Hypertensive Crisis
Because Kibagabaga is the referral hospital they get all the tough cases that are able to make the trip from district hospitals. The health centers in the villages can be as far as 25k from the district hospital. There are 10-12 health centers that refer to the district hospitals and there is usually only 1 ambulance per district hospital.The district hospitals refer there toughest cases to the referral hospital such as kibagabaga. Anyway, the barriers to get to the referral hospital are many.
We were working working one afternoon when a woman arrived with high blood pressure. Nothing moves quickly in Africa and this situation was no different. After the patient had been there for 15 minutes or so I went over to check her BP (not knowing that she was here for hypertension) and the reading was 230/120-zowie. So I informed the nurse Ildephonse and he got Dr Monique. She wanted to start some nifedipine so she had to send the patient's family out to go buy it. The first pharmacy they went to did not have it so they returned. Again they were sent out to another pharmacy. The hours tick by. Finally the decision was made to start some Magnesium Sulfate as we had it available. She was given a bolus by drip and then an hourly maintainence dose. Magnesium has the side effect of respiratory depression and/or respiratory or cardiac arrest if one receives too much medication. There is a protocol for measuring blood levels of magnesium in the US- but no labs are done here. One we got her stabilized we decided to proceed with a cesarean. We are ready to move on to the surgery but there were no clean linens- they need to be ironed and sterilized- So we wait. Finally she was given a general anesthetic because of the hypertension and we were ready to proceed.
Because the general anesthetic crosses the placenta it is known that you need to hurry to get the baby out so that the exposure doesn't cause the baby to have difficulty transitioning to extrauterine life. Anyway, thankfully we had the forethought to have Leanne to come into the OR to care for the baby after delivery. Anticipation is not the strong suit in Africa it turns out. Finally the surgery begins and the mother begins struggling against us and trying to yell around the endotracheal tube. We stop to try to get her more asleep and then proceed. Again, she begins to struggle. We can't enter the peritoneum or she will expell her bowel from the pressure she is exerting. Now on a good day the OR is about 90 degrees- we wear fishing waders, our scrubs, a heavy rubber butcher's apron, then the sterile gown and 2 pairs of gloves. Add a little stress and concern onto that. Anesthesia is afraid of giving her too much drugs, "She'll sleep for 2 days!" says the nurse anesthetist. "It may be the best 2 days of her life" I am thinking.
After 2 or 3 stops and goes we are able to proceed and deliver a baby with no respiratory effort, no tone and a weak heartbeat- too much exposure to general, especially for such a little human being. Thank god for Leanne- she began resuscitation immediately complete with CPR and the baby recovered. We take so much for granted in the US: good medical care (despite the issues we have, no one is going to have to go out and buy their own meds while they are in hospital), a healthy baby, a caring nursing system, etc. The end of this story is a good outcome- thank goodness- mom and baby did well.
