Two Liters Too Few.

Her precious children.

Angueth came in barely conscious. But by the time I was called, my translator had little time to do much more than learn her name and get her to lie down on the bed. It was a busy night.

So I busied myself with fundal heights and heart tones while he asked her more questions.

“Ask her how long she’s been sick like this,” I instructed my translator.
She responded but I couldn’t understand her words. She was slurring them.
“Is she drunk?” I asked again, confused and not a little worried, “Or has she had a stroke?”

The man who brought her in, didn’t know so he asked her daughter. There was a brief discussion,  during which it became clear that this man wasn’t her husband. He may have been a neighbor or a random stranger. But he wasn’t family.

“The girl says she doesn’t drink,” I was informed.

Angueth was barely hanging on at this point. Every few minutes she’d slip from consciousness and I’d try to pull her back.

Limp and cold, her extremities were swollen and her mucosa was white. She was severely anemic. I screened her for malaria symptoms.

She’d had all the major symptoms for some time, but she’d not been able to talk right for three days.

“This is outside of my scope of practice,” I explained to my translator, “Please get Dennis. I need his help.”

He grabbed the flashlight and left in a hurry, leaving me with Angueth, the Good Samaritan and a handful of kids.

Three to be precise.

Her eldest looked to be about 10 years old; the other two were both under 5. And all three sat quietly on the bench in the hall.

I continued checking her vitals while I waited.

Search as I might, I found no heart tones and eventually gave up. She looked to be about 7-8 months pregnant.

“My lower abdomen hurts,” she mumbled softly while rubbing the spot.
“Is it a contraction?” I asked in Dinka.
“Yes, it hurts. It hurts.”

Although I could not see or feel any contractions, I suspected her body might be delivering in an effort to save her life. So I did a vaginal exam.

Sure enough she was dilating. She was already 5-6 cm along.

Dennis arrived and I filled him in. He assured me that she hadn’t had a stroke but was in the late stage of severe anemia. Surprisingly her blood pressure was stable. So we started her on antimalarials and admitted her for labor.

Late as it was, there was no hope of getting her to Wau for a transfusion. Plus the Good Samaritan had quietly slipped away, and we had no way of contacting her family.

When I told her that she was very sick and was delivering early, she wasn’t surprised. But when I told her that her baby was no longer alive it took her a while to come to terms.

“So my baby is coming?” she asked, bubbles forming at her mouth.
“Yes,” I said looking at her full in the face. Her eyes searched mine in an effort to understand.
“When he comes. Will he be alive or dead?” she continued on.
“Your baby will be dead.”
Whimpering softly in response, she closed her eyes.

I think she wanted to say more, but the effort to speak was too great. Staying conscious was a hard enough.

Margaret took over her care in the night. She told me that Angueth’s labor progressed naturally, and a few hours later she delivered a girl. She was dead but hadn't been for long. Fortunately, Angueth lost only the slightest amount of blood, and her blood pressure remained stable throughout.

The following morning when I went to check on her, I was surprised to find her fast asleep. But when I tried to rouse her, she was completely unresponsive.

Although she’d been assessed shortly before by our night staff, it was clear the vitals were off. So I took them again. And sure enough, I was right.

She was unconscious and in shock.

With cold extremities, high pulse, and blood pressure bottoming out, I called for re-enforcements. First I called Tom, who listened to her chest for the sound of heart failure in the form of fluid build up. But eventually announced that it was out of our hands, saying she needed a blood transfusion.

Yes. That was clear.

Then I called Dennis, who helped me elevate her legs and suggested I give her Hemosele (a blood replacement IV fluid) to see if her blood pressure might at least stabilize. It was 68/42.

Blissfully unaware of the seriousness of the situation, two of her three children napped on our porch while the eldest went to get porridge.

When she returned I asked her to find an uncle or an aunt. Anyone. I told her that I needed to speak to them urgently. Could she do that for me?

Eager to help, she smiled sweetly and left right away. And I returned to her mother. I continued to monitor her vitals, but the fluids didn’t help.

Her blood pressure continued to plummet, and her breathing became more rapid and hoarse. A choking rattle filled the room as I watched... and counted. She was up to 60 respirations a minute.

A few minutes later, she passed away, shedding two tears without waking. They streamed down her cheeks and onto the bed.

Then the rattled ceased.

At the sight of her tear-stained face, I couldn’t hold back my own. And I mourned for this stranger as if she were my sister, grateful no one was there to watch.

A few hours later, Albino was able to track down her brother and uncle. They hadn’t even heard she was ill. Apparently her husband left some time ago. She lived alone.

Her family gathered around and I told them the story of her death. They were sad but thankful to have a few answers. Then one of our guards walked her children home while the rest of us placed her in the ambulance.

Rigor mortis had already set in.

As I helped lift her body into the vehicle, I had to step over two shovels and a pick.
    --How long will it take them to dig her grave?

Lord, please teach us how to do blood transfusions and send us the equipment. I’m tired of watching these women die for the lack of two liters of blood. Better still... Lord, send them to us for prenatals.

And if by some miracle any reader out there knows how to do transfusions and can teach us what kind of equipment we need, I want to chat! Write me in the comment section.

I’m praying that God will send us the equipment and the expertise to do transfusions. Will you pray with me?

Hemoglobin.

 

A month ago she gave birth at home to her second child --a girl.

Because of untreated malaria she was already anemic when she started to bleed postpartum. She bled a lot.

She bled and bled; but she lived.         --Barely.

A month ago she gave birth to a healthy child but she has been too weak to hold her. She nurses lying down between episodes of vomiting.

She is severely anemic; and the malaria that destroyed her blood cells still runs in her veins --a month later.

Only after her family realized she was at death’s door did they carry her in. Too weak to walk by herself, she stumbled in with two strong men holding her on either side.

Tom saw her and immediately recognized the signs. He started her on malaria medicines, blood replacement fluids, and tested her hemoglobin.

Not having a lab technician we were not sure of the results but they were better than nothing.

She was said to have a hemoglobin of 2.8 mg/dl!

A normal level for an adult female should be 12-16 mg/dl. Again... I suspect the reading could have been off a little (or a lot), as the person who did it is not professionally trained.

Regardless, she needs a blood transfusion.

Her family rallied and got money to pay for the fuel to Wau, and we took her by ambulance this morning. Please pray for her to get the blood she needs and to make a full recovery.

You may be asking yourselves why she didn’t come earlier for help...
I asked the same thing. As it turns out, she lives 5 hours away by foot. Such distances are not realistic for a woman in her condition. It took a month of family discussions and pressure for them to bring her. I’m so glad they did.

Please pray for her to live. Her name is Adut. Thanks.

Monica's Story

A picture I took of her shortly before her death... when I still hoped.

It was a busy clinic day with lots of preggos coming and going and two labors in various stages of dilation. So when a car pulled up I didn’t even notice.

But soon afterward there was a small tap at my door. One of the newest translators timidly informed me I had a labor. Sighing in mock frustration, I quickly went to meet my new labor at the clinic entrance.

Honestly, I was not ready for what I saw.

A small girl --looking no more than 12 years old-- lay pathetically against the entrance door. Beside her a woman with pleading eyes locked gazes with me; she was doing her best to hold the child upright.

“Is she pregnant?” I asked not believing someone so young could be ‘in the family way’.
“Yes, but she is sick,” one of the translators informed me.
“Bring her inside,” I said and quickly turned on my heels. I needed to inform Margaret of this new development.

Once we got her inside, I could see the small belly-bump low in her abdomen. Yes, she was definitely pregnant.

“How old is she?” I asked, trying to hide the disapproval in my voice.
“Fifteen,” I was informed by one of the many family members in the room. It’s as if half the village had entered my 10 foot by 12 foot cubicle.

“What are her symptoms?” I quarried while systematically checking her vitals from head to toe.

She was lethargic and barely able to stay conscious. There were no fevers and no reports of convulsions but I instantly thought of malaria.         --It’s always malaria.

Desperately fighting to breathe she gasped for air at the rate of 90 breaths per minute. That’s a breath and a half a second!

By this time Margaret had joined me and quickly looked at her eyelids to see is she was anemic.

“She’s a plus-plus for pallor,” she informed me then showed me her paper-white lids. I’ve never seen anyone so pale.

“She’s severely anemic,” I informed the family, “How long has she been like this?”

As we continued taking her vitals, the family informed us of the little they knew of her case. She was living with her uncle in Wau. Yesterday, she came home to be with her family. They brought her in to see us once they realized she was having trouble breathing.

“That’s it? That’s all they know?” I asked more than a bit confused. This girl has been sick a very long time. Why were they only now seeking help? I wondered. But that didn’t matter. Caring for her was what mattered now.

She measured to be about 7 months pregnant, but she could have been more. None of her family members seemed to know, and she was too exhausted to speak.

As I searched for heart tones with my doppler, I wasn’t expecting much. If this child was still alive, it’d be a miracle.
        --But I found none and eventually gave up.

How does a 15-year-old living in a big city get this sick? How?

After wavering back and forth on whether to give her IV fluids and consulting with the rest of the staff, we decided to test her for malaria. There had to be an underlining condition for it all.

She was positive. Malaria --that parasitic curse-- had struck again.

We gathered her family together and explained that she was desperately sick. She needed a blood transfusion immediately or she would die.

They listened.

“If she gets new blood she can recover,” I assured them, “But we are a small clinic. We have no blood here. You must get her a ride to Wau right now, so she can live.”

Four pairs of eyes searched my face as I explained. They could see she was dying. The only question was whether or not she could live.

“Get her a blood transfusion right away and she will live,” I went on. The steel in my voice was unmistakable but I realized I no longer felt the need to beg. They would either go or not.

Once I finished speaking the grandfather left without a word.

The girl’s mother and two aunts helped us to get her to the observation room and we started her on malarial medicines.                                  --I had hope.

Three hours later, her grandfather had (miraculously) returned with a car. I had even more hope. I even took a picture of her so I could ask you to pray.

Five minutes later she died.

She died with a few final gasps with her head on her mother's shoulder while her aunts prayed. One aunt left the rooms in deep wails. Another sat quietly knowing --too grief-stricken to speak.

They knew long before I would even admit it.

She was dead.

Dennis and Tom came to pronounce her because I was unwilling to admit it. I kept fighting for more hope. But in the end her heart just gave out.

Later on as the pastors came to minister to her family we learned more of her story.

The pastors praying for her family after her death.

Her name was Monica. She was 15 years old. She lived with her uncle in Wau. When she got pregnant out of wedlock he was furious and kicked her out of the home. She begged for months from friends and strangers. No one knows how she survived. When she got sick she had no money to seek treatment and no money to get home. Finally a stranger took pity on her seeing that she was very sick and let her hitch-hike back to Tonj. She died in our clinic the next afternoon.

She died of heart failure due to severe anemia caused by untreated malaria.

All of it could have been prevented had she known about us and come. Had she been able...

Pray that such senseless loss would end. Pray that we can find a way to get these women the prenatal care they need and deserve. Pray that no more 15-year-olds would be lost.

But just pray...

Blood Transfusion?

Dr. Tom took over all the deliveries and prenatals while I was away. He delivered two babies and referred a woman with twins (one that died in utero) to Wau for a cesarean in the two weeks I was gone. I'm sure he saw a lot of prenatals as well.

One of those prenatal girls came in sick (initially testing negative for malaria) and was treated with a course of antibiotics. At that time, her hemoglobin was an 8. Anemic. In pregnancy, it shouldn't drop below a 12 or else even a slight amount of blood loss can cause her to go into shock. And a moderate hemorrhage, might kill her.

When I got back from my trip, I was told she had returned, still sick, and tested positive for malaria. She was treated, however in the week it went undiagnosed, her hemaglobin dropped to a 4.4!

Not good at all.

She needed a blood transfusion but we don't have the equipment for that. Dr. Tom looked up direct transfusions in his medical books and brain stormed the idea with Dennis and Caleb. They were all game to get her the blood she needed.

They started testing all her relatives for crossmatches and found two donors that would work. This was only made possible by George tirelessly working to screen them all in the lab. It was a lot of work.

The question was, could we actually pull it off before the blood coagulated? Nobody really knew. They tried a number of ways, using a variety of instruments and techniques, but none of them were working.

It was harvesting the blood that was the most difficult. 

Hours later we finally got a bit transfused without it coagulating -- but only about 30 ml. That's not enough to bring her around. It helped of course but she's not out of the woods. Our only option was to send her to Wau and hope that she goes.

The good news in all of this is we fine tuned our techniques and now know what works and what doesn't. And even though 30 ml is not anywhere near enough for an adult woman, it's plenty for a young child who might be suffering from anemia.

This gives us options we didn't have before. I'm excited.

Let's start praying for blood bank and transfusion section in this clinic! Anyone in?

Also pray with me that this girl is able to stay healthy and deliver well. Thanks.