Wednesday, July 30, 2008

Death, Guilt and Anger

Death Sorry to the faithful readers (Cath is totally my biggest fan, holler for her) for the 10 day hiatus, as the numerous posts will tell, much has happened, good and bad alike. I'm screwing around in the Kenyan big city capital of Nairobi (pop 3-5 million, give or take a couple million), classic Lorenz style--with stories coming faster than I can write them (a preview: the hardest Muzungu ever, sugar daddy and a prostitute...stay tuned.) I found a huge garage sale (market) yesterday, made some friends and watched that new badass Angelina Jolie flick. I fly home Thursday morning.

Cath, I ended up not making it to Arusha again, so I missed your friends. Just took the straight shot to Nairobi this time.

Jack. I'll send you an email with the book and details. It's a good one.

Thomas. You bought a house without me? How could you! I hope it's in Berkeley somewhere, right down the street from me and Dan. It's been too long, we need to talk.

Mikah. Thanks for the encouragement, very well put. See the following posts for ample discussion on getting to know oneself, personal growth and whether this is really for me.

Death, Guilt and Anger

(Written Thursday, July 24, 2008)

I thought twice about even writing this. There’s something…sacred about death. As if talking about it is sometimes inappropriate or uncomfortable. I hesitate to put down my thoughts on this young one for everybody to read. But it will help me to share it, and will tell a sadly common story in Tanzania.

Two of the children I have cared for have died. I think I mentioned the first—a 12 year old girl who fell 2 weeks ago, then presented to the hospital with right sided paralysis, aphasia and meningeal signs. I suspect she had a bleed in her brain, but am not sure. She died the following day. Without a CT scanner and a neurosurgeon, there is little to be done. And even then, the prognosis can be ominous. For her, there was not much we could do.

With the other girl, I’m not so sure. I worry I could have done more.

Naomi was a 2 month old little girl, who presented with headache (not sure how can you tell in a 2 month old), fever and respiratory distress. She had been diagnosed days before with uncomplicated malaria and given outpatient treatment which, obviously, had failed. When she began having seizures at home, they brought her back.

As I mentioned in my last entry, I saw her around 2:00 pm. It was the end of my horrible day rounding alone; I was tired, overwhelmed and exhausted. The last thing I wanted to see was an ICU level ill child. Just eyeballing her, she was sick. She looked dehydrated, listless, pale. She was not seizing. Her neck was supple, heart tachycardic and hyperdynamic. She had an enlarged spleen. She was febrile.

I was sure this was cerebral malaria. Or seizures from hypoglycemia (low blood sugar) from malaria. I reviewed her orders—antimalarials, blood transfusion. I added anticonvulsants to control seizures, and broadened her medicines to include antibiotics for meningitis just in case, although I had low suspicion she had meningitis. She was deathly ill to be sure; we could only hope we got the medicine in her fast enough.

Because I was worried about her and the other seizing child (with meningitis), I returned to the pediatric ward around 7:30 pm to check on them. The meningitis baby was unchanged. When I went to look for Naomi, I didn’t find her in her room from the afternoon. I asked the night nurse, who told me, “Oh that one died.”

I’m not sure how I felt at that moment. Even as I think about it now. A combination of things. Numbness for sure. Shock. I knew the kid was sick. And really sick. But I was just shocked that she died. Denial that it could happen to her, and to me, her doctor.

At the same time, I felt horrible guilt. What could I have done? Should I have given more anticonvulsants? Sat at the bedside until I was sure she was stable and improving? Could I have given more fluids? Maybe more glucose? Should I have had Machage evaluate her immediately?

I reviewed the chart with the medical officer. She had just pronounced Naomi dead at 7:00 pm. The medical officer didn’t seem to have any reaction at all. Here I was, getting all worked up about what we could have done and the fact that we lost one, and to her, it was just another kid who had died of malaria. Happens all the time.

Not to me, it doesn’t.

We reviewed the chart together. Something that could have been improved—IV instead of IM quinine (the antimalarial). This was theoretical—we didn’t have the IV fluids to run it in with; we could only do IM. That was all she had to say. The lab results came back—positive for malaria. In patients hospitalized for malaria, there will be hundreds (100-400) parasite rings reported in a blood slide. This patient had 4,000—10 times the highest I’d previously seen. Tons of parasites in the blood, it’s no wonder she was so sick, with seizures, and ultimately, died.

Nonetheless, I felt horrible the rest of the night. I’m mildly nauseous still now. On the one hand, sometimes there is nothing we can do. People die. Kids die of malaria. And there a point when it is too late and there really isn’t anything that can be done.

On the other hand, malaria is a treatable infectious disease. Treat the underlying infection, support the rest of the body in the process (give fluid and glucose, control seizures and temperature, etc). I know more could have been done. But many of the things I know how to do—continuous vitals monitoring, checking blood electrolytes, giving oxygen—they just don’t do here. There is no intensive care unit for patients like this.

There was nothing we could do vs. I didn’t do enough. Sometimes, the truth only lies in the heart of the doctor. Other times, nobody knows.

I do feel like I could have done more, even here. More aggressively lowered the temperature, controlled the seizures, given more glucose.

But I doubt it would have made a difference in the end. Perhaps the worst thing about this—I will never know for sure. Maybe if I would have done all that, things would have turned out differently. Maybe if she were in the ICU at a childrens hospital in the US, she would have survived. You never know.

It’s been a couple hours since I wrote the above, where I largely felt guilt for what had happened and not being able to do more. After a couple hours, things have changed: now I’m pissed.

I’m angry. At everything. Mad at myself for not doing more. Mad at those parents for waiting until that kid was having seizures to bring her back to the hosptial. SEIZURES--Helloooooo! Mad that the hospital staff doesn’t seem to give a damn that another little kid died of malaria. TREATABLE DISEASE, PEOPLE! Pissed at Machage for dumping his pediatric service on me, and then neglecting both me and his patients. Mad at the stupid mosquito that carries malaria, and the even stupider Plasmodium parasite itself. JERKS! Angry at Tanzanian heath care, that they don’t have more treatment options, more money. And the corrupt Tanzanian government. Mad at the rest of the world for not caring more. Pissed at the nurses for not paying closer attention to the sick kid, and doing exactly what I told them. I’m just frustrated as a doctor that knows that this kid could still be alive but—for a hundred reasons to get mad about—isn’t.

Before I got here, I was shaking with excitement. Well now, I’m shaking with rage. And I’m blasting anything that moves with it.

I don’t know what I was thinking coming down here. As if I’d be able to save these kids. I’m in over my head. I wasn’t trained to do this. Seeing 30 sick kids a day dying of diseases I’ve never seen is more than I can handle. Two days on the peds ward, and I’m gunna crack.

I want out. I want to go home. I want to get on that motorcycle and just ride to the lake or the mountain or somewhere far from this frustrating hospital and get away.

This kind of limited medicine sucks. It’s frustrating. And right now, I don’t want to be a part of it. Watching kids die when I know something could have been done? Fuck that—it takes it’s toll. Either you toughen up and disconnect from patients, or you suffer. Right now, I don’t want either.

Ya, sure, they do their best with limited resources and think about all the good we’ve done—blah blah blah. I don’t want to be positive right now. I’m pissed and irritable and am going to be that way. IT’S JUST NOT FUCKING RIGHT. It’s not fair—shitty health care, growing up with malaria. I’m not even going to start with the comparisons for a kid born here versus the US. This goddamned world.

I went to medical school to do something about this stuff. Save the world, work for justice. What a fucking joke! This is more like my own little luxury vacation to feel really good about myself, and it’s sure doing me a lot of good. Two weeks is nothing. Even if I devoted my whole life to a hospital here, it would barely be a grain of sand on the beach, or a drop of water in the ocean. 40 Million Tanzanians—millions die of malaria a year. MILLIONS! Huge, the problem is enormous. Every time you treat and discharge one, the bed is filled the next day with another dying of the same damned disease. And the system changes to really make a difference are so much deeper, long-term, structural—that it makes things seem even more…


Sorry, but I’m pissed and depressed and that’s how I feel right now. If I were at home, I’d get on the love sack by myself and watch Just Friends or Toy Story or something and eat a ridiculous amount of MacDonalds, Sprite and heavy butter popcorn.


Camilo said...

Larry, it's good to be angry sometimes. Own that s***. Then take a deep breath and recognize that you are making a difference. Sometimes we just have to be a witness and to care, and that's all we have to offer. But that's still something. And the world's better off for it.
I have to believe that.

Blair said...

It is great to read your thoughts buddy. It is ok to pissed at the world in your situation. We live in insanity. Absolute brutality, where people can die like animals from preventable illness. I am sure your anger can turn to righteousness and you will use it to energize you for future good works.
Keep reflecting bro.

barryllium said...

Bud, as much as I can sitting here at a desk in South Bend, Indiana - I feel you. I'm constantly disgusted by the gluttony of others and myself while the things going on in the rest of the world keep going on. And I'm also disgusted with the fact that so many people think their life is so much more important than the lives of anyone else. If you ever come up with a better plan to save the world that I can help with, I'm right there with you.