She's Just a Girl

​Sayla  (1997-2012)

Sayla died on Wednesday and we are all very sad, a little overwhelmed.  Sayla was the first patient in the diabetes clinic we set up on during our weekend rounds at JDJ.  Shortly after, when Seongeun began accompanying us to the hospital to do arts and crafts, Sayla would be the first one waiting for her at the door.  She helped Seongeun set up the area between the pediatric ward and mother’s room and was an eager participant herself, coloring intently pre-printed pictures or making paper crowns.  Sayla was fifteen years old. 

Seongeun tells me that once when a pesky four year old began terrorizing others by stealing their rare crayons including Sayla’s, Sayla turned to Seongeun and without speaking, gently communicated, don’t worry, it’s okay, she is just a little girl.  Each Sunday when we left the hospital, Sayla would grab our hands with the two of hers and say, “Thank you for coming.”  This was one of the few consistent phrases shy Sayla ever spoke. 

I wasn’t sure much about Sayla’s personal life because she would never give me details. When it was her turn for me to see her in between the gasping, heaving, unnaturally still or writhing patients in the Intensive Care Unit, I would bring her in from the art room and ask her about her studies as a distraction against the blood sugar test she was about to get and she would look at Augustine my health assistant and say, “Fine.”  

I would say, Sayla, why don’t you look at me when you speak, it makes me feel like you can’t hear me.  And at this she would glance in my eyes for just an instance before letting her gaze fall quickly into her lap where her hands were clasped.  “I am fine,” she whispered again.  

We would continue in this way.  I chirping one thing.  She chirping back, but a truncated version.  Her sugar would be high at 280 but not too high to adjust her insulin regiment since we were basing her treatment against innumerable conditions anyway-- whether Saya was eating, what was available to eat, her activity a particular day, the weather, whether she was staying with her mom or dad, how well the family was storing the medicine.  Once a month Sayla brought in a dusty navy blue cooler, containing bags of melting ice to take home insulin, which we supplied.  Placing the insulin in the box I always wondered how long this type of cold chain could last.  I tucked the medicine between two slightly cool bags as if tucking them to bed, only I didn’t want them to warm.  I would watch one, two, or three dirty droplets run down the slippery plastic walls before quickly closing the lid.  The contrast of white against dark would stay with me for a blink or two.

I first heard that Sayla was sick ten days ago.  She had come in with vomiting and fever and been diagnosed with malaria for which she received Quinine.  

Then George, the JDJ clinical manager, called me six days ago that Sayla’s sugar level wasn’t even registering on the machine. She had started breathing fast.  I was just leaving to attend our weekly coordination meeting.  I told George to give Sayla 1 liter of fluid over one hour and start her on an insulin drip at 0.1 units per kilogram an hour.  Since Liberia doesn’t have infusion pumps I reminded George that 60 drops in the IV tubes equal 1 cc, that 1cc contains 1 unit of insulin, that Sayla weighs 40 kg and not to kill Sayla. 

​Sayla at Princess' birthday party

Then last Sunday, during rounds I was happy to see Sayla’s sugar under better control.  She was even hungry so we got her some rice with cassava greens and pepper sauce from the kitchen which she ate.  I shut off the insulin drip and changed her to an injectable intermediate and short acting insulin regiment.  I helped Augustine write out the new nursing care instructions.  I then proceeded to see the other patients in the room and strike the balance between encouraging the medical staff and pressing them to be much better, trying not to yell. 

Ten minutes before leaving, after four hours of sweating, after discovering that the hospital was again out of high calorie milk, that two patients including a ten pound one year old had not been fed in three days; after yelling at a nurse for accusing a mother of lying (“The guy who sells phones at Lonestar doesn’t treat his customers like that,” I said.) and thinking maybe all is indeed hopeless relative to so much effort and time, Sayla started to moan.

 “What’s wrong, Sayla?”  I asked, but of course, Sayla did not answer me.

“Augustine,” I asked, “What’s wrong with Sayla?” 

“She feels hot inside,” he discovered.  This helped me little.  I listened to her heart and lungs:  slightly tachycardic and clear.  I pressed on Sayla’s belly:  tender but no guard.  We retested her sugar:  180. 

Sayla’s  moaning continued and I was acutely aware of my irritation-- this non-cooperative, sick girl.   I remember now the thick grit and callousness of such un-doctor-like emotion and it fills me with tumult and even shame.  I think maybe Sayla had a heart attack from too high of potassium; that this wasn’t only gastritis from stress.  I have never seen a heart attack in a patient with diabetes before though it is certainly possible.  Sayla’s potassium levels on the last read were high but we had also responded to this and clinically, she was improving, that is, before the moaning.

I left after prescribing some ranitidine and asked the staff to keep me informed.  Over the next four days, JDJ was fortunate enough to have an excellent expatriate doctor from UC San Francisco visiting and in addition to placing him in the sweltering JDJ emergency room to model good behavior, I had him personally manage Sayla with me using all the medicine that we knew and had.  We thought it would be good enough.  We thought she was getting better.  But then Sayla developed a 104 degree temperature.  Then she was unconscious and there was no more moaning.  We placed her on double intravenous antibiotics.  Her kidneys stopped functioning.  We gave her multiple boluses of fluid while being distinctly careful not to drown her. But on May 9th at 2 a.m., while we slept, Sayla died.

We are going to develop some pictures we took of Sayla and frame them for her mother.  She almost certainly doesn’t have pictures of Sayla.  We are going to give the family money for the funeral.  Funerals like weddings are extremely expensive in Liberia.  We are going to allay the fears of the other diabetics:  Daniel, Felicia, and Princess and explain enough of what happened so that they can still believe all will be okay for them.  Once again, we will sift through the medical chart for clues of that which we must have missed.  Yet, these efforts are reactionary, perfunctory.  I can’t stop thinking this.   Our diabetic clinic didn’t do squat.  Western medicine and training did not prevail in the end.   Sayla’s Mom lost her daughter, a strong generous teenager who had only just started to live.  It’s hard to know how to process any of this with suffering so relative.   One can only say we miss you, Sayla; we are sorry; and the world is less now that you are gone.