quinta-feira, 11 de março de 2010

Mother of 10

I think that this is a nice music to hear while reading this story....

I am far away, and very emotional at this moment and maybe that is why I decided to write one of the most intense, difficult to share, and painful stories of my life in Congo.

I decided to write this stories and somehow make them immortal because I don’t want to forget, and I don’t want people to forget what is the reality in some places of our planet….I want that my insignificant voice reach as many people as possible, and tell how unfair life can be for some, and how important it is to be aware of this distant reality, for most of us…

And distant not only in terms of geographic display, but most of all, distant from our eyes, from our years, from our mind…. It makes me sad that some wars are so “famous” and get so much international help, and some others, nobody knows, nobody cares, and because of that, will go on forever causing suffering in millions of innocents, that think about PEACE as a dream impossible to achieve….

By knowing our heart will be touched, and after that for sure we will help; with money, with ideas, with our work, and by changing the mind of the ones that make important decisions…. And believe me, it feels really good to help those that need the most and appreciate our help so much…..

The story now….

It was a Sunday afternoon, and I was called to the hospital….nothing new, it happened almost every Sunday that was suppose to be our relaxing day…. There was a 39 years old woman, that gave birth to her 10th son, and she was bleeding continuously after delivering…. For a while they tried with all the available medicines to stop the post-partum bleeding…. But no success! So it was decided to try to stop the bleeding surgically…..when I arrived to the operation room, while getting dressed I knew immediately that it was very serious, I could hear the heart rate (from this device that we had to access the oxygen saturation and the heart rate)…. Bip, bip ,bip , bip …..it was 180 beats per minute….way to fast…. first sign of serious bleeding and hemorrhagic shock …. When I entered the operation room, she was conscious , very low blood pressure 60/30 mmHg…. And I knew that whatever it was that we were looking for it was probably too late…

On that moment….a million things that we don’t have cross, my mind…lab exams that we use almost automatically in our world, but there we could only measure the Hemoglobin level, and that was about it (concerning the lab work that I would need to access that patient properly)… So many times more than ever it crosses my mind “ I wish I was with this patient at home….” The hemoglobin level was very low…. 5 mg/dL….in the begging of the surgery, and she was going to bleed more for sure…. Luckily we had 2 packs of red cells available that matched her blood time…. I say luckily , because our blood bank was always empty…. That population, doesn’t like to give blood….I think that they see it as giving a part of yourself way….like giving a leg or an arm….so they almost never give their blood even if we explain it very well…I guess that they just don’t believe in the strange white people many times !!

I had to intubate the patient (placing a tube in the trachea through the mouth) to protect the airway , and control the ventilation….The surgery started…..they opened the abdomen to see what was wrong…. She had what we call Uterine Atony….. the Uterus was just not contracting anymore….and that was why it wouldn’t stop bleeding…. She just had her 10th baby, and maybe even with more pregnancies in the middle ….. The Uterus, is just not made to be used so many times…. Even though we insisted so much in family planning, for many reasons….these women just don’t stop having children….and probably the biggest reason is the fact that men just don’t accept to use condoms, or even allowing their wives to take the pill…. Because they believe that it’s a sign of their manhood the number of children…. This is very common in “this Africa”…..

The surgeons tried to control the bleeding, but is just the whole Uterus that is slowly bleeding everywhere….for a while they had doubts if they should remove the Uterus (Hysterectomy) or not…. I just told them…. “Do whatever you have to do to stop this bleeding as fast as possible…. Here condition is very critical and it will be difficult for me to keep her alive….and for sure tomorrow she would never survive a second surgery”…. Because I knew that if she would survive she would stay in a critical state for some days…and would never be strong enough during those days to another surgical intervention….not there, not with the conditions we had ….. So they decide to remove the uterus…. Meanwhile, I was trying to control her life, the vital signs, despite the blood that she received….her blood pressure was still low and dropping….and she needed a lot of fluids…. And this is the dilemma!!! Fluid management….too less and her blood pressure would go to low, killing her by lack of perfusion of the main organs (brain, kidneys, heart, liver, lungs….) too much fluids would cause her lung edema (too much fluids in the lungs) killing her after I would remove the endotracheal tube….

I was trying to give her the maximum that I thought that she could handle….and also adding adrenaline (to increase the blood pressure and compensating the inflammatory reaction of the surgery and the transfusions)…but its very difficult to use adrenaline without a perfusion machine, that I didn’t have…. as the flow rate has to be totally exact ….

In my mind is a patient….mother of ten….and the science that I had to use in order to save the life of this woman….

The surgeons finished the surgery, and were happy about their job…and they did a very good job….but I told them….the worst is yet to come….removing the endotracheal tube…

I am a very young doctor with a lot to learn, but with some experience on my favorite area of Anesthesiology….Critical patients…. Dealing with life and death….

After a few minutes, waiting for the effects of the general anesthetics to wear off, I took my time to see if she was able to breathe by herself, and accessing the lungs about the lung edema … The blood pressure was always very low, even though I gave her a lot of fluids and the adrenaline flow rate was quite high….. What she needed was good Intensive Care….and to stay mechanically ventilated for few days….but we had nothing similar….

When I thought it was the right moment, I removed to tube….and she developed this very serious lung edema very fast….causing her heart to stop !! I intubated her again and started cardio-pulmonary resuscitation for a while, compressing her chest as hard as I could, with sweat falling on my hands…. But I lost her…..She died….in my hands….

I have seen many people dying in my short career, and many times I took them in my mind with me for a long time ….but never like this one….. For the first time in my life I had the feeling, that maybe it was my fault, maybe I did something wrong, maybe I could have done better…. For the first time I felt guilty….and until today I think about it with doubts if I could have done better…. I wish I had, there, somebody to share decisions to agree or disagree with my actions….but there was nobody with knowledge of critical patients to take my nightmares away from me….

She was mother of 10 …. we had no idea where the father was…. The oldest children was a girl with 14 years old, already taking care of the newborn and now with 9 brothers and sisters to take care for life…. It was just too strong to see this scared young girl with a baby in her arms receiving the news that her mother was gone…..

I went home, and I suffered in silence for hours…. My colleagues tried to shear me up, saying that I did all I could …. But I just didn’t feel that…. The sad fact that this woman would never die in my hands if I had the means…. And the guilt!! Did I do all I could? Did I do it right?

Was I responsible for these 10 innocent kids being orphans?

Staring at the sky full of stars trying to get answers, of these questions that I asked myself so many times was how I spent that night…. But that sky that covered the beautiful mountains of Eastern Congo, full of life, full of pain….full of war…..gave me no answers….

segunda-feira, 1 de março de 2010

My best friend for a while

Hope you can listen to this music of Emmanuel Jal while reading a story dedicated to him...

I will tell a story about a kid that was my best friend for a while, and besides the fact that we established a strong connection and friendship, there were things that I saw in his attitudes that made me think that he was special, and during that time that I was in Congo I was reading a book, of an amazing true story, maybe the most amazing life story that I have ever heard about …..Emmanuel Jal, was born in south Sudan, the same year as me 1980, but for him wrong time, wrong place…. He saw all his world turning upside down, when his mother was killed, his father was fighting, he got lost from his brothers and sisters, and was living for few years in a refuge camp, until he fulfilled his dream of fighting the ones that were killing is kind, the Muslims from the north of Sudan, so when he was 11 he was already carrying a Kalashnikov and getting military training ….. to kill !! He nearly died from the war, from starvation, from a desert cross, he saw all his friends dying next to him, almost ate one dead friend to survive (12 years old)…. A childhood that one can not even imagine, and luckily he survived all this to write his amazing story and to dedicate his life to peace in Sudan….expressing himself by music, nowadays Emmanuel Jal is a famous rap singer whose music and life story leaves no one untouched…. War Child …. A reality that is still happening in many places in Africa, like Sudan, Congo, Somalia, Liberia, Sierra Leone….and probably others….

I was sure that in Congo where I was probably many stories like the one of Emmanuel Jal were happening around me…and for that reason, his book, his story touch me very deeply….

When we see our kids, playing football, laughing, enjoying their young years, still so naïve, and then we imagine that there kids the same age that are starting to get used to carry a Kalashnikov , and whose mind is being set to kill….hard to imagine, but its true….War Child !!

My friend, was 10 years old (whose name I don’t know), was not a war child, not that I know of….and he was not even a war victim, the reason why he was in the hospital was a very bad infection of the fingers of his hand, that needed surgical cleaning and treatment…. And this young friend reminded me so much of Emmanuel Jal….. Why?

The same age of Emmanuel Jal, when he started shooting, …the same easy smile and charm that later on saved the life of Emmanuel, and the same courage….he was tough, he was brave, I am sure that he would be tough enough to deal with things that I couldn’t imagine…..maybe he saw something, or he lived experiences that I had no idea….

When I first saw him, I saw this shinning eyes, with a suspicious look telling me … “ I don’t trust you!” “ We can either be best friends or worst enemies!! “… Like in all the other stories, I couldn’t talk to them due to language barrier, so, playing, smiling and non-verbal language played a very important role in gaining trust, something so important to the doctor-patient relationship…. After exchanging a few smiles and hand shakes, I started boxing with him for fun…and he loved it, he laughed so much…. Its hard to describe the difference between our kids and those kids….their laugh is so strong, so genuine, so pure, so warm, so full of life ….. like many other things in Africa they do it not knowing if it will be the last time….And this kids laughing makes you feel that special power….

The first time he went to the operating room, in other to perform the surgery that was not so complicated, I was going to give him a shot of Ketamine Intra-muscular…. And I was going to do it in the anterior part of his thigh ….ufffff….it was tough there were 4 men holding him, and me to inject the Ketamine, he was stronger than many men…..he was tough !! And willing to fight…. In the end of the surgery I performed and an Axillary Brachial Plexus Block, witch means that I injected local anesthetic in his armpit , to block the nerves of the arm, so he wouldn’t have pain after the surgery (that can be very painful)…. And usually we do it with a nerve stimulator, but I didn’t have one in Masisi, Congo, so I had to use a old fashion way of doing it that I have only read in anesthesiology books, but never used it before…. And because when you block the nerves its normal to have some motor block ( difficulty in moving that arm for some hours)… I explain that to the mother, of course with a local nurse translating French to Swahili…. The next day that I arrived to the hospital, the first thing I did was to check on him… And with no translator, I was able to ask if he had pain, and I was glad to see that he had not ….and then I wanted to see if his muscular activity of that arm was not still decreased (witch wouldn’t be a good sign 24 hours later)…..So I asked him to stand on his bed, and then I opened my arms so he would imitate me and open his arms (to see if he had the power to have both arms elevated at the same level)…..but he saw that sign in a different way, so when I was with my arms opened, while he was standing on his bed he took a step forward and hugged me very tight….. It was so, so sweet …. And what I wanted to evaluate was already done, no pain, and normal muscular activity!

After this operation I also gave him this hat made of this fabric....and he was really happy using it for many days .....

Few more days, playing with him, and boxing with him ….he loved that….and he had to go to the operating room again…. And his attitude was something that I have never seen even in an adult … I think that because of our strong connection he trusted me quite a lot…. But he is a kid and nobody likes needles …. And I was about to do the same thing as before, injecting Ketamine in the muscle of his thigh, and I explained him that, with the nurse translating, and I told him to lie down on the operation table…. And he refused… I thought it was strange, and I insisted ….but he refused, and I told the nurse to tell him that if he is sitting it hurts more because the muscle is not relaxed…. But he told the nurse: “ He can inject it in my leg but I want to see!” …. And so I did, injecting the Ketamine, while he was looking at the needle with an expression of strong pain , but not moving and no sounds of complaining what so ever…..he was tough….he was a fighter !! Brave as they come!

Few days after, I went to the hospital during the night for a Cesarean Section, and after I went to the surgical ward to check on my patients to see if there was anything new, anything wrong, or if the nurses needed some help…. But besides that I got another lesson for life…. It was around 3 a.m., and my young best friend was not sleeping like he should, he was standing next to another patient´s bed…. What was he doing??.... The other patient was a soldier with a horrible gun shot wound in his leg….but when I say horrible, you have no idea how impressive it is to look at this wounds where you see all the muscles it smells really bad from the infection that is always there….its impressive even for somebody that saw a lot of those there…. But my friend was not so impressed or repelled by that, he was helping this young man to urinate , right next to him…holding the potty, showing me how big his heart was….brave enough to be there, and good enough to help the ones that couldn’t move…

Its strange to say this, but its what it happens when you live day by day in a hospital and get really close to your patients, but when he was healed and was released I was sad to see him go… He was my friend and I missed him after that….

These is a story of a brave and good kid that remind me so much Emmanuel Jal….but Emmanuel had not many options in life but to kill to survive and my friend hopefully will not be caught by the war lords….because I am sure that he was tough enough….

Its very different the childhood for some in Congo or in Sudan….Many kids don’t know what is SpiderMan or Avatar….but they know how to clean, set and shoot a Kalashnikov…. The most common toy in Africa…

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