Death...

I mentioned in an earlier post that I had seen a man die for the first time in my life here. And honestly, as terrible as it was, I dealt with it fairly well. I didn't know his name. He was elderly. The first time I saw him, he had already collapsed and was being carried to the bed where he immediately died. 

Today was different. 

This was a beautiful young woman of about 18. She had had an operation here on Wednesday. I knew her name. I had talked to her and held her hand during dressing changes. I had checked on her when I did the dressing changes in the evening.

And today, just like that, she stopped breathing. I was a few beds away doing dressing changes when I heard the wail and saw the family start to cry. Her younger sister being carried away by the brother of another patient. The mother covering her feet, then her arms, then her face. Someone brought a guerney, and the men transfered the wrapped up body. 

It didn't take more than 5 minutes between the first wail, and the body being wheeled away, leaving behind just an empty bed.

Through it all, I watched as if in a trance. I couldn't move. I felt completely powerless. I wanted to do something, but what? I wanted to scream that we couldn't just let her die like that. No! We had to fight! Do something! 

I can't shake the feeling that in a different hospital, in a different country, with better equipment and facilities, she wouldn't have died. That was a senseless, unnecessary death, and I watched it happen and did nothing. 

There was nothing I could do. No defibrilator, no respirator, barely any drugs. 

I felt outraged and numb at the same time... I pushed it all down. I still had dressing changes to do... there were other patients who required my attention... I would have to deal with my feelings later. 

The thing about Malaria...

A couple of days ago, when I went in the evening to do the dressing changes of the two patients who are on twice a day dressings (one who is improving, one who is not), I saw two little babies in our "ICU" brought in with Malaria. 

Again, one had a hemoglobin of 2g/dl and the other 5g/dl (at that age, normal values are 11g/dl - 14g/dl).

The malaria parasites (mostly P. Falciparum in these parts) invade and destroy erythrocytes (red blood cells) causing anemia. 

The hemoglobin in the red blood cells is what carries oxygen in our blood. Without it, you can have all the oxygen in the world available, you're still going to slowly suffocate because there's not enough hemoglobin in your blood to carry oxygen to your cells. 

Hence why we immediately check hb levels and give blood transfusions, along with drugs to kill the parasites in the blood, and the hypnozoites which are maturing in the liver cells waiting to be released into the blood stream. 

Malaria, if diagnosed and treated early enough, is curable and you should feel well again in about 3 days. 

Here, these kids come in when they're already so sick, they're barely alive. The percentage of parasites in their blood is so high, it takes a while for the drugs to help. The transfusions improve oxygen transport, but don't fix the underlining cause. 

The drugs and the parasites damage the liver, and once they get jaundiced (sign of liver failure), there's little we can do. We have to stop the drugs, and then the parasites in the blood can once again roam free, worsening the anemia until the child is dead. 

That's what happened to one of the babies who came in Wednesday night. He was still alive last night, and I actually thought he was going to make it (when they come in that sick, they usually die in the first 24hrs)... but he was no longer there this morning. 

I broke my rule and asked what happened, and the night nurse said he got jaundiced, they stopped the quinine and the family took him home to die. 

In comparison, this is Chrystelle: 

She's the little girl I mentioned in this blog post: http://livinglifewithoutfear.blogspot.com/2014/08/the-day-i-did-everything-i-shouldn.html?m=1

For a few days after that, she would hide from me, because she knew I was the cause of her getting pocked full of holes so we could finally get her meds, fluids and blood. But it doesn't matter. She's back to her smiling, adorable self, went home with her mama, and even accepted a kiss on the cheek from me. Her parents always have a big smile on their faces when they see me. 

I might not be able to control the infection that is rampant in some of my fracture patients. 

I might not be able to save all the little babies that come in already half dead and unconscious from advanced malaria. 

But I will take heart in the story of Chrystelle. She might have been one of those who came in too late to be saved, if I hadn't stepped in. 

She'll probably not remember me after I leave. I, on the other hand, will never forget her... 

A day of firsts...

**WARNING** Graphic pictures, not for the faint of heart!!!

Today, in the middle of rounds, they bring a man in carrying him in a very awkward position, sort of vertical... When they passed by where I was standing, his eyes were rolling backwards and he seemed to have no muscle tone. Apparently he had fainted when he went to the bathroom... They put him on the bed as I finished the bandages on another patient. I immediately went over there, and the Samedi, our Chadian doctor had just stopped looking for a pulse. He was gone. I grabbed his wrist, nothing. Looked for his carotid pulse, nothing. He was still warm. 

The daughter let out a scream, almost fainted herself, and walked out crying, accompanied by another family member. The wife stayed there, wailing and touching him, and covering him, and touching his face... 

It was heart wrenching... 

It was the first time I actually saw someone die. Not even my own family members, (my dad!), I had not seen them after they were dead. 

I have seen dead bodies, cadavers in Anatomy Lab, but it is **really** not the same thing. They're cold, bloodless, and feel like rubber. It's hard to think of them as humans.

He was warm. It's hot here, so he was a little sweaty. He had come in for a hydrocele and had seemingly nothing else wrong with him... 

There are no autopsies here. He just died. I'll never know why. Maybe he had a stroke, or a pulmonary embolism... who knows...

People here seem to have coagulopathies, either they clot all the time, or they bleed and bleed and bleed. Probably a product of their poor diet... 

They also have cancer. Giant cancers. They let it go on for too long, and usually come in when they have giant fungating masses that smell awful and look even worse... 

That's supposed to be a knee. There's nothing that can be done, except amputate above the knee, but at this point, it's certain that it's in his lymph nodes and has spread to who knows where. There are no CT scans or MRIs here. He's going to die. We just don't know how soon. 

The surgery was gruesome. I had only seen a big toe amputation (diabetic foot) and the last part of an arm amputation, but I was scrubbed in and holding his leg from beginning to end. 

Separate the muscle from the bone 25cm below the hip joint, pull back the flesh to expose the bone, bring on the electric saw...

Those are my hands holding his stump.

Did I mention he was moving? He had a spinal block and ketamine, but apparently it was not blocking his motor functions. Thankfully, it *was* blocking his pain receptors, so he couldn't feel a thing.

It was the saddest surgery I've ever seen... 

I had to leave and go make myself some coffee... It was a really rough morning. 

In the afternoon, there was a hernia repair, no complications, a simple operation... So I scrubbed in as the first assist! 

That was awesome. I had my fingers inside this lady and pushed her intestines back into place. It made me realize that in the OR, when you're focused on what you're doing, you forget everything else. For a little while, I forgot about the man who died, and the other man who lost his leg... 

I guess I understand why some surgeons say the OR is their sanctuary... I think it might be mine too...