22 October 2017

Not enough blood or water

Version francaise

Democratic Republic of Congo

There's one example I use whenever I talk about grief. How I came to understand grief in medicine. Grieving in Africa. Grieving when children die. And how people keep going.

It was 10 years ago. A Sunday, late morning. I was awake enough, outside on my porch, maybe reading, maybe walking down to the hospital to see friends. I saw Doc running. Yvonne running. Cecile running. Julie running. So I went. And in the salle de consultation was a disheveled mother, listless child on her lap, Cecile connecting an IV from her arm to the child's arm, there wasn't time for a real transfusion. I was there for minutes or hours, or seconds, standing back, watching them work, not knowing how valiant it was in the face of most likely futility. And the child died. And I forget at which point or who noticed it first. There weren't any chest compressions that I remember or anything else done for resuscitation. But we didn't have oxygen, I don't think, and I know we didn't have anything else.

I remember the mother throwing herself on the ground, screaming, outside la salle, where we'd have 100s lined up for vaccinations. Banshee-wailing. It went on. I don't remember where the child was at that time. It was the first time I had seen death happen, and I don't know at what point it happened, and in the events of attempted, urgent resuscitation, and I had wanted so badly to be in it.
I remember going back (500 ft) to my house, lying on my bed, staring up at the ceiling through the mosquito net canopy. I remember wandering into town that afternoon and finding bananas, which I hadn't seen in weeks, I remember talking to a friend after that (no power, but the landline in town was working that day! 1/100 occurrence) and when they asked me how my day was, I said, "Great! I found bananas!" And I meant it.

Severe anemia. From malaria. Died from not enough blood. It's a common story for malaria in kids.

I remember thinking about the mother wailing (I still hear her, I still see her) and the concept of letting grief in so that you could let it out and get up again and keep moving because you can't stop moving. I've told this story many times. I've written many poems about this story. I don't remember the little girl's name, but I'll put her on the level of my first patient who died in med school(K), the first newborn I took care of a few months later (also K). And so many other later.

That child died in Mvangan, Cameroon, in the summer (small rainy season) of 2007.

Yesterday, in a first for an internist, a four-month-old girl died under my hands. Severe anemia (for the doctors among you, her hemoglobin was 2.1 g/dl). From malaria. Died from not enough blood. I was at the hospital to follow up on a few patients, but then the HIV/TB nurses saw me and took me on rounds. In the intensive care ward, we went to see a man, late 30s, with HIV, (I diagnosed) TB, and florid, beautiful Kaposi's sarcoma on both his legs. I hadn't seen it so widespread in awhile.
I turned and saw another doctor starting chest compressions on a baby, while bag masking her. I don't know why I turned, because there wasn't sound, yet. It's soon after that, the mother started crying, wailing. It's soon after that someone took her outside. One of the nurses and I went over, to help, and the vague familiarities of ACLS protocol came back (...I'm the only one with a watch. I should be timing) (How much epinephrine have we given and when was the last one) (Do we have a fingerstick) (Two fingers on the femoral pulse, check carotid) (Is air entry bilateral) (Are compressions fast and deep enough) (Are we getting an oxygen level) (Has the pulse come back?) (Yes. Briefly) (Can you hear the heart?) (No) (Can you hear the heart?) (No) (How are her pupils?) (Fixed and dilated) (Is there a pulse?) (No) (How long has it been?) (20 minutes). Not my code. Not my call. With her hemoglobin level and without blood --- even if we acquired it then (and I don't know if memory serves correctly about the mother to child transfusing above) -- there really is nothing we could have done. I know that now. And I know that about the child in Mvangan. This time, I was the doctor, my hands were there, and the child died. Democratic Republic of Congo. Also in the equatorial rainforest. October 2017.

Doing compressions on an infant isn't the athletic event it can be in adults, the exhaustion after 2 minutes, kneeling on the bed, all your force directed into the heels of your palms, coming back from a 45-minute code sweaty, exhausted, probably borderline hypoglycemic.

I never counted the adults who died under my hands. I've counted my own patients who've died. But most of the ones I did compressions on, whose ribs I broke, whose time of death I might have called, whose heart I might (rarely, rarely) have helped to restart, were anonymous except if I was writing the code leader note or death note or looking up labs or prescribing medications. I have no idea how many. Many.

I know how many children. One.

And counting.

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