A baby boy died at 36 hours of life. I had first heard about him back at the staff quarters at around midnight, when a seven month pregnant woman had just given birth in the bathroom. He was small, 1.5 kg. His heart rate was very slow, and we started bag-mask ventilation quickly. The mother had been having abdominal pain and vaginal discharge for a few weeks, had received no antenatal care, and was finally brought to Bayalpata Hospital (about twelve hours away from her house) because a health worker in her village had trained briefly with us. Arriving in labor, she was initially evaluated and stabilized in our Emergency Department. She then got up to go to the bathroom—outside, in the dark, unconnected to the Emergency Department—and the baby precipitously delivered there. She and the baby, blood dripping down her legs, then came back into the Emergency Department.
Bijay Acharya (one of Nyaya’s founding physicians), Sizan Thapa (Medical Director), and I took turns providing breaths. The bag itself was clearly not as sterilized as it should be. One of our outstanding Health Assistants, Prakash Madai placed an intravenous catheter, and our Nurse Midwife Kamala Sharma gave ampicillin, gentamicin, and hydrocortisone, and started fluids. While providing these breaths, the team provided stimulation and used warm water bags and a radiant heater to warm the baby, as we had no infant warmer. Use of the radiant warmer itself was made possible by our recent solar installation. Providing bag-mask ventilation—providing breaths for a patient when they have stopped breathing on their own— has a feeling of organized hyperactivity in the teaching hospitals that I am more accustomed to. When you are trying to resuscitate someone at Brigham or Children’s Boston, you call a code and a team of highly-trained professionals come to the bedside. The lights are on, numerous monitors are going, the stress is high, but you are not alone. At Bayalpata Hospital, resuscitation is different.
There is an eerie calmness during resuscitation at Bayalpata, because there is so little for you to know, so few interventions, so few tests (in his case, none that were relevant), so few monitors (actually, none), so few specialists. Yet beneath that simplicity lies the most complex of physiologies—the dying neonate—that is essentially a black box. And so it was that we continued to resuscitate the baby for three hours. At one point, we thought about intubation, as ridiculous as that sounds, to bag the baby through what could be—and it is impossible to say—a finite period of respiratory distress. Not having smaller than a 4.0 size endotracheal tube, and perhaps not knowing what else to do with ourselves as we rotated bagging this child without any monitors, Bijay fashioned one out of nasogastric tubing and a syringe. We talked through the various scenarios and ultimate plans for this child who we were keeping alive with our most bare of resources. Thank goodness we didn’t ultimately use that makeshift tube; the baby started breathing spontaneously. We observed the baby for some time, and then resolved to check his vitals every fifteen minutes and see where his young life would take him. We had little other choice. He did well through the night and the next morning.
Somewhat predictably, he started to crash midway through his second day. Without a neonatal monitor, it is impossible to say when he first started to have issues. The end result however was another extensive round of bag-mask ventilation until his heart rate dropped and dropped and dropped and then stopped. Niroj Banepali, a visiting physician who is friends with Bijay, performed chest compressions for a few minutes, after which we acknowledged that the infant had died and that our resuscitation had failed.
We conducted a mortality and morbidity conference on this baby—the first one we’ve done for several months since the recent upheavals. I was again impressed with the teamwork and collaborative spirit. The meeting was concrete and productive, and I hope we can implement most of the recommendations, because we can do better. This is 2011. A child like this just should not die. There is essentially 100% morbidity-free survival for a child like this in the United States. With a few basic changes—a neonatal pulse oximeter, a neonatal pressure gauge, protocols for resuscitation, a cardiac monitor, a radiant warmer—this child could very well have survived. All of these are simple things that don’t require huge investments in financial resources.
But for this child, and for his parents, such plans are meaningless. Bijay and Sizan talked with the parents and explained what had happened. The parents seemed to have a certain numbness, an acceptance of life’s harshness. From the beginning they had expected the baby to die. The next morning the baby’s mother, with blood still on her feet from the delivery, and without any footwear, started the long walk home. Her husband carried the baby’s small body in a plastic bag.
My mind, trained in hospital systems, in hearing of this, first thought: how can we ensure better washing facilities and sandals for our mothers? I am appalled at my own impotent thinking. Is that all that I can come up with? There must be a more bold response to such abhorrent injustice and indignity. That image cuts deep, and yet I have little else to offer.
I do know that he will be the last child to die in the old delivery room. A few days later, Sangita sister conducted the first delivery in our new delivery suite. We were all proud of that achievement. But that moment of progress was too little, too late, for that brave mother making the long walk home with her bare and bloody feet and her dead child in a plastic bag.
Duncan Maru, MD, PhD is the co-founder of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program and fellow in Global Health Equity at Brigham and Women’s Hospital and Children’s Hospital of Boston.