Matters of life and death
Exploring the deadly chasm known as the research-to-practice gap
I probably write 5 posts per week in my head, most of which never seem appropriate for public display. Perhaps I have just been writing this post 5 times each week in my head and now I am finally getting it out.
My time in Tanzania has convinced me of one thing: We do not need to go on researching so many new things when we simply cannot do what we know we need to do. Last week, I experienced that firsthand in a life-and-death kind of way.
Everyone involved in maternal health research and practice around the world knows that postpartum hemorrhage is the #1 killer of women, and that it is also frequently preventable and manageable. Last week, we had a mom that was transferred from an outside facility on the account of anemia. She was one-week out from a cesarean section, and she needed a blood transfusion because her hemoglobin was 4.7 mg/dL. (A normal postpartum hemoglobin should be more like 10–12, and at less than 4 you start to face serious problems.) That is understandable, that is what we do as a referral hospital. (It is a different issue that a completely negligent doctor left a large amount of placenta in her uterus at the time of surgery which lead to her life-threatening anemia, but that is for another day. )
This young, first-time mother began to bleed profusely before she could receive a blood transfusion. The reason that she had not received a blood transfusion was that there was no blood available for her blood type. So here we are…already severely anemic mom is bleeding profusely. What do you do?
Research and practice in the West tells us that you do several things: uterine massage, uterine evacuation, drain the bladder, give some medicines, etc. All those things were not working. That very day, a research study had been publish from Kenya in a major international journal for OB/GYNs that reported the use of a Bakri balloon to prevent death from postpartum hemorrhage. Yes, that is what she needs! The Bakri balloon is a conservative measure that can save massive amounts of blood loss, prevent hysterectomies and forced infertility, and literally save lives right before your eyes. The study, which took place from 2013–2015, showed that 55 out of 58 women successfully avoided life-threatening surgery and had good outcomes. 95% is an overwhelming success. It verified what we have known for years from research studies in other countries.
So naturally, what did we do at now several years after the idea of uterine tamponade has been available? Of course we reached for the supply of these life-saving devices that the study told us were so valuable. Only, that supply doesn’t exist. There is one Bakri balloon that is locked in an office that is inaccessible 80% of the time and few of the younger physicians know that it exists.
So how do we ask this woman and these doctors to jump over that research-to-practice gap?
Thankfully, the same effect of a Bakri balloon can be obtained using a condom attached to a catheter (pictured above). All you need is some balloon-type device that can hold 15–20 ounces of fluid, fill up the uterus, and hold pressure against the bleeding parts of the placental bed.
Knowing the life-saving nature of the $1 solution, I carry a condom in my bag at all times. Bethany found it in my bag once and asked “What are you doing at work?”
On this day, because I was there, because I was prepared, we saved this woman’s life. I am convinced that if we would have had to do a full hysterectomy on this mother, whose hemoglobin was down to 3 mg/dL after her hemorrhage on the ward, that she would have died. As OB/GYNs, we get to feel like we “save lives” pretty frequently, so the thrill of that cliche has worn off. This case was different though. I could feel that something special happened that day. I am not a special, superhuman physician, but I have been taught and mentored by wonderful people. I take the threat of life-threatening postpartum hemorrhage seriously and have been trained to understand that anticipation is the key being a good doctor.
How can it be that we live in a world where on the same day that a research paper is published claiming incredible results to prevent deaths from common problems that a woman nearly dies because no provision has been made to secure reliable access to the researched live-saving measures?
Sitting with that question for a while will stir up all sorts of emotions: fear, outrage, apathy, hope. These are the emotions that I process everytime I attempt to write a post. I am not sure which one will come out. My time in Tanzania has taught me that all of those emotions need to be in play at any given time, and that the world will be changed by people that hold all four of them in check like a dog walker controlling large dogs on leashes.
I am not going to be a grant-funded researcher for the rest of my career and this is exactly why. I do not believe that the path to human flourishing, which is God’s desire for the world, goes through research. It goes through the hearts of people, cultures of institutions, and priorities of governments. I’m trying to affect the hearts of people and influence the culture here. I believe in these residents; it just pains me to see the chasms they have to jump over. Some of those gaps are societal, some are institutional, and some are personal. I pray for wisdom to identify them appropriately and the skill to build bridges over them.