Anemia

Friday I saw a 22-year-old girl die. You might not want to continue reading and that's ok, this is a difficult entry. I came into the labor ward at 7:30 and saw her in the high-risk section, sitting upright in bed, breathing fast and hard with obvious effort. The night nurse said she had delivered a stillborn a few hours previously and although she only lost a normal amount of blood, she was so severely anemic that the loss was enough to start her down the road to heart failure. I watched the second pint of blood slowly drip into her vein as I placed my stethoscope against her chest, hearing her heart racing and the sound of fluid filling her lungs. I tried to put an on oxygen mask on her, but even when another nurse translated for me to explain why she needed the oxygen, she refused. I went and found Dr Tarek Meguid.

He examined her and agreed that she needed to be transferred to the ICU at Central Hospital ASAP (Central is maybe two miles away from Bottom and has the only ICU in the Central Region of Malawi). What she needed was to be "knocked-out" and put on a ventilator, enabling her body to rest while she continued to be transfused and hopefully stabilized. At the moment she was running an endless marathon and sooner or later her heart would give out. The fluid in her lungs was a sign that it was already starting to fail. Dr Meguid called Central but there was no available bed in ICU and there was no available bed in the High Dependency Unit (HDU - the ICU step down unit). There was no alternative, so she stayed with us and we watched her all morning. In between deliveries we watched her breathe hard, and we watched her concerned mother stand helplessly at the bedside. Central never called to tell us they had a bed.

Sometime after 11, I was taking a break eating some peanuts at the nurses' station just a few feet from her bed, and noticed that she was now slumped on her side. I went over to her and her mother frantically tried to tell me something about mtima (her heart) - pushing her daughter, who was lying on her side, onto her back and pointing in-between her breasts. I didn't need my stethoscope. I could see each beat of her heart as it slammed into her chest wall fast and hard. I asked the mother if her daughter could understand her. The woman frantically called her daughter's name but the girl only moaned.

Just then Dr Meguid walked in, the situation was clearly worsening but being a midwife (someone who has studied normal birth) I didn't know what we could or should do, I just saw his presence as hopeful. He told me that we could not intubate and ventilate her at Bottom because we had no ventilator and because we didn't have the staff to care for her. He examined her again and asked for a diurectic. I went to the fridge, retrieved one vial, drew it up and pushed the medicine into her vein. He asked for another. But on my way to the fridge someone else called me away to help resuscitate a pale floppy baby. A small group of nurses and clinicians had started gathering at the girl's bedside, so I started the resuscitation and asked someone else to get the Lasix. After a couple minutes the baby started crying and then the order of things became a blur.

. . . I heard Tarek pleading on the phone for a bed, saying "She's DYING," as I stood at the her bedside. I saw her body go completely limp. I saw her eyes roll back in her head. I heard Tarek say, "That's it, W-E L-O-S-T H-E-R." I watched pink frothy fluid pour out of her nose and mouth. I looked at Tarek disbelievingly through my tears and heard her mother wailing from beyond the corners of my vision. Time stopped. The anesthetist appeared and somehow I managed to bring the suction machine from the otherside of the room, connect it, and start suctioning her airway. Tarek started chest compressions. Other nurses and clinical officers drew and pushed medications. The woman on the other side of the curtain unattended, and perhaps unaware of what was happening, called out continuously in the agony of normal labor. I just stood there doing my task, holding the suction catheter as though it contained all hope.

After several minutes her heart started again. She did not regain consciousness. She did not begin breathing. We continued with the bag and mask. A patient was discharged from the ICU. A bed was available. The ambulance was waiting. A stretcher appeared and we moved her from the bed. I bagged her, as the janitors pushed the stretcher down the hall past countless expectant guardians - waiting for word of their daughters and sisters - and countless pregnant patients roaming the halls in early labor. I focused my eyes on the girl's face, but in my peripheral vision I saw their bodies and feet as we flew by and I felt their concerned quiet presence. We loaded the stretcher on the ambulance. The clinicians climbed aboard and then I realized her mother was missing. I ran back to the labor ward and found her sitting on the waiting bench by the door talking in a very concerned tone to two nurses. (Later I found out she was asking about the dead baby, asking if someone from the hospital would bury it.) They told her to go with me and I escorted her, half pushed her, to the ambulance. She was a small thin woman, the top of her head only reaching my shoulder, and as I walked down the hall with my hand on her back the other women stepped closer - each telling her something, offering strength, showing concern - and then parted again as we moved forward. I only understood one, "Osalira" (don't cry?!). I helped her into the ambulance and an equally thin and frail man tried to board behind her (I assume he was the father). There was not enough room and he was told to get out, so he stood in the doorway and watched the ambulance drive away.

The rest of the day I tried not to cry. I went back to the ward, assisted a few students with deliveries, and found a couple small reasons to laugh with Deb and Maureen. (Deb is an American med student who came this week and will be in the ward for 10 months, and Maureen is a Dutch med student who has been here since August and will stay until February.) Clement showed up unexpectedly and I told him about the story as I ate my lunch in a spot of shade outside the hospital. He shared his own recent difficult story from the medical ward. On my way back inside Dr Meguid found me and asked if I was doing all right. We talked about the sequence of events and he said, "Didn't you know she just wasn't going to make it then?" and I said, "I've never seen anything like that before. That was my first time. I didn't know." I felt my tears surge and he gave me a much needed hug.

At the end of the day I mentioned to Dr Meguid that I wanted to go to Central to see her and he said he would call first to find out if she was still alive. Deb and I exchanged glances as he put his finger to his ear and turned his back to the ward. She had died at 2pm. I looked at Deb whose eyes filled instantly with tears and gave her a hug. We left together, and over ice-cream floats we cried and talked about what we had seen, about death, about mortality, and about privilege.

The problem is we did everything we could, but there was nothing to do. If there is no facility, there is no choice; there is no alternative. Tarek often says that maternal mortality here in Malawi today (1,800 per 100,000) approximates what it was in Europe in Medieval times. He says the difference is that then we didn't understand why women were dying, today we know why, but we still can't stop it. Women like the girl who died on Friday are almost beyond hope by the time they reach the labor ward. Their bodies are functioning with no reserves and the smallest insult is more than they can bear. Just to give you an idea, the hemoglobin level of a healthy woman should be between 12 and 14. Women have walked into the labor ward with Hbs as low as 2. Physiologically the problem is chronic anemia caused by parasites (in addition to and including malaria), malnutrition, and other disease. But, there are so many other factors: cultural (e.g. preference for white nsima, which lacks nutritional content), poverty (e.g. not having more than one meal a day, not having money for timely transport), education (e.g. not understanding the risk factors of pregnancy to be personal risks; not knowing when to seek help), infrastructure (e.g. not having enough ICU beds or even iron tablets to distribute), and on and on. The solution to this seemingly black & white issue is one which continues to elude all the dedicated clinicians and policy-makers. In spite of everything, maternal mortality is on the rise in Malawi.