Right now I’m lying in bed. The computer is in my lap and I’ve just been watching the cursor blink on and off on an empty screen because I don’t know where to begin. Usually I start with ‘yesterday’, don’t I? As in ‘yesterday I worked x hours at the hospital’. Yesterday I worked x hours at the hospital – doesn’t matter how many, but it was a lot… more than a day, and without sleep – we were slammed. There was a dude whose face was split in two, and the girl whose deltoid I pieced back together. They were both combative and noncompliant. The girl I had to wrestle to the floor so she wouldn’t hurt another patient who, coincidently, slashed her with a glass bottle. The guy… lot of blood, lot of anger – it doesn’t really matter. The point is I was already frazzled when the taxi pulled up; they slung a limp body onto a gurney and something ominous quickly permeated its sick self through the emergency room – the way the air feels before a tornado comes through.
As the story turned out, he’d been given an ampiciline injection earlier that day in his community hospital two hours outside Esmeraldas. Not a big deal – just an injection, so he went home to do whatever 14 year-olds do on Sunday afternoons. Shortly thereafter he went into respiratory distress and, presumably, anaphylactic shock. I imagine it got worse and worse to the point where he passed out – at least that’s when I first saw him… unconscious on a gurney. The story, though, we didn’t get right away – all we knew was a kid in front of us who could barely breathe.
Safadi instinctively grabbed his keys, raced to his locker and came back with the ambu bag – a balloon with a mask used to force air into someone’s lungs. Fitting, wasn’t it, that the oxygen tank didn’t work and the back-up was misplaced. I took off looking for a tank that worked like a bat out of hell, pens falling out of my pocket, stethoscope off my shoulders, shouting for people to get out of the way. Finally got him some oxygen. Safadi slipped a tube down his trachea so air went straight to his lungs.“Quick – blood pressure” I asked a nurse. 80/40 – half what it should be. I looked up at Safadi “We need to start an IV stat”. One of the easiest ways to raise the blood pressure is to dump juice into someone’s veins – while the circulatory system stays the same size, the volume of liquid (blood) increases, so the pressure rises. But it was a disaster – five people standing around watching as one tried to get the IV going. One of my biggest frustrations is that some of the staff lack medical intuition.
“The body’s cold, some one bring me a thermometer”. The lowest number on the scale read 35 degrees Celsius – his temp was less than that. Normal is 37. Shit. Quick, cover him. We need bags of warm IV fluid. What? Don’t have any? Okay – heat up some water and cover him with warm blankets? What? No blankets? Shit. Give me whatever you’ve got – we’ve got to get his temperature up.
Suction! What’s in his lungs? A lot of fluid. Okay, clear his lungs every three to five minutes – it doesn’t do us any good pumping air in and out if his alveoli are covered and gas cannot exchange at the cellular level. She agreed but 5 minutes later was nowhere to be found. By that time I was on the cart, my body on his body with a paper gown wrapped around both of us, trying to give him whatever heat I could.
His BP rose steadily, although at the time it didn’t seem quick enough. There was a sigh of relief, though, when the cuff read 130/80. The decision was made to move him from the ER closer to the operating room where the heart monitor is located. They wheeled us down the hall – I’m still covering him, my elbows straddling his neck, propping me up, keeping the pressure off his airway. His mother was a mess, understandably.
The oxygen tanks in this hospital aren’t like the little portable green ones we have in the States. They are huge, like missiles, and they weigh a ton – you have to wheel them around on dollies, which is probably why the oxygen tank didn’t make the trip with us down the hall. Unfortunately the O2 tanks in the room outside the OR were malfunctioned and the patient went a couple of minutes (more than 10) without anything. As a reference, brain tissue starts dying after 5 minutes without oxygen. We finally got him on the monitor and his heart was all over the place – sometimes down at 70 beats per minute, but shooting up to 208 and holding steady. When his heart does this we press his eyes or massage the carotids in his neck, which stimulates a parasympathetic response that slows his heart back down so that it has enough time to fill with blood. Complicating matters, the pulse oximeter showed less than 25% of his red blood cells were carrying oxygen – as compared with 99% that you and I have at room air. Basically his body was not being fed. And so it was a constant game between ventilating and suctioning – the liquid in his lungs had to come out, but every second spent suctioning, not oxygenating, was costly. So we suctioned and his oxygen saturation plummeted – we ventilated and his lungs filled with liquid.
When I asked a nurse to squeeze the Ambu bag and breath for the kid, she told me that it was a man’s job - then left to catch some sleep (really, she was out in the hall on a gurney sleeping). Shit. Why? Aghh. So a few of us took turns bagging the Ambu for 4 hours. In the actual operating room was a machine that could do all the work automatically, but the director of the hospital wouldn’t give permission to use it. “Someone get me a knife,” I sarcastically ordered, “we’ll give him a little cut on the back of his leg then have reason to use the OR.” After a few hours we stole a portable ventilator from the Pediatric floor. It wasn’t being used, but the political levies broke in the morning because it wasn’t our equipment. Safadi and I were calling the shots, but I let him take the heat on this one – because technically I’m only supposed to be observing. He asked the question I wanted to pose – what else were we supposed to do? The hospital director’s response: we should have told the mother we didn’t have the equipment to take care of her son and left it at that. My spine froze.
We did everything we could but it became hopeless – he was most likely brain dead, although we did not have EEG confirmation. The family was also economically disadvantaged and could not afford keeping him alive even if we had got him stable. “Do we continue or do we stop?” asked Safadi. We stop. The decision was unanimous. So we gave him oxygen but stopped the Ambu.
Two others were with me when his heart stopped beating. I glanced at the monitor. That’s what a flat line looks like, huh? Then I sighed. Pobre cito. Little one, it wasn’t your fault and the world is not fair. Your mom does not know that you’ve gone yet. Let me take these tubes out of your mouth, these lines out of your veins, the death out of your face. Close your lips for me. Close your eyes; let me tape them shut and wash your body so your skin can catch your mother’s tears. Let me do this for you.
I wheeled him out and accompanied his family to the morgue – a dirt floor under the rafters of the hospital. They asked for the death certificate but nobody moved - a combination of fatigue and distress. I felt strongly that it was their right to have this done quickly. Somehow, then, it was on my shoulders to get the papers and explain them to his mother. It’s not a job I woke up wanting to do, filling that void, but it was important and eased her grief. She broke down in my arms and wept - and I hugged her and told her I was sorry, and I held her for a while and did not know how she would respond. But then she thanked me, and I melted, the tension in my body dripped away and I didn’t care about anything else – just that she knew we did everything we could – we who stuck it out.But the everything that we did was not the best that we could do. We can do better. I know we can. Nurses vanished, directors twiddled their thumbs, and even some of the doctors shied away. In Esmeraldas this is just a job, a salary, a way to pay the bills, and sadly there is a disconnect between the responsibility that is called for and the heart that is needed. But not everyone embodies this mentality. There are a handful who care, who feel - who want to become better. Although it is counter-cultural, I’ve called a Morbidity and Mortality meeting for this handful to discuss the case, not as a blame game but as a means of learning from our experience - what went right, what went wrong, what we learned, and what we’ll change. I’ll let you know how it goes.
-BH-
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