Saving Lives

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[Ann Emerg Med. 2010;56:69-70.]

I wasn't supposed to be working on the maternity ward at Kirehe Hospital in eastern Rwanda that day. In fact, I just happened to be passing through, in search of the hospital's lone ultrasound machine, which often went missing from its official location in the pharmacy (one of the few rooms in the hospital with a reliable deadbolt). That day I was assigned, as I was on most days, to the emergency room, a small area near the back entrance of the hospital that certainly does not deserve the title emergency department; even calling it an emergency room might be a bit of a stretch.

As it happened, there was a young child in the ER that morning, with several weeks of cough and spiking fevers. He had already received the standard courses of therapy for malaria and pneumonia at his local health center without improvement. On exam, I thought he had reduced breath sounds on the right and dullness to percussion (although I must admit that since graduating medical school, my attempts at percussion have generally been limited to looking for studs in the walls of my apartment). The x-ray machine at the hospital had been broken for weeks, but I was hoping that the ultrasound might reveal a pleural effusion that I could tap and, with the aid of a microscope, a Ziehl-Neelsen stain, and a lab tech who actually knew what she was looking for, catch a few mycobacterium red handed. It's not that the diagnosis was in doubt; both the nurses working in ER that day and I were pretty certain that the child had tuberculosis. But the Ministry of Health guidelines were quite strict in this regard: when it comes to TB, you've got to prove it to treat it, which is no easy task, especially in children who rarely produce sputum for microscopy. The rules were made largely to protect the drugs, as opposed to the patients, but I was hoping in this case that the ultrasound machine might allow us to do both, and so off I went on a hospital-wide search for it.

It was my second stint at Kirehe, where I volunteer with a nonprofit organization that provides support to several rural, government hospitals in Rwanda, a small, achingly beautiful country in the heart of Africa with a dark past but a (hopefully) brighter future. My last trip had been in March, during the rainy season, when the tile floors of the small 2-story hospital were covered in successive layers of muddy footprints. Now it was July, the dry season, and the white tiles gleamed in the bright sunshine that poured in through the open windows. After stopping first by the pharmacy and receiving an apologetic shake of the head from the pharmacist, I proceeded down the hall to try my luck in maternity. I passed through the empty antepartum room, with its 2 green plastic mattresses sagging in their rusty metal frames, and into the delivery room. By coincidence, both midwives on duty that morning were in the middle of deliveries. I took a quick look around the room, taking in the 2 women about to deliver, separated from each other by a thin blue curtain, and the neonatal resuscitation table, covered in a white blanket with a single 100-watt-bulb lamp hanging low over it. I poked my head in the large cabinet containing metal specula lying in their baths of disinfectant and looked underneath the wooden desk with its neat stacks of medical charts, but I saw no sign of the ultrasound machine.

I was about to continue my search on another ward when 2 men walked in somewhat hurriedly, carrying an obviously pregnant woman in their arms. I rarely see people hurry in Rwanda, and so these men with the woman strung in between them made me pause. The woman was clearly in labor, moaning and grabbing hold of her gravid abdomen with both hands. One of the midwives looked up briefly from her delivery, cocked her head towards the door, and with a brief command in Kinyarwanda, shooed the 2 men out into the antepartum room. I followed the men and watched as they laid the woman carefully down on one of the sagging cots and then exited into the hallway.

I was halfway out the door myself when all of a sudden I had this idea that I should stop and check the progress of this woman's labor. After all, it might be some time before the midwives had a chance to see her. Maybe she was already crowning, and after making such an effort to get to the hospital, she shouldn't have to deliver unattended. So I threw on a pair of exam gloves and, in broken Kinyarwanda, introduced myself as a doctor and explained that I was going to examine her and check on the baby.

For a long time after beginning my emergency medicine training, whenever I called home, my parents would ask, after their usual questions about the weather in Boston and whether I was eating enough, if I'd saved anyone's life that day. After a brief pause to run through the list of atypical chest pain, abdominal pain, and minor trauma patients that I'd seen on shift, my answer would uniformly be, “No, not today.” Eventually, my parents stopped asking the question, but I still found myself turning it over in my mind for some time to come. After all, I was an emergency physician; wasn't I supposed to be saving lives? And of course, over the years, I have probably saved many lives. It's just difficult to pinpoint which ones. If you define saving a life as helping to perform interventions or prescribing medications without which the patient would likely have died, assuming that they didn't simply get the same care by another clinician or at another hospital, then I probably save a life every day. But in practice, working in the United States, it generally doesn't feel that way. In the developing world, though, the line separating life and death is far narrower and less ambiguous. I spend more of my clinical time there standing helplessly by while patients die, but when I do get the chance to save a life, it tends to be pretty obvious. As it turned out, this was one such occasion.

I reached in with my right hand to check the woman's cervix but didn't get very far before my fingers brushed up against a bulging, wrinkled occiput, just seconds away from crowning. I sat down at the foot of the bed, held the woman's perineum with one hand, and applied steady pressure to the baby's head with my other hand as it began to emerge. A single contraction later, the head was out and I grasped it between my 2 hands, getting ready to guide its anterior shoulder down and out, when I realized that the baby felt stuck. I let the fingers of my right hand glide down to the baby's neck and felt a slimy length of umbilical cord wrapped tightly around. The half-smile that had been lingering on my face up until that moment vanished.

I called for help, and one of the midwives poked her head out of the delivery room, saw what was going on without the need for any explanation, and ran back inside to grab 2 clamps and a pair of scissors. A short while later, I had the cord clamped and cut and the baby delivered, but something was not right. The baby had a bluish tinge, with shallow respirations and floppy arms. She opened her mouth as if to cry, but no sound came out. Uh-oh.

I brought the baby back into the delivery room and laid her down on the resuscitation table. In Boston, this exact scenario would have triggered a tsunami of clinicians—obstetricians, pediatricians, nurses, respiratory technicians—armed with thousands of dollars' worth of equipment, all working in concert to resuscitate the child. I spent the next 20 minutes or so alone (the midwife had returned to delivering the other baby) armed with a small plastic bulb that I used to suck thick green gunk from the infant's nose and mouth, an ancient rubber Ambu-bag hooked up to nothing but the stale air of the maternity ward, and eventually, once I had the chance to grab the oxygen concentrator, a couple liters per minute of oxygen delivered by an adult-size nasal canula that I taped to the infant's face. Still, by her 21st minute of life, the baby had turned from blue to pink, was waving her arms as though trying to pull away the plastic canula, letting me know her displeasure with long, deep-throated cries that were music to my ears. With great humility (after all, it could easily have gone very differently) but no reservation, I can say that I saved a life. Now, if only my parents had called that day to ask….