A Hard Day
“This is where you see the gap in healthcare really widen,” Dr. Scott said, as we both stood in a quiet deserted operating room at Bundibugyo Hospital, waiting. “Our only anesthesiologist is already in another surgery, I’ve called for him, but I don’t know when he’ll get here.”
Our pregnant patient was on a gurney in the hallway, on all fours with her bottom in the air, trying to keep her baby’s umbilical cord from getting compressed and shutting off blood and oxygen flow to her unborn baby. She was transferred from a local clinic, for a cord prolapse. From the time of diagnosis, including the journey in getting here, and then now having to wait, it had been a long time. Too long. Hours. (She had been transferred with vaginal packing, for my medical friends wondering why we weren't actively managing the prolapse.)
“Please save my baby. Please God. Please.” She moaned facedown into her kitenge. The nurse and I steered her into the OR. Before we made it to the operating table, the tread from one of the wheels on the gurney fell off and lay at my feet, mocking our efforts to literally move forward.
After about 20 more minutes, the people that needed to be in the surgery assembled, and Dr. Scott started the cesarean section. My nurse colleague Moreen and I had a simple resuscitation table set-up. We clarified our roles. She was going to breathe for the baby. I was going to do chest compressions if needed.
Just a few weeks ago we had a mother with a cord prolapse who ended up having a c-section and the baby was crying and vigorous seconds after being born. I was shocked and delighted considering the amount of time it took to get that surgery started. An unusually good outcome from a risky situation.
I held on to a glimmer of hope for this mother, because of what I had seen before. Because you just never know.
But Moreen and I agreed, this baby most likely wasn’t going to be doing well.
As Dr. Scott pulled the baby out, it was completely tangled in umbilical cord. He unraveled him and handed him off to me. I walked the baby over to our resuscitation table, as Moreen quickly suctioned out meconium from his mouth and nose. I checked for a pulse and found nothing. She started breathing for the baby, and there was good rise in the chest from what she was doing, meaning her technique was solid. I rechecked for a pulse, still finding nothing, so I started giving chest compressions.
After 5 minutes nothing was happening. No spontaneous breathing, no heart rate.
“Kacie, I don’t think…” Maureen trailed off right as I interrupted her.
“Just keep going…” I said.
Then I called out to Dr. Scott, “there’s no pulse”.
“You need epinephrine.” He said.
I had assumed, because we sometimes don’t have gloves, running water, or oxygen, and because I have never seen a resuscitation table set up here with epinephrine, that surely it was one of those things I considered essential but just wasn’t available. Or that I hadn't seen it because it was being prioritized elsewhere.
We called Dr. Jennifer who was in the pediatric ward. “We need epinephrine!”
She quickly came to us. Opened the baby’s eyes, looked at each one with her light, and said “the corneas look clotted. How long have you been resuscitating?”
“10 minutes.” I said.
“Did he ever have a pulse?”
“I checked from 10 seconds after delivery, and no, not since I’ve checked.”
“You can stop your resuscitation now. I’m sorry.” She said.
We stopped, standing there, defeated.
“Ei, ei.” Maureen said dejectedly.
She wiped the baby clean and then bundled him up.
It is sort of unbelievable, to look at a perfectly created human, who never got to breathe air, or cry, or see the world, or be held in his mother’s arms. To try and come to terms that this is it.
Everything about a lifeless baby is just wrong.
The mother was still under general anesthesia, unaware of what had befallen her, despite our best efforts.
Dr. Jennifer gathered us together, along with two other people in the OR whom I was unsure of what their roles were. She used the moment to teach, to refine how we set-up, how our team could have been more proactive in asking for help and offering help, and in affirming that we resuscitated the baby skillfully.
I made mental notes of what I would do differently next time.
I looked at the baby, thinking if he were my baby, I would want to cradle him. I asked Moreen what she was planning to do next and she said it was the decision of the mother’s family.
But first, we had to let them know.
We took the bundled boy and walked out of the OR, where the family was waiting eagerly. I held a tray of soiled resuscitation gear and followed right behind Moreen. The aunt and grandmother walked behind me, peering over my shoulder to catch a glimpse of the baby.
My heart ached knowing what they were about to experience.
We went into the maternity ward where she placed the baby down in what I now know to be a sad sad corner. The auntie walked over. Moreen made it simple and told her the truth quickly. There was a true knot in the umbilical cord. Then the cord fell through and the baby was deprived of oxygen for too long and he died.
My stomach churned as she looked at her sister’s baby and took in the news. This was a private moment for them, so I walked out and to the front into the nurse’s duty room.
The head nurse had already heard the terrible news.
“Kacie. I am sorry. Today is not a good day for any of us, because of what has happened.”
Somehow, the comfort offered by somebody who is also in the trenches, is the most comforting thing of all.
“Thanks.” I said.
As I walked out and down the hallway, a procession of distraught faces walked past me, making their way to the auntie just around the corner. These were the same hopeful but worried faces I saw looking through the doors right before we had gone into the OR for the cesarean section. I know it isn’t my fault, and that the situation was dire and a good outcome was highly unlikely, but I still hated how it felt to just pass by them in the hallway.
“I’m so sorry,” I said to them in Lubwisi.
I went into a room to wash up. Somehow there was a smear of dried blood I was just noticing all down the back of my right arm. As I scrubbed myself clean, my eyes clouded up with tears and the knot of adrenaline and sadness started to loosen, but nothing happened.
Later I drove my coworker home. If I talk, he talks. If I’m quiet, he’s quiet. So I just turned on the music really loudly, kept my glasses and N-95 mask on, and let myself be sad while the tears fell.
I was sad for that mother. For the family. For all the hopes and dreams and potential in that little body. For our medical team. For me. For a country where losing someone you love in childbirth, whether mom or baby, is not unusual.
The other night Mike and I watched a sermon by Paul Kim at Redeemer Presbyterian Church in San Diego. It was on the Good Samaritan. One of the questions he posed was referencing Jericho Road. Sure, it was the Samaritan that went out of his way to help the man in need, but what about Jericho Road? A dark, unsafe path where people were often put at risk. God's mercy and justice needed to reign down there too, on that system, the place where people were constantly robbed of their possessions and potentially their lives.
There are certain times when I look around and think, how and why is it like this? People are being robbed of safe care here, which ultimately costs lives.
I see students performing tasks that should most definitely have oversight, yet they have minimal supervision if that. There are mothers in labor who have never had a set of vitals taken, because the one blood pressure cuff has been broken. Urgent surgeries that aren’t waiting on people, but on sterilized linens, that are hours away from being available. Severely anemic children with orders for a life-saving blood transfusion, waiting days for a bag of blood to show up.
We need God's mercy and justice here, too.
It has been hard to write these last two months, because life is heavy for everyone, and I don't want to add to it. But I value feeling connected, of having you along on our journey, and I get that through sharing both the good and the bad.
I guess I’m writing all this, not to bring anyone down, but for a few other reasons too.
First, I need to process my harder days, and I do that through writing.
Second, writing helps give a glimpse into a specific part of my life here. But to help add perspective, many of my days are spent at home, living very ordinary days, doing my best to love the people closest to me.
And last, well- I’m having a hard time putting words to. I’m sitting next to my kids right now while they watch Charlotte’s Web, and I just heard Wilbur the pig arguing about being loaded into a crate. His friend tells him to resist being loaded into the crate by struggling with whoever comes to put him in it.
He doesn’t like that plan. “But if I struggle, then I’ll get dirty!” He says. He wants to stay clean.
So I guess it’s that. I am writing this all out, to remind myself:
If you enter the struggle, you do get dirty. Wilbur is right.
It’s a part of it.
Literally and physically.
You are bound to run up against the parts of life that don’t seem to have a solution you can see. Where it’s just hard, there aren’t easy answers and you can’t make everything okay. Where you find the pain of someone elses situation smeared across your forearm.
And I’m learning, that some days are harder than others, but even within those days or perhaps even MORE on those days, God’s mercies shine through. Not as a cop-out excuse to try and be positive about truly devastating things, but as a real and tangible truth to acknowledge.
God is still here. He is in it, with us. He has always been and will always be.
On this particular day, I have seen this in three ways once I got home from my shift at the hospital.
After showering, Robinah stopped what she was doing and lent an extraordinary kind and compassionate ear to me.
Then, Piper came home from playing and immediately asked if I could read her a book. She went and found Breathe Like a Bear, a book of “30 mindful moments for kids to feel calm and focused anytime, anywhere.” This is a book she rarely picks, but the timing could not have been more perfect.
She, Winnie, and I sat together as they chose the “Bunny Breath” exercise:
“Sit up tall and hold your body still.
Make bunny paws with your hands.
Take quick, little bunny breaths in through your nose: “sniff, sniff, sniff, sniff!” and then let the air all the way out…”
Robinah walked by the bedroom door, all of us sitting cross-legged with our hands out like bunnies. It was a strange moment, but so right. I needed the Bunny Breath, and my rosy-cheeked daughters, and their mischievous grins and silly laughs.
Lastly, when the girls went back out to play and I was still in their bed reminiscing about the day, somehow our puppy escaped from his backyard space and snuck into the house. I looked down and saw him looking up at me. He wasn’t being naughty trying to run around and chew everything. He was just staring at me with a knowing look in his eye. As if my sadness were a magnet. He was coming to sit and be with me.
These were gifts this afternoon, mercies amidst a challenging day.