The woman arrived on Tuesday, 31 weeks pregnant, complaining of abdominal pain, fever, malaise. Her face was oddly swollen – the skin around her eyes stretched out. Her blood pressure was normal, though, and she didn’t have enough protein in her urine to make a diagnosis of pre-eclampsia. She did have a positive malaria test, though, and quinine was started. She had an ultrasound that day which showed that the baby was alive, and that there were no obvious problems.
She didn’t seem to get any better on the quinine. On Wednesday, another ultrasound was ordered when the nurse couldn’t find the fetal heart beat. This time, the child was dead. Malaria can do this; can end pregnancies overnight.
On Thursday, her face remained swollen; her blood pressure in the normal range. Her abdomen was soft. Her breathing was regular. Her pulse was strong and regular. She was not feverish. But she lay in bed, writhing around, crying and clearly in distress. A test of her hemoglobin was ordered – the doctor tells me that she has seen swelling with anemia before, and malaria is a common cause of anemia. But her hemoglobin comes back in the high normal range. Another hemoglobin is ordered, she looks so pale, the test can’t possibly be right. It comes back again, high normal. The nurse checks her over completely, thinks she might be going into shock, but there are no physical signs of it. The doctor comes in; check her over. The vital signs are all within normal limits. At this point the woman is not fully conscious. She responds to her name, but little else. The quinine drip is running; the woman has received all her meds. There is little to be done.
When I came back to check on her an hour or so later, she was dead. Her face was covered, her body wrapped in the brightly colored cloth that all women wear here. Despite the distress I had seen her in earlier, I didn’t understand. Where was the nurse? Her family crowded around her. What happened? I asked. They look at me as if I am crazy. She died. They say. I understand that, but I am looking for a reason. Did she have a seizure? Was there sudden hemorrhage? Something must have happened. But, they have no answers for me. They ask me if they can take her away. No, I say, wait first. I go to find the nurse, but it is shift change and she is gone. The night nurse is in the break room. Oh, yes, she says. She died about 15 minutes ago. She comes outside with me and sits on the bench. She, like the family, tells me nothing happened. She just died. There was no change in vitals, no event that signaled that death was imminent.
I walk over to the doctor’s house. That woman in bed 8, I say, she died. The doctor has not been informed. We walk over together to the hospital. The family is already carrying the woman out. The shape of her belly distorting the cloth that covers her. The doctor shakes the hands of the family, gives her condolences, but the family barely stops, and are off the compound in seconds.
As a medical student in the US, I haven’t seen much death. 3 of my patients have died. Maybe another 1-2 who I knew, but wasn’t directly caring for. With every single one of those patients, I knew exactly was caused death. I went home and studied it, made sure I understood where the physiology became pathology. We had tests, monitors, and imaging to tell us what was happening inside and out of every patient. My father, who has been in practice for over 30 years, tells me that he has had 8 maternal mortalities in his career. I have seen half that many in 2 weeks. People die here with alarming ease. And without the protective armor of knowledge or the opportunity to learn from each death, it is hard not to be caught up in it.
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