Mary

December 1, 2009

Well, I didn’t make it to Longonot last weekend. I got called in twice to the hospital Saturday night, and didn’t leave the second time until 4am. The 7am hike time was not looking good to me. Dustin managed to go, and took some amazing photos. But we’re a sorry looking bunch this week—Dustin hiked and then played ultimate frisbee on Sunday, and had donated a liter of blood to one of my patients last week, and I think got himself dehydrated, so has had a two-day headache and is looking paler than usual (which is hard to do…) Vy has a cold, although we tease her it’s malaria, or TB. I’m sleep deprived, and have some strange rash on my hand and a stye in my left eyelid (who gets a stye??)

Anyway, my call Saturday night involved running in for a quick vacuum delivery (leaving me feeling like the hero) and then a really difficult surgery afterwards. I got the call that one of my favorite patients, Mary, had started to bleed. She’s a 16 year old who’d been admitted about 10 days prior, weighing about 70 lbs with severe anemia (Hb of 3) and tachycardic to the 160s. She’d been bleeding since January (10months) after a pregnancy that resulted in a D&C because of some bleeding (she had to have the pregnancy terminated for a reason she didn’t know at an outside hospital). When she presented, she had a palpable mass in her uterus and a negative pregnancy test and bleeding. She was also very hyperthyroid, which is why her pulse was so fast, that and the blood loss. We gave her meds for her thyroid, and transfused her many units of blood, and took her to the OR for another D&C to see what this mass was—we realized immediately that this was cancer. The pathology came back Placental Site Trophoblastic Tumor or PSTT (very rare) and it results usually after a molar pregnancy (a complication that is also rare, and probably the reason she had to have the original D&C). PSTT has such a high HCG level that our urine pregnancy test was actually negative—too high for the test to read! And very high HCG can cause hyperthyroidism. We knew she’d need a hysterectomy for this, but it was hard, since she is 16, and she was not well enough for surgery. So we were transfusing her and she was looking better every day. Her family was so pleased that she was improving—they thought we were miracle workers.

Over last week, her blood count remained low—too low for surgery. And only her parents would donate blood, and they had exceeded their limit for donation. The blood bank at the hospital only gives out blood when the families also donate, so there was no blood left for her. So we started asking around, and Dustin donated a liter for her. Her surgery would have been today, except that she woke up Saturday night and went to the bathroom and passed a lot of blood. So my intern called me at 11:30pm to let me know Mary was bleeding, and that she was bleeding a lot. I told her to make sure she had IVs in place, fluids running, a new Hb, and to cross-match her for emergency blood if available, and I ran in. By midnight, she’d already bled about 1 liter, so I called the obstetrician. She was not on call, but I knew that Mary needed her hysterectomy, and that the general surgeon would not have been excited to do it. The obstetrician was confused, but I told her “hysterectomy now” and she came right in. I had to wake up a nurse anesthetist and a scrub tech too. Mary was on the operating table by 12:30am and had lost about 2.5 liters of blood.

Sadly, Mary had some tumor growing through her uterus, so she will definitely need chemo, which she may not be able to afford. Also, she did not stop bleeding. During our operation, we suspect that Mary went into DIC (her ability to clot was gone) and she continued to bleed and bleed, no matter what we did. At 3:30am, we decided that the more time we tried to stop the bleeding, the worse she was getting, so we made a patch with her peritoneum and stuffed some surgicel into the site to help her to clot, and closed her up and prayed (I really prayed!)

She needed fresh blood to treat her DIC (we have no platelets to give here) and so the obstetrician started calling people in the middle of the night who are on a registry to donate. She also announced it at church the next morning, and we got 5 people to come donate. And Mary is doing well today! It’s amazing… she asked me today if she could go home! I think we’ll keep her another few days, and then she will hopefully go to get chemo sometime soon.

Anyway, that’s why I didn’t climb Longonot… I’d say it’s an ok excuse. I spent the next day finishing the third book in the Twilight series—so good to lose yourself in a little American teenage drama amidst a very different, real life, Kenyan teenage drama.