By Paul Gross
Paul Gross worked with Dignitas in Malawi as a medical resident and shares his reflections on a particularly challenging day at Zomba Central Hospital.
Today was a crushing blow to my spirit. Some days, the world and all its soul-numbing realities hit you in the face and knock you to your knees. I started the day to hear that one of the most valuable and honoured members of the hospital staff died, suddenly and unexpectedly, on the medical ward. Though I didn’t know her well, I understand she was well loved and made remarkable contributions to both Ministry of Health and to Dignitas since 2004. With that shocking and terribly sad news, I took to the pediatric ward hoping to help patients in whatever small way I could.
I spent most of the day taking care of a 12-year-old girl who was terribly sick. Her heart was pounding out of her chest, a gallop rhythm running through the tubes of my stethoscope signalled severe heart failure. Her anemia had not responded to the transfusion she received last night for a hemoglobin of 4.1 g/dL. Her other blood counts were dropping and her chest Xray looked ominous with a large heart and a wide mediastinum. While she was taking a breath per second, a rate the body simply cannot maintain for long, I was trying to piece it all together and realized that there was still much to do. After rushing her to ultrasound, a repeat chest x-ray and yet another transfusion (which took all of four hours to accomplish), I felt things were becoming clear. Parvovirus would offer the possibility of a unifying diagnosis with bone marrow suppression and global myocarditis to explain her failing, enlarged heart and might explain that vague rash which has left a few subtle dew drops on the sides of her face. However, in the absence of advanced diagnostic tools, it’s exceedingly challenging to find Occam’s Razor that might account for unusual clinical syndromes in sick patients. Then her HIV test comes back positive. Tragically unsurprising, another sick child found to be HIV-positive in Malawi. She had never been tested before. At 12 years of age, the possibilities for why an otherwise healthy-looking girl would have a positive HIV test are limited. That’s not an issue for today though. She’s breathing like a fish out of water and we’re trying to figure things out.
After committing her to a course of dexamethasone and digoxin, a young paediatrician and I felt we had really done all we could to get ahead of the pathophysiology that was pushing her system to the limit. There is no good evidence to reassure us that we are guiding this patient in the right direction, often we are taking a therapeutic leap of faith over a chasm of uncertainty. We hope, ever optimistic, that we will all land safely on the other side.
While I was rushing to help this patient, the grandmother of a 2-year-old girl lying in a bed crowded with three children motions urgently to me. I consult my Malawian colleague who tells me she is worried about the girl but that she was just admitted a short time ago and her blood tests are all at the lab being processed. All the appropriate treatment has been given to the child, we have only to wait for the pending lab tests to indicate whether she needs a transfusion to help her system overcome a severe case of malaria. As I was busy with a critically sick patient, I had decided to go to the lab very shortly and follow-up on those results. After all, it’s clear that if one pushes to get things done, patients benefit. In a setting like this, as strained as it is from all directions, sometimes that’s the difference between life and death. One blood transfusion. So, I briefly left the ward to review another patient with a colleague and returned to the wailing cries of a woman; probably the mother of a patient who has just died. This soul-wrenching cry is sadly commonplace on the pediatric ward, a daily reminder that for many little ones, life here is tenuous, occasionally ephemeral, ever in the balance. I rush to the ward worried it might be the 12-year-old girl who I had tried so desperately to help for most of the day. Instead, I find a motionless mass covered in chitenjes, the traditional cloth women wear around the waist and use to sling the young to their back. The little 2-year-old who that grandmother had called me to see had died. Now, I was called to do something that is hard enough to carry out on an adult, let alone an adorable 2-year-old girl. The ultimate medical act is the pronouncement of death. It is a solemn procedure. In the midst of the wailing of the mother and grandmother, I found the child had indeed passed. Fixed pupils, a silent heart and absent respirations demonstrated the final signs of severe malaria. Her conjunctivae were as white as paper. However, her skin was still warm. I felt that somehow, as the heat left her body and the blood that was now frozen in her circulatory system cooled down, she would transfer some final, fading energy to her loved ones as they embraced her.
On a day such as today, I find myself wondering how it is that a 2-year-old can die of such a preventable infection. Most of the time, I see the reasons why, the determinants of health that have contributed infinitely more to the appearance of falciparum parasites on that child’s blood smear than the simple bite of an unsuspecting mosquito. There is a world of interconnected reasons to account for this tragic tale. But today, I am left with a simple human emotion, a feeling of profound sadness. There is nothing just about this story, and yet it could be told daily across the world, in more ways than one. Often times, we have to spend time coming to terms with the suffering and sadness in this world. On occasion, it creeps up on you, but today it was a sudden rush of cold, brutal realities; as we tried desperately to help one child, another dies. Such is the balance of our efforts here. I have endless admiration and respect for the clinicians who witness this on a daily basis, live their lives, and continue coming to work hopeful and energetic. After a day like today, and the welcome solace of deep introspection and open expression on this page, all that is left to do is wake up tomorrow, roll up my sleeves and get to work again.