Mortality and Calling

I had my first child die yesterday. A child born in a developing country is thirteen times more likely to die before they reach their fifth birthday than those born in industrialized countries (WHO Secretary General, 2008). “In 2006, more than 9 million children under five died of preventable causes. Of these deaths, 53% involved some level of under-nutrition” (When Healthcare Hurts, p. 234).

The child had pigbel, a disease I had never heard of before coming to PNG. The condition is an overwhelming infection of the intestine by clostridium, usually following a high protein meal such as pork in someone whose diet is predominately starch (potatoes).  The major complication is necrosis of the bowel requiring surgical resection. This child, a 5yo boy was so sick on arrival that surgery was postponed to try to stabilize him first, as it was not felt that he would survive surgery. He declined significantly overnight and was close to death by the time of rounds. After examining him, I touched his mother’s shoulder and she knew what was imminent. She began sobbing loudly, the sound echoing through the ward. Not knowing what else to do I stood there with her until local staff came to be with her.

It’s been a difficult transition here. This has not been the first child to die since I have been here, although he was the first one whose care I was directly involved with. There seem to be a number of potential responses to the immense suffering here. One that I see predominately in the local staff and missions doctors who have been here for some time is an acceptance. At it’s extreme is fatalism; this is how things are and how they will always be. It is something I have seen in other impoverished communities, a way of coping with the brutal reality of life in desperate poverty. It is not unusual to lose a child, even, perhaps, more common than not having lost a child. I do not think the response is a lack of love or compassion, but a survival mechanism to continue to care for what remains and continue to live life. On the opposite end of the spectrum, one of the physicians told me the story of a volunteer who got upset and yelled at local staff after a child had passed away in the E.D., something she thought might have been preventable if everyone had acted appropriately in performing resuscitation and bringing supplies for intubation, IO access, etc. As an outsider it can be easy to compare healthcare here to America and note all the shortcomings and flaws. However, it is often difficult to see how certain practices are the best way to compensate for a shortage of equipment, medications, personnel, etc.

On a more personal note, it has been a difficult experience seeing how quickly my heart can go to a fatalistic perspective. Multiple times in residency I have struggled with burnout, which often leads to difficulty empathizing with patients, particularly after a long shift. Too frequently I can see a patient as burden or nuisance instead of fellow child of God. In PNG there have been different challenges. Not speaking the language or knowing the culture, it can often be difficult for me to place myself in the patient’s shoes.

However, I have been incredibly encouraged to see the doctors here care for their patients. They often take time to pray with them after a difficult diagnosis or before a procedure. They stretch themselves to create a quality healthcare delivery system in this small community, and I can see the gratitude in the people they treat. I am starting to remember the reasons I started medicine in the first place. And standing with that mom beside her dying son I could feel God’s grief and reaffirmation of that calling to care for the suffering.

On a lighter note, here is a snapshot of what my day looked like on Saturday when I was on call to give a better idea of what life has been like for me here in PNG…

Rounds start at 8am. I start on Medicine ward and start seeing patient’s while my proctor starts on the other end. We work with the nursing staff and nursing students to go through vitals, orders and come up with a plan for the day. After rounds we do a quick I+D on a lady with cellulitis and an abscess in her foot that had been admitted for IV antibiotics. Then we head to our Obstetric Ward to see antenatal and postpartum patients. We do a couple ultrasounds on patients with suspected PROM (the diagnosis in PNG is based solely on pooling or leaking onto a pad which can often lead to ambiguity). There is a patient with CPD who we plan to take back for Cesarean delivery. While that is being prepared we swing by the E.D. to see a couple patients who came in early. After the C-section I go back to the Medicine ward to splint a man who was admitted after a fall who has a broken left ankle. I get a brief break for lunch and then get called back to the E.D. to see a couple of patients. One is a G1P0 at 18weeks whose ruptured 3 weeks previously. We ultrasound her and miraculously her baby is still alive, although her AFI is 0. After we finish in the E.D. we swing by the OB ward and find that one of babies getting delivered (normal deliveries are done by nursing students in PNG) is having bradycardia. We get ready for a vacuum but she is able to push baby out with the next contraction and my preceptor and I start resuscitation. The baby had thick meconium on suction and required PPV for 10-15 minutes but stabilized to go to the nursery. I’m able to go back to my residence for a short period of time and am just starting to heat up dinner when I get called back to the E.D. for a knee and a child. The knee is a classic ACL tear during a rugby game, which is unfortunate as surgical repair is extremely unlikely here. The child I am told has had a cough and fever for one week. When I see him he is lethargic and ill appearing with his neck arched back. I call my preceptor immediately and we perform an LP that shows cloudy liquid-acute bacterial meningitis. We start antibiotics immediately and admit him to our Pediatric ward. As I’m getting ready to leave, an old man from a remote region, about 2 days away comes in with abdominal swelling for 3 months and gradually increasing dyspnea. He has been treated as an asthmatic for a number of years but recently developed severe swelling.  He has severe ascites, lower extremity edema and fine crackles in his lung fields with an abnormal heart rate. A quick look on US shows a severely enlarged heart with diffuse wall motion abnormality. His blood pressure is borderline at 90/60 so we admit him for a gentle diuresis. I finally head home for a late dinner and some sleep before rounds the next day. I’m amazed at the breadth of knowledge of the physicians here and what they are called on to treat on a regular basis.