Reckoning

We start in the corner and follow eight beds in parallel each holding 2 patients casually.  Three of the kids are going to die.  I know this because of their size and the way they look.  “Sick, sick, not sick, not sick, very sick, very sick, “ I point, as if I am conducting a Liberian medical symphony.  “That kid needs to go home.  That kid is too fat. That kid we are starving to death.  That kid has problems…” The physician assistant, nurse and nurse assistant on my team look at me as if I am mad. 

It’s not hard to be pediatrician.  You can go to butchers school and know ninety nine times out of a hundred the difference in appearance between a well child and a sick child, so long as you stop and care.  Stop and care.  There, I said it.  I am the most unmanly man.  I am a Susan Sommers' Saturday infomercial.  But, it’s true.  Kids aren’t like adults. They don’t just die on you.  When they die, it’s only after showing a long tortured pattern of sickness that you have to be either derelict or blind not to see.

There are many derelict blind clinicians in this world, unfortunately.  I am in Liberia but honest, the same things goes on in the United States.  Here, I look down at a seven month old baby being treated for pneumonia looking only to the right.  In New York, I ask an obese fourteen year old who comes in for a cough, why he limps around as if he suffers polio.  “Oh, I’ve been limping around like this for six months,” he says, “but my doctor said there wasn’t anything wrong with my knee.”  The kid turns out to have kind of dislocated hip called SCFE—a classic presentation of a fat boy maturing on too flimsy a thigh bone to the point he slips off it.   The boy I send to surgery that day.

Here in Liberia, I lift up the child and he is stiff as a board.  “Uh, John,” I say, “Do we really think this kid has pneumonia?”

“That ‘s what the emergency room diagnosed,” John the physician assistant says

“John, the emergency room doctor also says that this boy is a 40 year old man with a drinking problem.”

John furrows his brow in confusion, “That can’t be right,” he says.

“It isn’t, ” I say, “But your job is to make sense of what you see with what you know, not to simply carry over a diagnosis from the ER from someone who apparently doesn’t know what the hell they are doing.”

I shouldn’t cuss, but John is new, clumsy and not very good and I am mad that everyone coming from the ER is being treated for three diseases simultaneously (malaria, pneumonia and sepsis) when usually they have none of them.  The most sensitive sign of pneumonia is breathing fast.  The body responds to fluid filled lungs by breathing faster to maintain the same level of oxygen exchange.  This baby is not breathing fast.  No flaring of the nostrils or showing of the ribs when breathing.  I time the baby’s breath for a minute and it comes up 32.  Normal. 

On the other hand, there aren’t too many things that make you stiff like a board.  Tetanus can do it.  Seizures can do it.  In this environment, meningitis—infection of the covering of the brain-- is a likely choice.  The inflammation from the infection is building up against an unforgiving skull, in a sense, crushing the brain and causing its dysfunction.  The child has had fever.  Reading through a week of notes, only one physician assistant wrote three days ago, “meningitis?” and no one has mentioned the child only looking to the right.  There has been no attempt to confirm or exclude the diagnosis or any alteration of the care plan, which would have to happen if the child indeed has meningitis. 

I have the nurse gather the materials for a lumbar puncture, a procedure that allows us to see the composition of the cerebral spinal fluid, which bathes the brain—a poor man’s view of the central nervous system.   Spinal fluid doesn’t have white blood cells in it and it certainly does not normally contain bacteria.  If the child has meningitis, then when we look at the fluid under the microscope we will see white cell silhouettes not unlike melting snow flakes—immunologic jelly fish in the body’s fluid morass.  I explain to John who has never done a lumbar puncture before the importance of securing a proper diagnosis so we can know the best drug to treat the disease and for how long.  I explain the landmark at the back right above the butt crack of an imaginary line connecting the top of the hips to designate a space two vertebrae below where the spinal cord ends.  It is here we will safely place the spinal needle.  John asks, “What happens if we put the needle in the spinal cord?”  I want to slap John. 

I wasn’t supposed to be at the hospital this morning and I shouldn’t be so smug.  I came early this morning, rousing myself out of a comfortable bed, because I realized the F100 formula recipe I concocted for the starving baby in the other corner of the room the day previous would kill it.  Following my typical Saturday afternoon at the hospital, I had been studying the treatment of the severely malnourished for a grant proposal I was putting together when I realized that I was about to give our 4 pound 1 month old patient voluminous diarrhea.  F100 is catch up milk meaning that is contains 100 kcal per 100 cc of milk compared to breast milk which contains about 75 kcal per 100cc.  Malnourished kids let alone any infant less than six months of age can’t handle this concentration of calories.  Their bodies have adapted to a diet of little, slowing things done and resolving electrolytes and fluids into compartments that don’t usually contain them.  Simply giving a malnourished child intravenous fluids can drown it, the heart suddenly infused with a load that it is not accustomed to pump-- an old man’s heart.  Giving a malnourished child diarrhea through ingestion of high calorie milk is worse, like flooding the system as described, then quickly emptying it in a torrent of shit.  That is how a doctor who doesn’t know what they are doing can kill a patient in Africa.  That doctor yesterday was me.

And yet I have to admit, for an instant, it occurred to me not to come back to the hospital this day.  I have been working 80+ hour weeks and am really tired. I had just spent six hours of a day off seeing patients.  I rationalized that the kid with F100 had more of a chance to live than it did without F100.  Shouldn’t the next health professional be able to catch my error?  I thought about calling the hospital but there isn’t a central number.  The staff constantly switches around and honest, I haven’t learned most everyone’s names.

The predicament cast me back to my time in Rwanda in 2007 when going to sleep literally meant that people would die.  I was in a hospital with three other physicians who didn’t give a damn.  We lived not fifty meters from the inpatient wards and at night, the guards would rap at my window signaling to me that someone was very sick.  No words, just the knock of knuckles against the steel window screen.  I would startle awake, my head caught in the mosquito net as I sat up suddenly, “Yes?” my voice rising way too high.

But it wasn’t my turn to come to the hospital. But I have been up for three days straight.  But I am a pediatrician and chances I wasn’t being asked to come to the adult ward.  But I am only one person…  The rationalizations were infinite but when it came down to it, you either went or you didn’t.  You either cared or you didn’t.   You either decided to do your best or you pretended you were doing your best. 

When I arrived at the hospital 30 minutes from my Monrovia apartment this morning, the ICU was quiet.  Turns out that the kitchen staff trained by MSF had caught my error and prepared diluted F100 instead of regular F100, which was just what the baby needed.  Saved by the kitchen staff!!  The baby had started on his new feeding regiment.  I knew this because the feeding chart we had constructed was getting filled out and for the first time the baby was resting comfortably, not crying in hunger.  I swear could see meat growing on his bones right there on the spot.  Being already at the hospital, I thought I might as well see a few patients while mentoring the clinical staff, which today means rounding with poor John.  I don’t let John do the lumbar puncture on this day.  See one, do one, teach one.  John needs to practice seeing.  I do the procedure and the fluid that drips out is off white and cloudy.  The baby turns out to have meningitis.  We change his medicines and we hope for the best.  Change and hope being the operative words here.