t work at all as her one leg was too weak to move. But slowly, over the course of the past week, she has gotten to the point where she is now walking out the door (of her room, anyway). In the course of our testing we have found out she has atrial fibrillation and had a blood clot in her heart that caused the stroke. Now she can’t leave the hospital until she is fully anticoagulated so this doesn’t happen again.

Through this all her family has been with her every single time I’ve gone to see her. Her sister stays overnight with her & helps her take care of the twins, who sleep in baskets on the counter in the room. Keep in mind she is in a room with 5 other high-risk postpartum women with all of their babies (and some women who have lost their babies).  Today I went to see her and she was lying down, breastfeeding her baby boy while her sister had the baby girl bundled up. I admired them both and told her how lucky she was to have two beautiful, healthy babies. She asked me, “where’s your baby?” and I smiled and told her “next year.” She laughed and said, “you can have one of mine.” Her amazing smile, sense of humor, and generosity in the face of such an unfair, nearly deadly, condition that she will have to deal with for the rest of her life is inspiring and humbling.