Softball

Someone tossed me a softball the other day.

She was three years old, her head shaved an eighth of an inch to the scalp. There were thick secretions spilling from her open mouth, her limp body hanging in mother's arms, the two of them slumped over in the corner of the bench.

It was the middle of a long day, a long week, a long month at Queen II, and I was walking out the door on the way to the lab, in search of missing results. I saw her from the corner of my eye, and like a cartoon character rubber necking at the site of a big juicy steak, my gaze ripped my body around to look at her. If I've earned nothing else here, I've at least honed the skill of recognizing who's sick and who's not. Who's checking out tonight, tomorrow, or maybe in a week, and who might actually make it through. This one looked like she was still making up her mind.

Her eyes barely flickered when I rubbed my knuckles on her chest, hard. Her ribs heaved with each breath, the liquid trapped in her lungs reminded me of the sound of blowing bubbles through a straw submerged in a glass of cold milk. I didn't need a stethoscope, I could hear her lungs from practically the other end of the room.

And like so many times before, I turned to the closest nurse, ordered her to the acute room, and told the medical officer to follow and figure out what was going on. I'd seen something like this before, and I knew where she was headed, and I knew what was coming. I was literally praying for the diagnosis, because in a way, I needed it.

The past two weeks have been especially difficult. Every morning finds me face down in my pillow, pushing the snooze button on my cellphone one more time than I did the day before. It's partly due to the sheer physical exhaustion of the job, of waking early and pushing through the day, but lately, it's a little bit of my head and a little bit of my heart that are having a harder time rolling out of my bed.

Maybe it's part of coming down from an amazing holiday, from the perfect trip with good friends. Or maybe its the recent departure of my brother, on his way back home, that made this month a little bit harder from the start. Maybe it's just the job.

There are parts that are taking their toll. The medical officers for example. They're the ones that worry me the most. They have varying years of experience; all have completed medical school and one year of additional training as interns, but outside of that, their work experience are varied with no semblance of consistency. They're randomly assigned to work the medical wards, at the discretion of the medical superintendent, and this randomness in assignment and experience results in their taking less ownership in the day to day operations of the children's ward. If forced to, I could do most of the job without their help. I could round on all of the kids in the ward and manage patients exactly like I wanted to.

But part of their being here, and my being here, is so that some training can be passed on. After all, I'm only as good as the work that's done while I'm here. If I really want to make an impact in this country, one that lasts long after I've left and extends to more patients than the ones I see in my time here, then I need to pass on as much as I can in the relatively little time I have.

So it breaks my heart when I see them dragging their feet, not following up on their patients, or making excuses for places that they'd rather be. One in particular has been particularly draining. He's been absent for about fifty percent of the time that I've worked with him, making it very difficult to rely on him. If I can't rely on him, he's more of a liability than a boon, and I'd just as soon have nothing to do with him. When he called me last week, after being two hours late, he explained that he had wrecked his car that morning. That it was still driveable, but that he wanted to shop around, take his car to a couple mechanics and get some estimates. When I asked him if he had any plans on seeing his patients that day, he said he wasn't feeling up to it, that he had too much to do.

I railed on him. I told him that his first responsibility was his patients, and that any issues with his car, which was still driveable, could wait until he ensured that his patients were still alive. I hung up the phone, smoldering over his decision, and apparent irresponsibility.

Every day, I worry what will happen when my time here is done. Because the simple fact of the matter is that there are not adequately trained personel. Before Baylor stepped in, there was only one pediatrician, Dr. Phiri, serving the nation. And when we leave, who fills those shoes if not the medical officers? We train nurses to do HIV counseling and management of complex drug regimens. But its the abstract thinking that extends beyond simple drug management and single disease focused care that our patients need. More than nurses, more than medical officers and general practitioners, we need pediatricians to serve the children here. We can prop up the health care systems with these providers for a period of time, but at some point, we're going to find that this country and its people won't escape the adolescent state of its healthcare system unless appropriately trained professionals can step in. So I take it especially hard when they don't deliver. When they don't show up to work, when their priorities are somewhere else. For the portion of the day that they are one the wards, I want them to give everything, to raise the stakes, to treat every child as if he or she is their own. And I worry when they don't. So it's got me down a little.

It doesn't help when the hospital is full, when we're literally up to our ears in patients. When the beds are full and the only room left in the inn is on the floor. Then I worry that someone will get forgotten, someone will fall out of sight, only reemerging when the mother realizes the fight is over, and letting the ward know with her screams.

I spent all week watching things go from bad to worse for one of my patients. A little less than five years old, she came in on Monday with her right side paralyzed. We worked her up for meningitis, and started her on broad coverage including TB, just in case. Tuesday, she was obtunded - unresponsive. Wednesday she had a seizure and developed respiratory distress, likely choking on the vomit that came up with the seizure, resulting in aspiration pneumonia - a particularly disturbing diagnosis because it implies that the fluids produced by the body to digest the proteins and fats that comprise your daily meals are now sitting around in your lungs, chewing through tissue, to say nothing of the bacteria that have now found a new home. Thursday she started having large bloody stools. Friday she started posturing, her body taking the tone of a iron rod, responding to the crushing pressures squeezing her brain through the base of her skull. Saturday she started seizing. And today, when I walked in again for weekend rounds, she was gone.

Its been another difficult couple of weeks. The frustration of a medical system I know I can't turn around by myself, the apathy of a few medical officers who will inherit this country and its shortcomings, and the continual reality thrust upon me, that I'm in over my head; they've been adding up.

So I thank God for the three year old who came in, ready to die. Her mouth foaming, her pupils constricted, her breathing agonal. Turns out, she had been playing at a neighbors place, unsupervised. About an hour after getting home, taking a bath, and being put down for a nap, she awoke with a wail, and then slipped into the troubling mess of diarrhea, salivation, labored breathing, and comatose state that she had become. My guess was organophosphate poisoning. The chemical compounds used in fertilizers, pesticides and agricultural products were legendary for the constellation of effects they caused. We loaded her with atropine, gave her lasix for her lungs and waited to see some change. In an hour her breathing slowed. Her salivation dried up. Her lungs started to clear. Her eyes flickered. When I saw her the next morning, she was speaking in full sentences, playing with her mother, smiling at the staff. We all needed to see that. We all needed to know that there was one that we could save, atleast for the moment. One that we could definitively fix. One that could show us what it felt like to win. One that could keep me rolling out of bed in the morning.

I don't mean to sound arrogant, but someone tossed me a softball the other day, and it felt good to blast it out of the fucking park.