Here is a man we can help. He’s a forty-two year old farmer and migrant worker to India who is extremely sick, but fixable. I first heard about him a few minutes ago from one of our superb Health Assistant, Chanakya, who found me while I was going through expired medicines in the surgical building with our Country Director, Greg. He wanted to ask me about this patient in the emergency department on whom they had run several tests. Even our modest laboratory showed severe illness. Our i-stat demonstrated acute renal failure (creatinine of 3.4) and acidosis (bicarbonate of 12), and our QBC machine showed severe anemia (hgb 5.7) and an elevated white count of 25,000 (though his lymphocytes were only 500). Seeing him confirmed this. He was breathing extremely rapidly, with cool extremities, in acute renal failure from severe dehydration, unable to phonate likely from a stroke, impaired gag reflex, with a large right-sided pneumonia and perhaps a pleural effusion. Given significant inguinal and cervical lymphadenopathy on exam, and the aforementioned lymphocyte count, he almost certainly has HIV. But we have oxygen, intravenous fluids, and antibiotics. We can get him through this sepsis and pneumonia and get him on antiretroviral treatment. He has had fifteen days of cough, fever, and shortness of breath and was only now carried to Bayalpata Hospital from his village, which is two and a half hours away. Over the last few days he has developed difficulty speaking, possibly from a stroke, though he is not neurologically devastated. Despite the very late presentation to care, we can do this. We start some more fluids. He looks extremely sick and is breathing rapidly, but we need to get an x-ray. Here is a man we can help.
We get him on the x-ray stretcher, which is an aspect of the system that I have not appreciated before—one of so many systems issues that you don’t see until you’re going through them. I’m glad, however, that it’s not monsoon season. We walk him the 20 meters to the x-ray. Our X-Ray Technician, Dhan Bahadur, gets him ready. I step out. Outside, one of our Health Assistants (HAs), Chanakya, approaches me saying that the patient’s HIV test was positive. Sizan (Medical Director) and I talk about broadening his antibiotic coverage. The team had already given him ceftriaxone upon admission. My mind stupidly floats to imipenem (a very broad spectrum and expensive antibiotic that we don’t have). Gentamicin can’t be given due to his renal failure. Levofloxacin would be a good choice, but we don’t have it. We settle on ciprofloxacin and discuss renal failure dosing. Here is a man we can help.
Someone (I forget who) comes out saying the man has passed out. I rush in. Unresponsive, without a pulse, I start chest compressions and ask for a bag-mask ventilator. Our code team training in residency doesn’t prepare us for this. There is no anesthesiologist, no STAT nurse, no EKG, no monitor. Just you and your palms. Hard, fast, deep. Our training is about systematization, about ordering chaos, or at least attempting to. There is nothing ordered or systematic about running a code today in Achham. We will fix that, we will—but right now, we are not there yet. Still, we can do chest compressions well. Hard, fast, deep. We don’t have a defibrillator; all we have are our hands and some epinephrine. The other HAs and nurses are all there, helping. The room does have an element of quietness that is eerie compared to the loudness of codes in the US. Sizan asks that I switch out. I’m impressed by the chest compression technique of the staff, and especially the readiness to quickly rotate out to avoid fatigue.
It is odd waiting for the x-ray to dry while doing CPR. When it has dried, the x-ray shows complete opacification (“white out”) of his right lung. Sizan correctly points out that he likely had a significant aspiration event. Compressions are ongoing. After some time, I remember that we do have that Welch-Allyn vitals monitor in storage that has a pulse oximeter. We had not started using it, because without a protocol it would soon be broken or misused. I ask for it. It proves largely unhelpful, though I do note that it helps us to assess the quality of our CPR, based on the heart rate and oxygenation.
We give epinephrine and calcium, and then some more epinephrine. We set up a dopamine drip after it seems his heart has re-started, after about ten minutes of CPR. At that point we also ask for a laryngoscope to consider intubation to protect his airway, as insane as that sounds given that the nearest ventilator is about 15 hours away. All we can find, however, is a pediatric set. That I think is for the best, though it still feels awful not being able to make those tough decisions.
Ultimately we call the code and stop the resuscitation efforts. His pupils are fixed and dilated. I do my duty, listen to the heart for a minute, and assess for complete cessation of respirations. Sizan gently informs all the men, who had come with him from his village and had gathered outside the x-ray room, of what happened. They seem appreciative. We chat for some time. In the United States, one of my deepest privileges is to console patients’ families in the intensive care unit when their loved ones are dying. In fact, it is one of the few unambiguously right things I feel that I do as a physician; most of our treatments lack evidence, but compassion-giving needs no evidence. Here, I do not deserve such an honor. In the emergency room, I mutely shake the hands of all his village members and touch them each on the shoulder. They seem to understand that we tried our best. The acceptance of death here continues to unnerve me. A forty-two year old father of four. We did not help this father, husband, brother.
I stupidly go back to grab the vitals machine. The dead man is still there, without a sheet on. Sizan comes back around and asks Urmila sister to bring a sheet in. I bring the vitals machine to the emergency room and put it in our “respiratory” area. We’ll have it there for now and try to protocolize it soon; it no longer belongs in storage. I leave the emergency room. The river looks so still below in the valley. The setting sun is painting the hills purple, red, orange, and yellow. Some women are gathered on the hill singing, their voices slicing through this rainbow. I think about the mother. What will she do now, with four children, in her dead husband’s village?
The body has been removed, and the family leaves. I think back to the tragedy, how we could have done better. I hesitate writing the above in such graphic detail because I do think the team performed admirably with such limited resources and experience. We did not deliver the high quality care that this man deserved. But tha is a systems issue and not a personal one. We can think back on a series of “ifs:” if he came in a day earlier, if this was detected in the community, if the team had started fluids earlier, if we did better CPR. He was so sick—acute renal failure, advanced AIDS, sepsis, pneumonia, stroke—but the bottom line is that “ifs” are not what Bayalpata Hospital needs; we need “whens.” We need to improve our systems. We are helping people, but we have so much to improve upon. That, I hope, is what we can do through reflecting on these tragedies.
Usually, in the medical world, reports such as this one end with the time of death. I don’t know what the time was. We did not record it.
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.