08 April 2013

Where there is air

A warning: the cliched "not for the faint of heart." It's not that. This is brutal and real and written in the way it was lived and that now, three weeks later, I remember. I don't dissimulate because, well, why should I. If you don't want to read it, and there's nothing wrong with that, then don't.

There is much more to write that I am writing or have almost finished, and I'll send those, too. There is more that is, actually, happy. The month was that, too, but this is the medical part. 
These are no longer chronological -- and -- I'm currently back in the States.

I started this piece during a workshop I was leading on public medical writing, and for some reason I decided to leave myself (explicitly) out, though in truth I was very much a part of all of it. A lot of what was happening was both the resident and me, or I was giving and carrying out orders that she gave. And yell is a more appropriate speaks strongly, or gives orders in an emergent situation because it's necessary.

I hesitated about writing and then about sending this one. I am anyway. Because it's the truth, and because it could have been written more graphically and more difficultly than it is.


The trauma room is caked in mud: people’s shoes, falling off of clothes, some mixed with blood but all mixed with small rainy season.
The aide from that week’s emergency room team was sweeping.
The patient had been wandering around for days, slightly bored and healthier than most. She couldn’t speak. She looked almost comical, if you’re allowed to think that sort of thing. Tongue protruding (macroglossia. Medical term, like hypothyroid? I still hadn’t read the chart; there kept being something else to do) from her mouth. Larger than tongues are. When she made sounds, they might have been words and just unintelligible. I’d never tried a conversation. The thick bandage is wound like spools around her neck. Her bed was in the front room, where it never made sense who stayed and who went to the other, quieter observation rooms with four beds and curtains or eight beds and curtains. In the big room, the front one, everything was open. So many nurses sit at the triage table, close enough to see most of the patients, bored. There are the two men in, basically, comas, another one with machete injuries who is too large to move, and her, sitting on her bed or wandering. I don’t know if she had HIV, after which I’d have to say “too,” adding to the list of so many others in the department.
 It happens fast. No one screams or someone does, and enough were in the room as she grabbed at her throat. It must have been uncomfortable and hot, anyway, in equatorial Africa, the highest level hospital has no air conditioning (and no mosquito nets in the big room). One nurse starts to unwind the bandage. Slow. An ER resident here from Belgium for a rotation yells for scissors. There aren’t, or no one knows where, or no one tried to get them. They keep unwinding. She keep grabbing at her throat. The bandage was off. And she was on the floor. Bed. Fell.
The aide kept sweeping.
The resident looks at the nurses. Move the other patients over. Make room. We need her in the middle. Is she breathing.
She is not.
The aide kept sweeping.
It's the second time for chest compressions in two days, the nurses had started to learn the first new rule – thin, gym-like mattress to the floor. No point in compressing a bed that’s only springs. There aren’t any boards here. Mattress to the floor.
The aide kept sweeping. The resident yells. Points. The aide left the room.
Oxygen, get oxygen, she says. There isn’t. But we did this yesterday, she says. Someone move her to it. Someone get the tubing and the mask. Minutes, minutes. This time, someone goes to get the adrenaline when asked. Someone else doesn’t have a syringe. Wait. Where to get a syringe. Steal it. Steal it from the other patient.
The intubation kit. After asked. After pounding on the chest for however many minutes (still a pulse), with the ill-fitting mask, some oxygen, bagging it into her lungs three times after every thirty compressions (still a pulse).
 Are there any other doctors? Get anesthesia! The resident yells at a nurse. The nurse walks. The nurse starts to run. Minutes. Thirty compressions. Three breaths, or pulses from the bag into the mask into her mouth. No pulse in-between. A nurse kneels hesitant, holding the wrist, slight pressure on the radial artery. The resident yells. Femoral. You won’t feel it there. Femoral. The nurse kneels hesitant. Hand moved to the other pulse. Is there a pulse (no) are you sure (no) are you sure (yes). Still waiting.
The resident tries to intubate. A tube. A larger one. A smaller one. The laryngoscope has a light. The woman is choking to death. Her neck is swollen beyond recognition of what a neck might be. There is no way to pass a tube. She needs a tracheostomy, she needs a hole in her neck to help her breathe. The resident doesn’t know how. There is no one else.
A nurse is back. Slow. Anesthesiologist is in the OR. Get him! The resident yells. Slow walk away. Is he findable. A doctor appears, the ER one, but either he’s new to codes or he doesn’t believe this patient will live anyway or he doesn’t believe any patients in this hospital might survive. He leaves. After the gesture of wrist pulse to groin pulse to a few compressions. Minutes.
He returns with the ENT attending and a resident. A kit. They start to prepare the tracheostomy. Is there a pulse? (not sure) Compressions stop. Does that rock the hands of the attending trying to cut into the neck? (Yes) Should they keep going? (yes) Thirty. Three breaths.  Starting a hole to the outside air. Minutes. Is there a pulse? (no) Tracheostomy finished. Is there a pulse? (no) Is there air? (no) How long? (Ten. Fifteen. Maybe). Compressions stop. There is no pronouncing in this hospital. There is sitting back and leaving the tools and closing her eyes and trying to close her jaw.
Then close her eyes. A nurse tries to close her mouth. Then pull her dress back down, the sheet up. Not fast enough. Not good enough at finding the pulse (why is that hard). It is.
There is finding the charge nurse and asking him what we say. There is calling for her garde malades, again, thinking or knowing that they weren’t there because the last three times we called no one came and the others standing outside—every family knows the others, at this point, and so many of them sleep outside—said they were gone. (How do we tell them).
This time, they came. Must have been away for a few minutes. They didn’t know. Two men. About her age. The doctor said, the one who’d called the ENT. I can’t remember the words in French, now. They nodded and pulled out their phones and started making calls. In this culture, in this hospital, the women who start to grieve wail, scream, exude, ululate grief. You know, everyone knows when someone has died. The men, first, pull out their phones.
The day before was the first time I had ever performed chest compressions. For anyone who’s taken the Red Cross classes, one of my first thoughts was that those dummies are actually pretty realistic. That is what it feels like to pound, press all of your weight into, compress a human chest. They tell you not to be gentle, at all, not to be afraid of breaking ribs because that means you’re pushing hard enough. That doesn’t matter. I almost hoped that I would break a rib. That day, the resident and the doctor and I were sitting in the consult room. Slightly stunned. He pulled a jus (bottle of soda) out of the fridge. Something I do after a death, he said. People might think it’s insensitive or irreverent. I don’t. We took a minute, there, to drink, to be quiet and think.
So on this day, the second day, I change my clothes just enough to be decent to leave the hospital. walked across the treacherous like all in Cameroon) road, andI buy the same jus we’d had the day before. I bring it back. Let’s do the same thing, I say, again. It’s right. And we do.
Later, I go to get her chart. I hadn’t known her name, or her age, or remembered them. Now I do. M---*. Twenty-six.
There are so many people we can’t save. There aren’t resources or they’re too far away. The blood bank is closed. It’s not fast enough. There’s not money.
We could have saved her.
We didn’t.
We could have saved her. 

No comments:

Post a Comment