Low Resource Health Care Decisions

March 1st, 2017 by Stephanie Peace

Operating in a low-resource health care setting is a huge adjustment. The physicians at Kiwoko Hospital routinely are forced to make life-or-death decisions that affect not just their own patients but the rest of the patients in the hospital. To illustrate, one patient arrived at the hospital 38 weeks pregnant with intrapartum hemorrhage. She was taken for emergency C-section for suspected placental abruption with fetal distress. The surgery was challenging (though remarkably the baby did well) with severe postpartum hemorrhage. In recovery, the patient received 2 units of blood (which already points to the severity of her condition, as they don’t routinely transfuse in adults here unless the patient is symptomatic with a hemoglobin < 5; by comparison, we would routinely transfuse at hemoglobin of 7 in the U.S.). An hour into recovery, we were alerted that she was bleeding with a blood pressure of 54/37. She was given pitocin, misoprostol, and methergine and then taken back to the OR for placement of an intrauterine foley balloon in an attempt to stop the hemorrhage. Her blood pressure became unreadable in the OR and she ultimately required hysterectomy due to uterine atony and continued hemorrhage, complicated by suspected DIC. We requested additional blood products and were told there was only one more unit in her blood type (B+), which she was given. The lab was reluctant to give up a unit of O+ blood, but it became necessary in order to maintain blood pressure. At the end of her hysterectomy, she really needed ICU-level care, which is not available at Kiwoko. The night shift is under-staffed both in terms of nurses and physicians (one physician covers male and female wards, pediatrics, NICU, and maternity and one surgeon covers any surgical patients), so it can be challenging to make sure patients get their vitals taken regularly, let alone more intensive care. Luckily a senior midwife was on the night shift and was able to carefully monitor her vitals throughout the night. Overnight, another patient, also B+ blood type, had a postpartum hemorrhage due to retained placenta following an intrauterine fetal demise. When we rounded on these two women the next morning, both were stable but shaky and pale with estimated hemoglobin of 3. We requested a unit of O+ for each of them, which they were given. This meant that the lab had no units of blood left available for any other patients who might arrive in need of blood products. The hospital was unable to get blood even from Kampala for several days. Ethically, this means that physicians at Kiwoko Hospital routinely have to make the decision to provide blood products for one patient knowing that other patients may be denied life-saving treatment simply due to lack of supplies. We discussed the option of staff and volunteers donating blood, but in Uganda blood product donation is strictly regulated due to the high HIV rate and this kind of donation is technically illegal. The entire situation was frustrating because there was so little we could do. It made me grateful, however, that we didn’t transfuse an asymptomatic patient who came in the day before with a hemoglobin of 5; had the decision been up to me, I would have transfused her based on U.S. standards but the result would have been even less blood available for the two women who required blood transfusions for survival. I have so much respect for the difficult decisions that Kiwoko’s physicians make day in and day out.