It’s almost 2 AM. I chose to open the car window and drive slowly down from the hospital’s parking building. The light around was sometimes dark, sometimes dim, and sometimes bright, depending on the streetlights along the road inside the university. Sometimes I like the soft white neon light. It’s like a light from the past. Every time I see the neon lamp on the electric pole, it always takes me back to the alley beside the district officer’s house in my hometown.
The dead-end alley is about 300 meters deep, branching off from the main road of Surat Thani city. At the end of the alley is the old orchard where my father and our family lived. At the mouth of the alley is an old house that has been abandoned since World War II. The abandoned house that sparked my imagination about the spirits residing there. In the dark of night, it was the starting point of the alley that made me exercise every time, “running flat out” because I was afraid of ghosts. See… just the streetlights can take my mind far away.
But on the way out of the hospital, taking me home, it was the familiar yellow light of the big city, which I have no past or memories to recall, so I chose to look along the road and breathe in the cool air to relax my mood.
Almost 2 AM is the time when normal people are comfortably asleep, snuggled in thick, soft blankets. But still, there are other groups of people working to earn a living, ensuring people’s safety, and taking care of patients’ lives, which, of course, includes us.
Yesterday I was on duty… it was unsettling… the past week has been so unsettling…
The 15-year-old girl who was almost due to give birth suddenly had a heart attack.
We used all sorts of methods to try to save her life from death, but in the end, we lost both her and the baby in her womb, which was truly regrettable. It’s really a pity. Look, she had just turned 15 a few months ago. I closed my eyes and thought of my two daughters, one 18 and the other 13. This little girl was clearly my daughter’s age.
Just this much can make our working hearts quite unsettled.
The unease from the loss is one thing, but what makes the heart anxious is the curse of “coming in pairs.”
We often joke that whenever a pregnant patient with a severe condition comes in, another will soon follow. If it doesn’t happen at our hospital, they will be transferred here.
The week before last, there was a patient who nearly bled to death at our place, and in less than a week, another was transferred in because of internal bleeding that almost killed her in our hands.
That’s an example. It’s something we joke about, but when we just lost a pregnant woman to heart disease mid-week, I was anxious.
That little girl suddenly had a heart attack without any prior cause. We think it might have been caused by some viral infection that damaged her heart muscle, causing the heart to stop working, leading to impaired blood pumping and eventually death. This kind of disease is very frightening.
“Professor Pae is here.” That clear voice can give you goosebumps. Usually, Dr. Ming, who is the head of the on-call doctors under my responsibility, called in. “There will be a patient transfer with peripartum cardiomyopathy.” She was telling me that the patient being transferred has a condition where the heart muscle is inefficient during late pregnancy.
This disease is as scary as valve stenosis or regurgitation, meaning it’s equally easy to die from.
I’ve told you many times that heart disease and pregnancy are a bad combination because pregnancy makes the heart work much harder, and eventually, it leads to heart failure, with symptoms of shortness of breath, chest tightness, difficulty breathing, coughing up blood, and death.
But the condition where the heart muscle doesn’t work well is not very common. It’s like it’s lazy to contract, so the blood supply to various parts of the body is insufficient, making the body resemble someone lacking oxygen. The more it lacks, the more it has to be stimulated to work harder, contracting. The heart will beat faster but with weak contractions. That’s a vicious cycle.
We still don’t know what causes it. There are attempts to explain it as caused by this or that substance, but it hasn’t been definitively proven. Therefore, most treatments are supportive, waiting for it to gradually recover and function well on its own. Alright, we use some medication, don’t boast too much.
“It’s her second pregnancy. During the first, she had heart failure after delivery, but no doctor knew about it this time until she started having heart failure symptoms for two days, with shortness of breath and inability to lie flat. The originating hospital didn’t have a cardiologist on duty, so they requested to transfer her to us,” Dr. Ming reported rapidly.
“She’s 37 weeks pregnant now, with uterine contractions starting and the cervix dilated to 3 centimeters.” Oh… she’s close to delivery.
“What do you think, Ming?” I assessed my student.
“I’ve accepted the transfer and informed our emergency room. I’ll take the delivery set down there just in case.” At this point, I admired her in my mind. Anticipating the disease’s progression and preparing for it is a desirable trait of a skilled doctor.
“I’ve consulted with the internal medicine professor about helping to assess and perform a heart echo as well.” “Good, Ming. What else?” I asked.
“It will probably be almost 3 hours before the patient arrives. I’ll quickly read up a bit, professor.” I was about to say that the condition the patient is experiencing is not common for us, so quickly reading up is important. And soon, the student sent treatment guidelines compiled from the American College of Obstetricians and Gynecologists, which had just been published last month, for us to read together.
Then, around 9:30 PM, she arrived.
“The patient doesn’t seem too tired. We should have some time to prepare.” She meant preparing the patient herself to be stable before delivery.
“The heart doesn’t look good, professor.” The head of the internal medicine on-call doctors also arrived at our delivery room shortly. He reported to me in medical terms to avoid scaring the patient too much.
Heart echo is using an ultrasound machine to examine the heart’s structure and function by placing the probe on the left side of the chest.
“The contraction of the left ventricle is very low, probably around 20% or less, with a slight valve leak, likely because the patient’s heart is very enlarged.” That’s the characteristic of a lazy heart muscle.
“The lungs are still quite wet, and there’s fluid in the pericardial sac.” This is a classic heart failure condition.
“Saraphee,” I called her name (of course, it’s a pseudonym again). “The disease is quite severe. The heart isn’t working well because it’s intolerant to pregnancy.” I was about to explain the disease to Saraphee.
“The first critical period has passed. The doctor there gave her a diuretic injection, and she urinated almost 2 liters, so her condition improved.” This case was quite well managed by the originating doctor.
“But when it’s close to delivery, during delivery, and when delivering the placenta, that will be another crisis she has to fight through with us.” I communicated this to the dark-skinned man as well. He is Saraphee’s partner.
“When the placenta is delivered, lymph and other fluids will flow back into the heart, making it a crisis because the heart might not be able to handle it.” That’s how it is.
“But we’ll give morphine to relieve pain, reduce the heart rate a bit, and inject diuretics to expel fluid through urine.” That’s supportive care.
Our team thought further ahead.
We thought about the need for heart-stimulating drugs, intubation, and, of course, chest compressions if her heart stops. I chose not to tell her now, but just after turning away, I talked a lot with her husband.
“If everything goes well, I have one request. Can we do sterilization?” I talked to her husband.
Some things are hard to say, especially if the person I’m talking to has religious beliefs that don’t accept sterilization.
“Yes, doctor. We have a child to raise together. My child needs their mother as much as I do.” This is the conclusion of the partner expressing love for me to understand.
“Stay at the delivery room entrance at all times. If there’s an emergency, we’ll come out and call you.” I told him before going back to see Saraphee.
“Eight centimeters now. Let’s take her in to push. Ming, you deliver yourself.” I told the team. “Tell the pediatrician, the amniotic fluid is thick and green.” The little one must be struggling too, as the mother has had heart failure symptoms for 2 days.
“Push, eeeeddddeee.” Everyone cheered.
“Inject another 2 milligrams of morphine.” I told the nurse. Her heart was racing, probably because of the pain and the urge to push. At this time, the heart would work even harder. Morphine helps a bit.
The little one is out… Not bad. The pediatrician took the baby immediately.
“Are you tired?” I held Saraphee’s hand. “Not tired, doctor, just uterine pain,” she said.
“The placenta will be out soon.” I told her. Normally, if it were other pregnant women, I would say it’s time to rest, but for Saraphee, the hard work begins after this.
Time passed.
Heh heh.
“Saraphee, do you know you came to us for treatment today because the head of the shift today is Dr. Ming?” Yes, this case is very demanding. “But you passed the crisis smoothly because of my shift.” I laughed at Dr. Ming. In the past, I was the gentleman’s shift.
Our shift isn’t over yet…
We received a patient transferred from another large hospital because the anesthesia for the cesarean section was completed, but the patient wouldn’t wake up.
We received a new patient who suddenly had a facial droop from Bell’s palsy. She was pregnant and had high blood pressure. We thought she was developing preeclampsia.
We received a patient who suddenly had an ovarian cyst torsion, causing immediate abdominal pain and peritonitis, requiring urgent surgery.
This doesn’t even include the many problems in the ward that I wasn’t aware of because the team of doctors working there handled them. On-call doctors in the hospital work like this…
“Your son is very cute. He got your fair skin. With a red little willy like this, he probably won’t be as dark as his father.” I talked to her while the man was cleaning the little one’s poop beside me. I saw him smile.
“You’ve trained your husband well.” I teased after finishing her physical examination before noon today.
“He’s been taking care of the child himself since the first one, doctor. At that time, I almost died too. This time, he’s probably scared.” She said. I felt uneasy because, after all, the war isn’t over yet.
Well, whatever will be, will be. Everything is predetermined. Tonight, I might get to hug my wife early. I haven’t hugged her tightly for a whole week because of the pain from the broken right elbow. Everything is truly predetermined.
Thanaphan Chuboon tonight is anxious
February 17, 2019
Source: https://www.gotoknow.org/posts/660536 h
Heart Attack During Pregnancy by Asst. Prof. Dr. Thanaphan Chuboon