Wednesday, October 29, 2008

Terminal 5

"On November 4th, you won't be able to vote, but we'll all feel the consequences" - BBC News

Sitting in the airport, halfway back to Lesotho, I was treated to live simultaneous broadcasts of Obama and McCain's latest entreaties to the people of Pennsylvania. It wasn't so much what they had to say that moved me, but rather the reactions of the international jet-set awaiting connections in Terminal 5 of Heathrowe.

I started this job ten weeks ago, and in that time, the work, the people, and the cause all have captured my attention in such a way that much of the outside world has been lost on me. I've missed Tina Fey, The Bailout, the faltering economy and the realization that thousands of people are losing their jobs.

Coming back was a little bit like walking into your old bedroom and flipping on the light and realizing that nothing's really changed, there's just a little dust lining your old pictures.

It wasn't a big transition. I somehow missed the dreaded "reverse-culture shock." More than anything, I realized that there was an alternate reality out there that I hadn't paid much attention to, and now that I was knee deep in it, I was a little embarrassed that I felt at times out of place. The past ten weeks have felt like I was in a parallel universe. Neither worlds overlap but in conversation, and even then it's easy to forget about the other world, except of course for the loved ones keeping us at bay.

The only time I felt one world invade the other, so to speak, was when the American Election found its way to the international terminal. Never have I been more proud of my country, never have I felt the incredible potential we have, and never have I hoped more for a still uncertain outcome. It's been titled by the worldwide community as "The Election That Affects Us All." Obama ended his speech with a quote from a supporter asking him to fight for them, in essence, to fight for injustice levied on the common American. And looking around that terminal, there were open jaws and stunned silence - think of what we can do if we are able to deliver on all of these promises.

The one thing that has bothered me with all of this, with the talk of fight, and the feeling of alternate realities, is how easy it was to turn off the light when I left the room, when I left Lesotho. It makes me wonder what it will be like at the end of all of this, when it's time to come home. Will it be so easy? Will I look back if I have no planned return. I've spent over two months here, but the minute I came home, it was business as usual. I realize that it's this feeling of parallel universes, and separate, unlit rooms that makes it easy to compartmentalize everything else that goes on in our world, to forget. I'd like to believe that with this talk of change, with the feeling of this impending renaissance, and the renewal of American benevolence, that the ability to forget/ignore this other world will become more and more difficult.

A couple weeks ago, a high ranking Sesotho military officer, in a moment of weakness imbued by drink, confessed to me that without the United States and it's aid, his country would be vastly worse off. Like it or not, there are people beyond our borders that are counting on us. It's easy to forget when you're on top of the pile how, ultimately, all of our lives are intertwined. With words like hope and change, I wonder if its finally the beginning of a movement, our time for redemption, our recognition that we have something greater to strive for. In Terminal 5, its very promise stopped some dead in their tracks.

Monday, October 13, 2008

Sometimes

The needle slid through her chest with a snap.

Her grandmother on her knees in the back corner, a murmured prayer filling the room.

And despite all our hope and desperation, nothing came back. Not air, not blood. The four people it took to hold her down all looked at me, a sick expression on each of their faces. Nothing on the right. Might as well try the left. I grabbed a fresh 21 gauge, hooked up to short IV tubing with a plastic clamp, and connected the end to a 10cc syringe. I found my spot: second intercostal space, mid-clavicular line. My finger jabbed each rib. Paranoid, I counted, recounted, verified the spot three times. Then I asked for a confirmation from a bystander. Then I rechecked. I felt nauseous. I felt anything but steady. I couldn't believe I was in the same shit again: another newly-diagnosed-HIV-positive-four-year-old-girl-with-impending-respiratory-failure. It's been a month of working in Queen II. A month of working in the most feared hospital in Lesotho. A month of trying to turn that reputation around.

The second needle went in as easily as the first. Nothing. I pushed the inch and a half needle all the way to the hub. Nothing. Not air, not blood, just a dead end. It wasn't a pneumothorax that was killing her. It wasn't a collapsed lung that was sucking the life out of her, causing her chest to cave in. The routine hardly ever changes here. They come in sick, they get sicker, we get desperate, we start stepping up care, and then we show up the next morning and absolution has come and gone.

But it was my last day, and when you’ve come to the conclusion that you really have nothing, absolutely nothing to lose, you start doing crazy things. I had never done one of these. I hadn’t ever seen one of these. It’s a pretty straightforward procedure done when there is the slightest suspicion of a collapsed lung, it doesn’t even require an XRay. The only difference in our case was that it wasn’t really clinically indicated. She didn’t have the requisite shifting of her trachea, the distension of her neck veins, the differential breath sounds between the two sides of her lungs. What she did have was a complete absence of any air moving through her lung fields, and she was getting dramatically worse in front of our eyes. Same song, second verse.

I looked at the other PAC doctor who was transitioning to take over the wards for a couple weeks in my absence; neither of us was entirely ready for this. But then, we had just spent the last twenty minutes resuscitating a child in the next bed. We had pulled her back from the brink, regained a heart rate, but she never started breathing on her own. And in the end, we bagged her, gave her breaths through a mask hooked up to a rubber balloon, until we could no longer hear her heartbeat. It’s gut-wrenching to try your hardest to bring a child back, to stabilize them, only to realize that at the moment when fates can change, you don’t have the what it takes to make the next step.

The only advice I got from the Dr. Phiri, the veteran doc looking on as we worked on her patient was: next time you do that, make sure tell all of the mothers to leave the room.

So when we walked back into acute room, our plan resolved, equipment in our hands, I took a look at the single nurse in the room.

“ I need every mother out of the room except the one for that child.”

The nurse translated, the mothers looked at each other, and then each one filed out. The mother for my child wasn’t even in the room, she was outside on the bench in tears, denying the obvious. It’s a bad sign when you’re child’s doctors are visibly scared.

After bringing her to the bedside, I tried to explain stepwise what we were about to do.

The reason – her child was very sick and we didn’t know why

The risk – if she didn’t have a collapsed lung, we could inadvertently introduce air into a vacuum cavity, thereby actually causing a collapsed lung. And if our aim was poor and we hit a major vascular structure, there would be bleeding – unholy amounts of blood.

The alternatives – none

The benefits – immediate improvement, comfortable breathing, re-expansion of her lung. But here was the rub, putting a needle in someone’s chest was only a temporary measure, it must be followed with a more permanent chest tube hooked up to a vacuum if in fact the lung in collapsed. I had neither the equipment for a chest tube, nor an available surgeon to assist me. DIY medicine only gets you so far if you don’t have training, equipment, or backup.

So as I stood there, planting the needle in her chest, watching for air or blood to come back into the syringe, I was secretly relieved that we had the wrong diagnosis.

With little else left that we could do, and driven by a mixture of desperation and bravado and the feeling that we had already gone this far, I wheeled a cart into the room and secured her 80lbs steel oxygen tank to the rails. Jill, the other PAC doc scooped her into her arms, and with grandmother and our translator in tow, we bolted for XRay, a ten minute walk to the opposite side of the medical campus, in an entirely different building. Because of its distance and our patient’s dependence on oxygen, getting an XRay was more dangerous than blindy putting needles into her chest.

Our group of four plus one sick child and weighted cart rattled over stone and pavement, through dirt and finally into the wards. As we sat her down on the xray table, her mouth opened wide, her eyes tearing, but not a sound came out. Something had stolen her breath, her voice, and hardly a whisper left her lips where there should have been a wail. There’s a condition described in the medical literature as “a look of impending doom.” I’ve seen it a dozen times this month, and each time, it has lived up to exactly its name. Bad things happen soon afterwards. Jill and I both recognized it as she sat there on the table. Everyone else in the room standing ten feet away from her as the XRay machine uttered a high pitch squeal, a click, and then fell to a hum.

Half an hour later, she was back in her bed, mother at the bedside, and we had an xray in hand. All of that effort - and the results: bilateral perihilar opacities. It told us nothing. We had come no closer to a solution, and I think it was at this point that I just gave in. When you’ve done everything, when you’ve thrown every antibiotic in your arsenal, when you’ve gone on a limb and done not one but two things against your better judgement and still nothing has changed, you know its time to start letting nature run its course. Sometimes it’s not about what we can and can’t do. Sometimes, despite everything, what our patients need most is time/luck/prayer. And sometimes, miracles happen.

Sometimes, they make it through the weekend.

I called Jill this morning to check on her. She was still alive, slightly more comfortable, still on oxygen. She had stabilized. I have no idea how she got there. I’m not sure what in the long list of things we did actually helped her, but something did. And for me, that’s enough. It’s enough to reaffirm all of this effort. It’s enough to make me take that next step, to use that desperation to push further, to fight harder for every single patient. The fact that three children left the acute room last week, escaped the hospital in better health than when they came in is all the encouragement I need to keep going. And even now, as things are starting to wrap up and I’m preparing for a short trip home, I am looking forward to coming back. The tone has changed. Nurses are working harder, the medical officers are engaged, and the staff is taking note. To borrow a term - there is a renewed sense of urgency.

Throughout Lesotho, the country's national referral hospital is regarded as a place to die. I'm making it my mission to change that sentiment.

Sunday, October 5, 2008

Effort

They know I'm trying.

Monday morning:

I'm walking through the wards, stopping off at each bedside, checking how my patients made it through the weekend. It's always anyone's guess, seeing as how there are five medical officers running an entire hospital. Some nights, there's not enough officers to staff every ward, and inevitably the children's ward gets left behind. Those are the bad nights. The only time a doctor makes it to the bedside it's when it's too late, when it's time to pronounce death.

As I was turning the last corner in room three, annoyed that it was noon, and today was going slower than usual, a mother walked out of the back room we reserve as the malnutrition ward. I always feel uncomfortable walking into that space relegated to the end of rounds and the back of the children's ward. Those children are usually stable, but they can get sick pretty quickly and it bothers me that they are so far away from any of the nurses or anyone else's attention. A kid could die there and no one would know until the next morning. Or Monday morning.

She had a straight face and was clenching her child's chart. She said she needed to talk to me. I looked up, recognizing her, and told her I'd be there in a minute. I went back to finishing my note on the child with unrelenting seizures. She just stood there, clenching that chart. I looked up again, starting to realize that the tone of the room was starting to change.

On her child's chart were the letters: R.I.P.

That particular acronym used to conjure up visions of the wild west, gunslingers and tombstones. Now when I see it, it still feels like a sick joke: R.I.P. I'm getting used to those letters.

I realize what's happening. The child that I worked so hard to help for the past two weeks, the one with encephalopathy so severe that her back took the shape of a boomerang, the one that I had stabilized and was feeling so optimistic about had passed away. I felt sick. After all that, it took just two days for a medical officer to kill my patient, not intentionally, not knowingly, but by neglect.

I took the mother aside, my translator trailing behind. After searching for a quiet corner without much luck, I pulled her into the least crowded patient room, figuring that would be better than the hallway opposite the bathrooms. I sat her down and put a hand on her shoulder. I asked her what happened. She just looked at me, expecting me to answer my own question. I took the chart and started flipping through it. I saw my last note from the Friday prior. It was thorough, and detailed, and optimistic. It spoke of feeding regimens, completing courses of antibiotics, long terms plans for physical therapy. There was no note from Saturday. No one had seen her that day. And Sunday's note cryptically stated in four lines: patient critically ill, placed on oxygen, taken to acute room, continue Rx (code for I don't know what's going on/I'm too busy/I've given up). There was a follow up note four hours later: called to bedside, patient pulseless and apneic. Pupils dilated. Time of death 2 am.

"Where were you?"

and

"I begged them to call a doctor. No one came. I begged them to call you, to see my child. They wouldn't call you. They wouldn't give me your number."

Matsudisi, my translator deciphered mother's story between her sobs. I stood there, my hand on her shoulder, dumbstruck. In truth, I wasn't "on" that weekend and had taken the opportunity to leave town to go hiking, but I was back by Sunday. Had I gotten a call I would have been there, at the very least I would have talked the medical officer through the weekend, but there had been neither the time nor the will to call me.

"The mothers, they believe in you. They know that you try. She thinks you could have helped her child."

And with that, I realized that, though I had bought time for only a fraction of my sickest children, it had not gone unnoticed. I have questioned what those mothers think of me. I have wondered whether they look at me as an outsider, and a child too young to care for theirs. It's a feeling I had to fight throughout my training. But I'm starting to realize that my efforts, though rarely changing the ultimate course of my patient's lives, are giving my patients something else.

As I coded two more children this week, I noticed when people started to walk away. First it was the translator. Then it was the nurse. Finally it was medical officer. And then there I stood, alone. Rushing to hang IV fluids, flush a clogged line, do chest compression, ventilate my child, and push cardioactive medications on my own. They see the flurry of movement. Those mothers see the round after round of compressions. My thumbs burning from pushing down on tiny little chests, breaking rib after rib. The desperation - it rarely amounts to much. But I want them to know that someone tried. I want them to know that when their child walked into a losing battle, that their life meant something. It is shockingly easy to write off a life. You'd think it's impossible, that it could never happen. I look at my staff and my medical officers, and even the other doctor on the ward with frustration and contempt. Sometimes I think they too easily walk away from sick children. Its just another child. Its been three weeks and I've lost eight children. Tomorrow I'm sure I'll lose another. After all its Monday, and no Monday is complete without some child getting compressions.

And it's exactly that attitude that I'm fighting when I'm the only one in the acute room tearing my hair out, begging my child to hang on for a little longer. The fight finds itself in my outrage as I try my hardest to not bitchslap the nurse that took my child off oxygen, the nurse that refuses to change his empty tank. I swear sometimes I'm driven to just inches from violence with the frustration I feel. I fantasize what it would be like to put some of them in a headlock. I have no idea what it's like to be a mother of a sick child in Lesotho. But I am doing my damndest to show them that someone cares.

And even now, as my self-rightousness builds, I am tempered by the fact that not one, not a single child that I've done compressions on, not a single child that received epinephrine, not a single child that I've placed on more than two liters of oxygen per minute, a perfunctory dose, has lived. So cleary, everyone else in the room knows something I don't. But I'm starting to realize, thanks to the mother that believes in me, that it's not really time I'm buying with all these efforts; I'm delivering on a promise that declares that their child is going to get the best of what we can offer, and that someone will bear witness to a death that shouldn't have happened.