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.