Dealing with death

Warning: this post is about death.  It is not cheery.  Read on at your discretion.

Today I held a patient's hand as she took her last breath.  She had been found down and brought to casualty (the ED) by a good samaritan.  We don't know if she had family or if she was homeless, but we knew she had had a rough time.  She was non-responsive, her right leg twisted inwards at an impossible angle, and she was crawling with lice.  She was 28.4 degrees C when we rounded on her (83.1 F).  An initial workup had been started last night, and she was put on empiric broad spectrum antibiotics, but she was too unstable for surgery.  This is patient who would have resuscitated and warmed in the ED, sent straight to the ICU and had a surgery consult within hours in the US, but here she was sent to the wards bradycardic, hypoglycemic and hypothermic, where she sat until we rounded on her at noon.  She was put in the back corner of the wards, despite being our sickest patient, so we didn't know about her until late in the morning.  After an ICU consult, we decided to treat her palliatively with morphine.  Her chance of survival was dismally low, and without family to supply funds there were very few interventions we could give her.  The nurse called me when her breathing became agonal.  I placed a gloved hand on her shoulder and watched as her breaths slowed to 4 per minute, then 2, then none.  One last gasping breath, and she was still.  Her chest sounded vacant, her eyes were fixed and empty.  For the second time, I declared a patient.

I have seen more death here in 4 weeks than I saw at home in a year and a half.  Last week was especially hard.  We lost 4 patients during the week, three within a 36 hour period.  Three of the four were my patients.  One was a 28 year old mother of three who grew up as a street kid.  She came in in septic shock, but had improved over the week.  When I came back from the weekend, she had passed.  I had tried for 2 days prior to the weekend to get her an abdominal ultrasound to rule out a surgical abdomen or abscess, but time and again watched as stable patients were taken to the ultrasound before here.  The second was an elderly woman with pulmonary TB and likely Guillan-Barre syndrome.  She was paralyzed up to the waist and tachypnic, but had been stable for several days.  When I came to work Thursday morning, she had died overnight.  The third was another 28 year old.  She was HIV+ and presented with a 1cm partially organized pericardial effusion, which was suspected to be TB pericarditis.  She had also been stable for days.  Thursday morning, just after I learned that the woman with TB had died, she started acting out, standing up during the middle of rounds, lying on the bodily-fluid covered floor and periodically yelling.  She was desatting but refused oxygen. In the afternoon a nurse brought her back to her bed and tied her hand to the metal bed post with a spare jacket.  I walked to the nurse's station to write a note, and when I returned the drapes were tied around her bed.  She lay on her bed, her right eye and mouth open, as if she had died in motion.  I asked the nurse about what happened, and she said, "She just passed," not looking up from the medications she was sorting.  I examined her, acutely aware of the difference between a live person and a dead body.  She was the first patient I declared deceased.

The last patient, B, was the hardest for me to lose.  She was the 19 year old wasted girl I mentioned in my last post.  I had researched causes of wasting, consulted oncology (who assured me that her prior diagnosis of paraganglioma could not cause the degree of wasting that she had), searched for her prior chart.  I presented her case in morning report and got input from my colleagues and attendings.  The medicine team leader even offered to pay for an abdominal CT if her family couldn't afford it.  Later that same day I got the results of her abdominal ultrasound: a massive neuroblastoma (related to paraganglioma) extending from her epigastrum to her pelvis, with a met on her IVC.  Her chest x-ray showed massive cardiomegaly and numerous nodules - also suspicious for mets.  It was crushing news to receive.  She was tachypneic when I went home that night.  The next morning her bed only contained her bed-mate; B's end of the bed was conspicuously tidy.  My heart sank, and sank again when the nurse confirmed the worst.  I felt both sadness and anger.  Sad for the loss of this sweet girl who had found her way into my heart, and angry at the injustice of her death.  Her old file was found hours before she died.  It revealed that she had a long history cancer and that she had not gotten chemotherapy when the tumor was smaller because her family couldn't afford it.

This is the hardest part about death here.  That most of the patients would live if they were in the U.S.  It can make me feel pretty helpless at times.  For each patient I ask myself if I missed something.  Was there another intervention I could have done?  Another investigation I could have ordered?  And here, in Western Africa, the answer is always yes.  There is so much more I wanted to do for each of these patients, but this place and these people simply don't have the resources.

When I learned about B's extensive tumor, I walked into the procedure room and cried.  A nurse came in and asked me what was wrong.  When I told her, she put her hand on my arm and thanked me for my empathy.  Empathy is what keeps us human - what prevents me from being just a doctor, and prevents B from being just a patient.  I know I can't dwell on the people that we lose, but I also never want to lose that feeling of loss when a patient, a person, dies.  I will allow myself a moment of sadness, a taste of the pain that their family feels.  And then I will turn back to the living and see what good I can do.  I will think about people like E, a 16 year old girl who presented with septic shock and now walks around the ward playing with blown-up glove-balloons.  For patients like her, I will feel happiness.