In the practice of medicine, various specialties have their unique emergencies that raise the blood pressure of the care providers to varying degrees. For those who, like me, thrive on the adrenaline rush, we are very much at home in the maternity unit where a moment of calm can herald the unannounced entry of a hurricane that would upset the Richter scale.
The only other unit that rivals our unit is the emergency room. This explains why most successful medical television dramas are centred on this department. Unlike the maternity unit where focus is on mums and new-borns, the emergency unit is like an open-air market. The emergency team moves from a burns patient, to a gunshot wound, to a heart attack and a trauma patient with multiple fractures in one breath, prioritising and stabilising them as they come.
As we continue to invest heavily in the reduction of maternal mortality in Kenya, haunted by unacceptably high figures, let’s take a look at a dimension that we do not speak much about outside the healthcare circles: Maternal near-misses. According to the World Health Organisation, a maternal near-miss refers to a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy.
AN OUT OF BODY EXPERIENCE
In Kenya, we are beginning to document data on these events and the statistics aren’t pretty. Hypertensive disease in pregnancy and postpartum haemorrhage are the leading causes of maternal near-misses. They do not discriminate across age, socio-economic background or even previous motherhood record. Every woman is at risk long as she falls in the pregnancy, childbirth or post-partum category.
Witnessing a maternal near-miss is an out of body experience. The most unsettling aspect of these events is the suddenness of it all. One minute you have a stable mother, then in the blink of an eye, the fight for life begins. All the interventions instituted to save a mother’s life will seem inadequate but there is no room for giving up. Team effort means everything and singular dedication to the fight is unquestionable.
Catching up with a colleague a few days ago brought the reality of the near-miss phenomenon closer home. She’s a gynaecologist who dedicates her life to caring for mothers, but even that wouldn’t keep the black hand of death away. After a completely uneventful first pregnancy, she went into labour smoothly and took her turn being the patient on the couch, instead of the caregiver standing at the side. She had a precipitate labour (when the progress is abnormally fast) and in less than an hour after admission, she delivered a healthy baby.
While everyone was catching their breath at the rapid unfolding of events and the new dad was still caught in the ecstasy of receiving his baby, the midwife suddenly called out for help. The new mum was bleeding a river that rendered her unconscious in a matter of minutes. She was whisked off to the operating theatre and all she remembers was waking up cold in the high dependency unit, hooked onto monitors with an on-going blood transfusion. She had one foot in the grave, but she survived!
You would think that having come this close to death and lived to tell the story, that fate would be done serving her the deathly platter. Despite the scare, she took a daring chance to have another baby. Thankfully, she handled the second delivery safely. She managed to juggle her new baby, a toddler, her post-graduate studies and the rest of her life peacefully for a year and her near-miss started to fade from memory.
Then she woke up one morning to find herself in the high dependency unit again, with a tearful mother-in-law at her bedside. How did that happen?
Out of the blue, like a thunderbolt with no warning signs, she had suffered a coronary artery embolism. All she remembers was reaching under the bed to collect her baby’s toy. Her nanny found her passed out on the floor and called for help. She was whisked off to the emergency room and the rapid action by her care team saved her life one more time.
Critical cardiac care, invasive treatments to dissolve the embolus that was blocking blood supply to her heart muscles, days spent in the ward allowing her heart to heal and restore normal function, and initiation of lifelong medication to reduce risk of recurrence, were all interventions she had to undergo to save her life. She couldn’t fathom just how deranged her laboratory indicators were yet she was still alive. Her heart tracing patterns on the electro-cardiograph were as abnormal as they could get, yet she walked out of hospital without any disability.
Despite countless tests, her cardiologist could not pinpoint any risks that had precipitated her near-miss. She had missed all the subtle signs of the impending catastrophe; being below 35 years of age, a heart attack was the last thing on her mind. Being a doctor did not help her be more alert to the lurking danger. The only glaring reality for her was that she was human and that life can be really fickle.
To the healthcare provider, a near-miss experience is unsettling. It tests your human limits to the very end. Despite all the knowledge and skills learnt in preparation to save life, this is the one time the provider feels impotent. Like nothing one does is enough yet the situation is sliding out of hand extremely quickly. Nothing prepares one for this.
Then just like that, things turn around and the climb out of the dark hole starts. The patient who is teetering on the brink of death takes a step back from the precipice and in one breathe, death is postponed. In moments like this, whatever your conviction, you will acknowledge that a higher power intervened; a very welcome invisible helping hand.
