Wednesday, April 8, 2009

"THE ALMOST DEAD WOMAN"

THE ALMOST DEAD WOMAN
By Martina Nicholson MD
Paraguay
Peace Corps, 1972-74

The almost dead woman came from seven leagues away, on an oxcart, on a Sunday afternoon. Dr. Orihuela came to our house to find me, to ask for my assistance, as all of the nurses were home with their families at farms outside of town that day. He told me she was in obstructed labor for 4 days, and that the baby had died inside, and that she was moribund. He said maybe a cesarean section would save her life; he wasn’t sure. It might be just too late. Still, the family had brought her, and he thought he should try. Of course I said I would help, but since I never had seen or assisted at surgery before, that he would have to tell me what to do. We went to the Centro de Salud, stopping to get the dentista on the way; this fellow had learned the art of dripping ether onto a gauze-covered strainer over the patient’s face— and thus was our anesthesiologist.
Dr. Orihuela had been trained at the Adventist hospital in the capitol, and he had meticulously taught some willing young women to be nurses, and to sterilize and keep the OR things ready for surgery. We had the pink alcohol which was used for lighting lamps, and yards of muslin bandages. All of the instruments were sterilized in an antique but functioning sterilizer. The OR was lit with sunlight, and one bare bulb.
We carried the moaning and glazed-eyed woman into the OR and put her on the table. The anesthesiologist put some ether over her mask. I was told to be careful not to breathe too closely to it. I remember how hard it was to get the uterus clean from the thick pea-soup meconium. The dead baby was removed. I realize now it was a classical uterine incision. Vertically cut into the muscle, at the top the uterus is so thick that it is very difficult to stitch together again, even in healthy tissue. This tissue was inflamed and wooden. The stitches kept tearing through. Dr. Orihuela worked carefully and as quickly as possible. When the anesthesia became too light, I would lean my arm against the patient’s thighs to keep her from writhing off the table. When she fell too deeply asleep, Dr. Orihuela would tell the anesthesiologist to take the mask off and let her breathe for a while, real air. Finally, all the layers were done, the skin was closed and bandaged. Beads of sweat were on my forehead, and my nose itched through the surgical mask. I helped lift the patient and carry her to the post-partum bed. Her urine was red as cranberry juice, and the doctor thought she was going to die of kidney failure or possibly lack-of-blood-clotting problems.
I could not sleep all night; I prayed she would live. The doctor’s wife, Na Irma, told me that one problem is that the patients would wait too long to come; and if they died, other people would believe the hospital was a place for dying, not a place to be saved and to become healthy. They would blame the doctor, instead of understanding that the disease was too advanced. She told me that when a patient is cured, people always thank God; but when a patient dies, they blame the doctor.
I paced in my room, and before dawn, I walked back to the Centro de Salud. The woman had a catheter, and the bag for urine was now full of pale yellow liquid instead of red wine-colored urine. The doctor came in early, too. She was very pale, but he said she would live. He took her in the VW van to the capitol, to get a blood transfusion. He said it would help her not to get a puerperal infection.
Two weeks later, I was giving my morning charla to the waiting patients at the Centro de Salud. A rosy-cheeked young woman walked up to me and said “Hello, doctora Martina!” and looked expectantly at me. I looked blankly, trying to recall ever seeing her before. “Don’t you remember me?” she queried, “I’m the patient whose life you saved! I will never forget you.
Twenty three years later, I am an Ob-Gyn. I have done many cesarean sections since, but none with a clearer sense of its life-saving potential. My desire to become an Obstetrician was born that day, and I have told this story many times to explain why I became a doctor. I have never regretted the long path it took to get me to where I could be able to perform such a service. I have also never forgotten how Dr. Orihuela had diligently and quietly prepared for that day. Without his foresight, there would have been no sterile equipment, no clean and functioning OR, no electrical generator and running water in the Centro de Salud. Almost alone among Peace Corps Volunteers, I was working for a physician who cared deeply about public health and was doing the best he could to be like the Johns Hopkins missionary physician who trained him. One looks back with gratitude to mentors who were truly men of great stature, and I will always be grateful that I worked in Ybycu’i under Dr. Orhuela’s great example.

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