A Better Doctor

In the end, she was my responsibility. I let her die.

I walked into the Acute room of Queen II on Thursday morning and saw a six-month old with a flailing chest and withering skin, dying of malnutrition. Her face, her hands, and her legs were swollen and the tissue thin skin was ripping under the added tension. She had been starving for who knows how long, and her particular brand of wasting was kwashiorkor, essentially a protein deficiency that results in fluid escaping to unintended pockets in the body, hence the swelling.

I struggle with a way to better describe her, but at the moment she looked like a tin windup toy ticking away, the key in her back unwinding slowly, inevitably. Her chest fluttered, pulling in whatever breath she could muscle. Mostly she just succeeded in collapsing her chest. Somewhere in the middle of her was a defect. Normally I would have called it a pectus, short for pectus excavatum - a structural deformity which causes the chest to take on a concave shape. It reduces the volume of the chest cavity and sometimes limits the function of the heart and lungs. In her, however, there was an additional deformity along her ribcage - three bony knots which bordered a concave region where her heart should have been. Either she had been neglected and abused, or she had a major congenital defect which caused her body to eat up far more calories, trying to stay alive, than she could take in.

In the acute room, a 10x12 space, much smaller than a single patient room you might find in the states, we managed to cram nine babies, eight mothers, five cribs, two oxygen concentrators and two tanks. She caught my eye. When I took her onto my team, I had every intention of giving her everything I could muster. She was the sickest kid in the ward, she was the reason I was there.

I started the antibiotics, started the oxygen, started the zinc needed for her skin, and the feeds she needed to turn around.

That was nine.

She was dead by three.

In the hours between, I was weaving through children, patients, almost, but not quite so sick. There was the six month old with meningitis so advanced that he could no longer feed, his neck and back arced back so severely that if I lay him on his back, only the back of his head and base of his buttocks would touch the mattress. He was on his seventh day of antibiotics without improvement. There was the two-month old wasting away, vomiting up bright red blood. There were the nine month old twins with HIV. One brother had suffered from his own case of meningitis. It left him devastated, blind, partly deaf and hypertonic - rigid as a board. His brother, slightly luckier, sharing his bed, was battling with dysentery - bloody diarrhea that had made him lose ten percent of his body weight. Their mother never left their bedside for a solid week. Every time I walked by their bedside, mother was either feeding them, changing them, or whispering secrets into their tiny ears. I love my twins. I can't help myself.

By the time I made it back to the acute room, my tin toy was winding down. The key in her back had begun to hesitate with each turn, with each breath. Each one was spaced a little further apart. Her limbs had slowed to a halt. Her eyes rolled upwards and her lips were quivering. Her eyes had stopped blinking hours ago and a filmy grey had settled onto the bottomless black that were her pupils. She was sick. That I knew. But despite my best efforts she was sicker.

In the states, when a child is dying in the hospital, alarms are screaming, code carts are being rushed into rooms, there's a confident sounding attending physician of skill and experience standing at the bedside barking orders and a flurry of staff tackling each one.

Here, there was a baby in a bed with mother a foot away, her head bent down on the mattress, trying to ignore the inevitable. And the confident sounding attending physician of skill and experience was nowhere to be found. Instead there was me.

I don't know why I walked away. I told mom that if anything changes, if her child gets worse, or doesn't seem to be waking from what looks like sleep, that she should call for me or the nurse right away. I think I was trying to buy time, trying to acknowledge that I was out of answers in a place other than in front of my patient whose eyes couldn't look away.

A question from another mother. A question I could answer. A problem I could solve. And when I turned away and looked back down the hallway, about to make my way back to the bedside, a nurse pulled me aside, summoned me into the treatment room. Two other nurses and Dr. Phiri, the other doctor on the ward, looked at me.

"Your patient," she started, "the one with the skin and the swelling, has expired."

Has died. And that was it.

It felt like an accusation. It felt like failure of the most personal kind.

I looked at my tin wind-up toy, lifeless on the table - the key in her back rusting in place before my eyes.

When my first one died that week, just two hours on the job, I knew we had come too late. As I mashed down on her cold bony chest, I knew that we were laboring to make ourselves feel better, a little less impotent. But this one, this one we had a shot. Back home, I wouldn't be her last hope, there would be a better doctor for her.

The only other doctor on the ward struggling to manage her own kids on death's doorstep, the two of us staffing what's supposed to be the major referral center for an entire nation's children, both of us overwhelmed.

I walked back into the acute room. I put my hand on mother's shoulder. She never looked up, her body quietly shaking, the mothers of the children around her circling, supporting her as best as they could, knowing that it could too easily be their child next.

In the end, I walked away, unable to deal with my own impotence. I couldn't save her child, and I couldn't comfort her.

I wonder what those mother's think of me when I walk into that room.