Sufficient

My stats:
9 days in the new year
3 ruptured uteruses
4 caesaren hysterectomies
1 ruptured ectopic in cardiac arrest
2 maternal deaths
4 nights of 7 spent at the hospital

Her stats:
6 pregnancies
1 postpartum hemorrhage
12 hours of uncontrolled bleeding
14 units of blood
1 uterus removed
24 hours later out of the ICU and into the general ward

In OB, I have often heard attendings and colleagues say, "Better lucky than good."  This refers to the many variables and nuances of medicine that can often be missed, but the patient doesn't suffer.  Or more often, physicians do the right thing without understanding why they are driven to do that particular thing.  It's instinct.  A sixth sense.  That little voice inside our head.  Luck.

Thus far, 2012 has been a year of exhaustion for me.  The holiday season has left us with an onslaught of difficult transports and very sick patients.  Volunteers are in especially short demand as well.  I am more tired than I have ever been and thoughts of "I don't know how much longer I can do this," are overwhelming.  And as I struggle with my own fatigue and doubt, I seek to encourage my team in a time when they are tired themselves and saddened by maternal deaths.

But I am happy to write that even in this most challenging of days, we are.....? Lucky?  No.  Humbled. Challenged.  And above all, blessed.  Maybe we are improving, but still not exceptional, but we are blessed.  

I received a call around 11 pm Saturday about Jane, a patient who had come into the Labor Ward at term with a footling breech.  She had been taken to C section without problem but since the surgery she had had copious vaginal bleeding.  I was asked to come and evaluate.  

On her exam, she was already showing signs of shock: low blood pressure, altered mental status, no urine output.  There was a large amount of vaginal bleeding that was not responding to any medicines (pitocin, etc..).  I proceeded to re-open her C section incision.  Inside I found that one uterine artery had began to bleed into the abdomen.  I ligated both arteries that fed blood to the uterus, stopping the bleeding in the abdomen but the uterus remained very large and bulky.  So we proceeded to do a hysterectomy.  She was receiving blood by now, but her blood pressure was still very low and overall she was not very stable.  

Once out of the OR, we began to fervently search for blood donors.  Unfortunately, before long she began bleeding again - this time from the abdominal incision and vagina.  Oftentimes, this is a sign of DIC - a condition caused by major hemorrhage, where the blood does not clot normally.  I estimated that she had lost 4000mL by this point.

Amazingly enough, people working in the hospital that night - and Jane's family- began to pour in to donate blood.  They donated, drank some juice and went back to work.  Others came by to pray by her bedside in ICU.  Meanwhile, I sat in the ICU, feeling very helpless, wanting to sleep, but just feeling like that had to be something MORE I could do.  That this patient was different.  And if I stayed - that the answer would come. 

At 730 am, the answer did come.  After 5 units of fresh blood, the bleeding had not stopped.  I knew that it was not just DIC.  So I called OtherDoc and asked him to help me take her back to the OR,  hoping that he would see something that I hadn't.  We found some additional bleeding, including a large hematoma that had formed since her last time in the OR.  Almost immediately, her vital signs stablized. 

Now, as I reflect back, I try to find out what I did right and wrong.  But the thing is - she was completely hemostatic at the end of my hysterectomy.  And the labs do support that she was in DIC.  Did I miss something?  Did the DIC allow her to form the hematoma?  I don't know.  I only know that if it hadn't been for the people who answered the call to give blood and the OR staff/OtherDoc's willingness to help me take a DIC patient to the OR....she would have died.  But today she was in the ward - breastfeeding her baby after a total 14 units of blood - basically a total volume transfusion!

And thus I am deciding it is better to be blessed than good.  Obediant to that inner voice, that sixth sense.  Humbly reminded that even in the mire: "My grace is sufficient for you, for My strength is made perfect in weakness.” Therefore most gladly I will rather boast in my infirmities, that the power of Christ may rest upon me." (2 Corinthians 12:9)