Chadian Massive Transfusion Protocol

At midnight the phone rang. “A woman who just gave birth is bleeding a lot.” 

In the OR Staci was performing a curettage to make sure no pieces of placenta were causing the problem. Medications oxytocin and methergine were in. Staci had also verified there were no major lacerations in the birth canal. We then quickly packed the uterus with gauze in an attempt to stop the hemorrhage. This woman had been laboring for days at home after her water broke. Her inflamed uterus was not clamping down like it should. Phillipe, our nurse who performs anesthesia, was infusing another bag of blood. 

Something drew my attention. It was the pulse on the oxygen sensor. Her heart rate was 170 beats per minute. My heart sank. Was that real? The last blood pressure (BP) reading was 80/50, was that heart rate true? It was ominous. The BP cuff finished cycling: 60/30. Her life at its end flashed before my eyes. Within minutes she would be dead. 

The blood was already pouring out in spite of the gauze packing. I asked Phillipe to run 2 bags of blood at the same time. “We’re doing a hysterectomy.” Opened the kit, threw betadine on her abdomen and began cutting. Her blood pressure was not measurable now. Quick clamp cut tie, clamp cut tie. “Please give more blood, yes, MORE blood!” Phillipe ran to the refrigerator again. Her blood pressure intermittently read at 50/30 when the machine would pick it up. Final clamp, cut, uterus out. Ahhhh, breathe…. bleeding stopped. 

The transfusion total was 9 units of blood.  

The husband was more educated than many of our patients. He was overjoyed when he heard his wife was alive. He understood we had to take out the uterus and said, “Whatever it took to save her, thank you.” 

Walking back to our house in the dark morning hours a flood of emotion overtook me. Her life, falling precipitously, was caught just in time. She is alive. People like the Netteburgs, by their sweat and tears, have developed the only blood bank in this part of the country. People hate donating blood here because it diminishes their “force” to work in the fields. However, every elective surgery patient must have a family member donate a unit of blood. We explain that if the patient needs it during surgery then we give it. If it is not needed during the surgery, we use it for emergencies.

Consequently, every hernia we’ve worked hard to repair this month was another life-saving unit of blood. The cost of generators, fuel, and the mechanic to keep electricity working (most of the time) is beyond what most hospitals in Chad can afford. We have the luxury of keeping our blood bank refrigerator running. 

Our transfusion protocol includes a built-in 1:1:1 ratio of red blood cells, platelets, and plasma. This has been shown to reduce hemorrhage in numerous trauma studies. Even many rural trauma centers in the US have not yet achieved this goal. We don’t separate the components. Consequently, all of it is whole blood, and that’s what we give. 

This woman will raise her kids. People are not surprised when a mother dies in childbirth here. It is so common. Many children grow up without the mother they lost in childbirth. Not for this family though. She is alive! 

COVID hits Chad

Ricky was coughing and breathing hard. He was a small 12-year-old boy with grey fluid and pieces of necrotic tissue draining from holes on his leg. I took Ricky to the OR, explaining to the family that he may lose his leg. The infected tissue encased his tibia from just below the knee down to the mid shin. 

On the OR table his oxygen saturation was 60%.  He was coughing and taking each rapid breath with difficulty. We have no ventilators and not even oxygen. We performed the operation with only local anesthesia due to the risk that Ketamine would worsen his respiratory status. It was painful for both of us. I removed the infected tissue, and left the skin open to change the gauze dressings in the wound daily. He also developed other abscesses in other parts of his body the subsequent week. 

With antibiotics and excruciating dressing changes, the infections began to clear. We now had a segment of exposed bone needing tissue coverage. Dr. Bill Rhodes, a plastic surgeon with 25 years experience in Kenya, graciously mentored me via WhatsApp on performing a saphenous fasciocutaneous flap to cover the bone. He prayed for me too. I’m indebted to him.  Ricky’s leg is healing wonderfully now. 

We will likely never know if Ricky had COVID-19 and consequently became more susceptible to infections, or if his respiratory symptoms were simply from the bacterial infection with resultant sepsis. We have no tests for coronavirus in this part of the country. 

The capital has limited testing for COVID-19. Over 800 patients have tested positive so far. Close to 10% have died. Chad has 15 million people and only a handful of ventilators. There is no capacity to manage critically ill patients here, even if they were spread out over a 6-month period. In spite of this, the country has prohibited all transport and non-food commerce since March. For the many people who eat by what they have sold at the market that day, the economic consequences are devastating. Our patients tell us that in the nearby city of Kelo, there are children crying on the street in hunger. Hunger is a serious problem at baseline in Chad which shutting down the economy has only exacerbated. 

We have a nutrition center to help combat hunger. A potentially more challenging problem however, is how to treat the surgical diseases that cut short or handicap many people’s livelihoods.

The city of Kelo is the commerce center for our district. It is 2 hours away by motorcycle and located on the main route linking the capital from Moundou, second largest city. This whole district, including Kelo, at the moment has only 1 trained general surgeon. Our hospital serves a population of approximately 100,000 villagers in its local district which does not include Kelo. However, we are the primary surgical center for Kelo. In addition, patients regularly come to our hospital from all over the country and surrounding countries. 

A physician in the district hospital of Kelo sent a patient to me to re-open after he had performed a laparotomy that day. He did not feel comfortable managing an intestinal stricture. It was apparent that he had performed a lysis of adhesions and was concerned about a part of the bowel that had become narrow from the compression of an adhesive band. However, the band had been cut and the narrow area would now dilate to allow normal intestinal transit. I closed the patient, reassuring the family and the physician in Kelo that he should have normal intestinal function within a few days. The patient did great. 

Another patient arrived from Kelo because there was no one perform his surgery there that week. He had a distended, hard, abdomen. He had suffered from abdominal pain for 5 days. He took his last agonal breath as I entered the emergency room to see him. I screamed with emotion asking why he had not come earlier. They said, “It’s God’s will that he died.” From a throat tight from crying I said, “NO! It’s God’s will that he could receive life-saving surgery earlier.” 

Then there is Ricky, and many others like him who are alive and walking because they came to our hospital. We do not lack patients. They crowd outside the OR. When I leave to see patients on the ward, or to try to go home they call out to me. It is exhausting. In a couple years we will have enough surgeons to start a top knife surgical training program. This will begin to beat back the onslaught of suffering we face daily. There will be so many more boys like Ricky, smiling as they walk. 

(Written in May 2020)

Morning Run

Andrew went for a run this morning and was surprised to see his patient also out for a morning walk. This patient came in about 6 weeks ago with a dental abscess with necrotizing infection of the neck extending to the mediastinum and chest wall. His prognosis was very grim. Thanks to God and to debridement, wound care, and antibiotics, this patient is still alive and doing very well.

Here are some pictures of how his treatment progressed:

This was at his original debridement. 

The debridement went all the way to the trachea. We don’t have ventilators here, so we were concerned that if the infection spread further it could be disastrous.  Here is two weeks later—after more debridement and aggressive dressing changes.

Two weeks later, after more wound care and smaller debridements, the wound was ready to close.