Death

It's early in the morning. I can't sleep even though it was a late night. I keep thinking back to yesterday. What could I have done differently? Why did it turn out the way it did?...

It started off innocently enough: a breakfast of potatoes and eggs hurriedly eaten so I could run off the make worship at 7:30. Andre read from the Psalms and we discussed being able to tell God everything we're thinking...even if it's nasty stuff like wanting bad things to happen to people and being extremely frustrated and confused. I guess that's what I've been doing since last night...

The report of the overnight guard nurse was uneventful. One kid admitted with Malaria. No problems with the hospitalized patients.

We pray and head off to work. Pediatrics is always first on the list for rounds. Now, instead of being depressing walking into a small dark room with dirty walls and floors littered with mats, wire charcoal cooking baskets, pots and pans and variously brightly colored cloths covering patients lying on mattressless metal beds with metal mesh as a base, now we walk into a brightly painted ample ward with fish, hippos, huts and horses painted on the walls along with colorful sketches done by some of the kids.

The first one is a 9 month old with Malaria. Doing fine, starting to breastfeed again, heart not beating too fast. The next is similar but anemic. Already transfused once, she's doing better but still has a really fast heartbeat and is somewhat pale. I'd ordered a repeat Hemoglobin on her yesterday which the parents still haven't done. Then there's the kid with an infection in the bone of his leg that had lasted four months. We'd unroofed the infected bone, left drains in and casted the leg to support the weakened bone. He seems to be doing better...at least his appetite has increased and there's hardly any liquid in the drains and it doesn't smell like it did at first. The next one is a 4 year old with Malaria and four different parasites in his intestines. He's fine and we send him home. We also send home a 6 year old with severe scoliosis who'd broke his ribs playing soccer...I guess he doesn't know he's supposed to be handicapped. The final patient is a little girl with burns on her abdomen and both thighs who had been treated at home for two weeks with a traditional goat hair paste and then came to us mostly healed but with a few infected places that now are almost completely closed after dressing changes and antibiotics. She's also our resident artist and has the cutest shy smile ever. She helps us as usual by carefully taking off her bandages to let us see the wounds.

Then, off to see the adults with their variety of post-partum, Malaria, diabetic foot post amputation of toes, and Koko, who will soon be the reason I am up typing this email.

Koko has been sick for 2 months. He came to us when I was in Denmark about to get married and was treated for Malaria. At the time he'd already been losing weight for one month. He then when to Kélo and was treated for Malaria once, then hospitalized later and treated for Malaria and Amoebas. Then, he came back on Thursday of last week and was treated for Malaria again and then Typhoid Fever. I just saw him for the first time Sunday. Yesterday was Monday. He's thin and somewhat wasted. It's his stomach that bothers him. Yesterday he was eating a little but his stomach was swollen and very tender. He had bowel function. Overnight his bowel function stopped and he started vomiting a lot. He looks bad. His stomach is bloated and doughy and filled with air but soft and tender all over but not extremely so. I suspect perforation from Typhoid or Tuberculosis or HIV with something else even weirder...I'd thought about operating on him yesterday and I think the same today...I'm uncomfortable with it though, he might die during surgery in his weakened state...but will it give him his only chance?

So I just order a CT Scan and get an Infectious Disease and Surgery consult (oh wait, I must've drifted off to sleep there and been dreaming...)...Instead I ask everyone to leave and ask him if he's ever tested positive for HIV. He says he's never been tested. We don't have any tests right (except for emergency blood transfusions) now but he says he does want to be tested if they become available. After getting the CT, ultrasound, and extensive lab test results back I...(wake up, James...) I decide he has something that needs to be operated on and even if he doesn't survive the surgery I'm pretty sure he won't survive if I don't operate. I don't feel comfortable with the decision but then decisions here are rarely simple as we don't have much to work with except clinical signs and a gut instinct...

I move on to consultations where I see a plethora ranging from constipation to hypertension to loss of appetite to testicular mass to miscarriages with products of conception needing to be pulled out to lipomas to hemerroids to Malaria to infertility to too much fertility (two women come in wanting tubal ligations: one has 8 kids, the other 9). I also spend some time supervising the nurse doing consultations and teaching the nursing student. My desk is piled with books that I have to consult frequently.

Andre passes me and says, "Make sure that guy you want to operate on doesn't die during surgery." Thanks, André, I'll be sure to remember that. Why would he say that anyway?

I finally make it home at 3pm for a lunch of fresh millet cinnamon bread and rice with one of Salomon's famous sauces. Sarah, Nathan and I play a few rounds of Rummy to while away the time. We're supposed to have a Managing Committed meeting but no one shows up.

At 6pm we bring Koko to the operating room, prep him, give him Ketamine, open his skin and find a seriously thickened peritoneum and a balled up mass of small intestine stuck together and to the abdominal wall. A thick greenish fluid comes out. Everything is covered with white dots. Tuberculosis. I free up some of the adhesions, irrigate well, leave in two drains and close up. He's doing fine. We wait for him to wake up. Pulse is fine. Blood pressure is fine. Oxygen saturation is fine. We have no cardiac monitor. He doesn't want to wake up. His kidneys have stopped putting urine into his catheter bag. His heart rate slows. His O2 sat drops. We have nothing really. We start bagging him and doing CPR. His O2 sat comes back. We give him the couple of medicines we have: Atropine and Bicarbonate. No pulse. Nothing. We do CPR for 20 minutes. He's dead. André's a prophet.

We pull out his drains, IVs and catheter. I call in the Guard Nurse who gets the head of the family. About 50 people are waiting just outside. They go to get a car to take the body. Nathan, Sarah and I wait with the body. Nathan offers me some Oreos. I accept. I'm drained and sickened. They finally come. As soon as they pull up the wailing and howling starts. Women flailing their arms and crying "Whoooo Whoooo whooo" and "Baaahooooh, baaaahhhhooooo"! I'm suddenly scared. I slink off in the moonless night to the small side gate as the truck piles high with many live bodies and one dead one. I watch from a distance in the dark. It's creepy. There are drum beats and slowly distancing primal howls and wails. I go back and eat some sauce and rice...I talk to Andre...apparently everyone but me knew Koko was HIV positive...I sleep fitfully...

James