Sunday, March 7, 2010

Oxygen

I am in the Labor Ward tending to a very ill patient and giving instructions on her care to the midwives when the Principal Nursing Officer suddenly appears in the window. She asks to borrow the oxygen concentrator from Maternity for a very ill child on the Pediatric Ward.

Oxygen is one of the most basic medical treatments available. Oxygen is routinely given during and after surgery, because their respiration can be depressed from anesthesia. People are given oxygen for asthma, any respiratory ailment, any cardiac ailment, sickle cell crises, and even certain types of headache. It is a very valuable and often lifesaving tool.

In an American hospital, oxygen is ubiquitous. Every hospital room has oxygen that flows from the wall, so that each hospital bed is equipped with oxygen if needed. Stretchers and wheelchairs are designed to have a place to secure an oxygen tank, so that a patient can be remain on oxygen in transit. If you need oxygen in an American hospital, you will get it.

This is not the case in Tororo. Oxygen tanks are difficult and expensive to transport, so there are none at TDH. There are oxygen concentrators, but very few and they often break and are not repaired. The theatre is supposed to have an oxygen concentrator, but it works only variably, and none of my patients have ever had oxygen in surgery – even when under general anesthesia.

The Labor Ward also has an oxygen concentrator, used for resuscitating infants after delivery. Infants are often quite hypoxic (low oxygen) after the strain of delivery – in fact, fetal physiology allows fetuses to routinely maintain levels of hypoxia that would be fatal to an adult. However, some fetuses develop such severe hypoxia in labor that they are stunned and fading when they are delivered, and require resuscitation. Such efforts are remarkably lifesaving – an infant that seems blue, limp and lifeless can be screaming within a minute or two, as long as the right techniques are performed. Teaching basic infant resuscitation to midwives is very effective at reducing the incidence of stillbirth (because some of those “stillbirths” are still, but not yet dead).

The child in Pediatric Ward needs oxygen, but I don’t know what to do. My patient needs the oxygen – so much so that I went to great lengths to drag the heavy concentrator over from Labor Ward to Gyn Ward, remove a different patient from her bed and move that bed away from the wall plug to plug in the concentrator, and set up the nasal cannula (the only available attachment) so that it fit the patient. But if this child is sicker than my patient, then perhaps we should give the oxygen to the child.

I decide to go over to the Pediatric Ward to assess the child myself. I walk there, and find a nurse, who takes me into the triage area where a woman is sitting with a two-year-old child in her arms. The little girl looks terrible. Her skin is wan and dry, her eyelids are half-closed, she is limp and her head is leaning backward, supported only by her mother’s arm. She is gasping for breath weakly. Good grief. I don’t know anything about children, but this one looks bad.

The nurse gives me a quick history that the blood smear was positive for malaria, and the child had recently been admitted at a private hospital for several weeks, but was sent home. I quickly assess her skin for rashes, injuries or marks, then pull out my stethoscope to listen to her heart. I am having trouble hearing through the coarse cloth of her shirt, and the neck hole of the shirt is too small to fit the stethoscope down, so I pull her shirt up to expose her chest. As I do that, I see a subtle change – she was limp before, but she suddenly goes slack. What the…? It can’t be. I put a stethoscope to her chest, and I can’t hear a heartbeat. I listen all over. I know that pediatric stethoscopes are smaller than adult, so I try using the small side of mine, but can’t hear anything. I am feeling for a pulse on her neck when I see the nurse looking at me ominously. She knows. She shakes her head, confirming what I want not to be true. The child is dead.

We don’t say anything to the mother, because we are both a bit stunned. The nurse informs me that she is not the mother, but the stepmother. The mother abandoned the child during the previous hospitalization, and this is the husband’s second wife. “The husband has just gone home to get some supplies,” the nurse laments.

What am I supposed to say? It’s hard enough to inform family of a loved one’s death in my own culture, but this is a totally different culture. What are the right words, the right actions? And did this child really just die in front of me? Should we have brought the oxygen sooner? And should I be resuscitating right now? I look at the girl’s lifeless body, her ruffled black denim skirt and black shirt with a red heart stitched on it. I look at the size of her body, and picture the child CPR I am required to re-learn every year. Is there a point to doing CPR? Then what would we do? We don’t even have oxygen, much less a defibrillator, a respirator, or basically anything that would keep this child alive. No, the aggressiveness of CPR would just shock and horrify the stepmother and every other mother lingering just outside the triage door.

The nurse hands me the chart, and I search it futilely for information. There is no information I will find that will bring the child back to life. I know this; I am reading the chart to avoid accepting the reality, for just one moment, that this child is dead.

I look at the child again. Who is she? Who would she have been? Would she have been a mother? Would she have stayed in school and become an educated young woman? Would she be playing with her brothers and sisters right now in a yard somewhere, maybe crying when she falls down? Would she see me in the road and shout “Mzungu!” while shrieking with giggles? It doesn’t matter, she’s dead.

The nurse looks at the stepmother. “The child has died. You must be strong. She is gone. You must be strong for her. You must not cry. She was too sick. You brought her here, you tried, that was good. But she was too sick. You must be strong.”

The stepmother’s face doesn’t change much, but she listens intently. Like many people here, she is very stoic. Then I see her lips twist a little. The nurse says a few more words of comfort. The stepmother says, “Then let me go home.”

“How will you get the body home?” asks the nurse. The stepmother shakes her head. “You will leave the body here?” The stepmother nods. “You must call a mortuary,” advises the nurse.

I don’t know the procedures, the customs, the rules. I feel useless, standing here, not able to say or do anything helpful. But I don’t want to interrupt either. I watch their interaction until it seems to end, although I’m not sure what the decision is. And this child is still in her stepmother’s arms, dead.

“I’m very sorry,” I say. I put my hand on her shoulder. It’s what I would do in the US, at a minimum. I don’t want to be too touchy in case it’s inappropriate, but I don’t know what else to do, and I want to show sympathy. I usually get some leeway for being a mzungu; our strange behavior can be chalked up to our foreignness. She doesn’t acknowledge my sympathy, but she doesn’t recoil, either.

The nurse thanks me for coming to help them. She is genuinely appreciative. I watch her for a moment, and imagine all the children she must see die in that triage area, without any guidance or assistance from any doctor. I don’t know how she does it.

I walk out of the Pediatric Ward. The other mothers don’t seem to know that anything has happened. On the cement walkway between Pediatrics and Maternity, I encounter a Pediatric nurse and one of the midwives pushing a stretcher containing the oxygen concentrator. They are having a hard time maneuvering over the chipped, uneven concrete with the concentrator sliding around on the stretcher. I wave at them to stop moving in this direction.

The stop, and look at me apprehensively, knowing what this must mean. “The child has died,” I say. They are both disappointed. The midwife shakes her head mournfully, and the Pediatric nurse laments aloud – telling us how difficult it was to get the IV in the child, how sick she looked when she arrived.

I feel a little bit shut down. I haven’t processed yet. If I had sent the oxygen concentrator sooner, would the child have lived? Later, I realize that the child was well beyond that. She was severely malnourished, and the malaria pushed her over the edge. She had been that sick for several days, as they had told me. Oxygen can be lifesaving, but not for a child that sick.

Children are dying like that all over Africa and all over the world. I know that, and it would be easy to write off this death as “just another one.” I don’t ever want to be the person who does that. I want to stay the person who is upset and moved by death, who needs a moment to recover after something like this. That child was someone; she was me, really, separated only by geography and luck. Maybe mourning this death is na├»ve or sentimental. I am not a particularly emotional person, but I don’t want to be so cynical that I see this death as anything but awful.

2 comments:

danengber said...

Hmm, Veronica, I can't say your blog posts are rays of sunshine on a cloudy day.

But they are powerful and moving and I feel like I understand the world better for reading them.

We love you and miss you.

Hope said...

Thank you for your work, and for writing this. It reminds me that I too don't want to dismiss any death as 'just another' inevitability.