The Doctor who Kicked the Hornet’s Nest

My wife has been filling the blog void, with all of our cultural faux pas, interesting finds and beautiful mountain stories, which make this whole overseas adventure seem amazing.  But living overseas sometimes give you a different view of the world, and you become quite certain that even with mountains and beautiful cultures, there is a whole hornets nest of bad in this world too.  So from my recent re-realization that this world isn’t a good place and for my own personal therapy, here are three separate ‘hornet’s nest’ stories from the hospital I cannot get off my mind.

Story One: Denied.

This is the freshest. I just got back from call and wrote it all out.  I was ready for bed, winding down from a busy day reading the book of Revelation (Stephen King has nothing on that book… it is SCARY!) when my phone rang. There is an unwritten policy that we hospital staff all help each other, no matter what the hour, if we have questions. So a call at 9PM asking me to look at an EKG is not all that strange. However, this did mean I had to put pants on and ride my bike in the dark to the hospital.

The patient was a 14-year-old boy. His echocardiogram done several months before showed a number of problems with the valves, the chief of which was severe aortic stenosis. Basically this 14-year-old kid had a heart pumping at all times as if he were running up-hill, but the aortic valve (the last stop before blood gets out of the heart) was so stuck closed that only a tiny jet of blood could squeeze through. Laying in bed, I could see his chest bounding due to his heart’s effort, but still his limbs were cool and his pulses barely could be felt. The solution to this problem, most likely caused by rheumatic heart disease (an auto-immune problem where the body confuses heart tissue with a specific bacteria, and ends up attacking the heart) is surgery. When he had his echocardiogram done many months before and the problem was diagnosed, he was astutely sent to Kathmandu where there is a program for valve replacements, done free of charge, for kids 14 and under with rheumatic heart disease. But instead of scheduling him for surgery, he was told to return to the clinic in a year. Now, I can only speculate as to why he was sent away and told to come back in a year. Perhaps they thought when he was a bit older he could tolerate a big surgery. Perhaps the few surgeons who do this surgery had full schedules saving other rheumatic heart disease kids lives, and had no openings for the next year. But my personal feeling is they simply didn’t want to operate on this boy. They saw how sick he was. They knew his recovery may not be a quick one. But instead of giving him a go, they sent him home with a one year follow-up, which they knew he would not make it to.

So instead, this little boy showed up in our hospital, and I was looking at his ECG at 9PM. I will save you the details, but since his heart was going too fast and he had no blood pressure, we shocked him. From that point on his sick heart only got worse, and after an hour of on and off CPR, we threw in the towel. What this boy needed was heart surgery months earlier, and more CPR wasn’t going to fix that.

An interesting thing happened just before our last round of CPR with that little 14-year-old boy. A moth landed on my shirt. Not a huge deal since the entire emergency room was full of them buzzing around the lights. But this moth would not budge, and unlike usual moths, he seemed to care far more about my T-shirt than the glowing lights above. I brushed it off, and at that moment felt as if I had just said a good-bye. I know this sounds sappy, but it felt as if the moth was the soul of that boy trying to let me know what his departing body could not. I found a very similar looking, if not the same, moth sitting on my helmet when I went to leave the ED to come home and write this to you, so hmm.  A second chance to say goodbye maybe?

Story 2: Lack of resources, lack of care.

A 30-year-old woman. Her husband was dead, I don’t know from what, and all she had left was her brother and his wife. This woman was bleeding. Originally seemed to just be coming from the stomach. She vomited blood several times. But then the bleeding worsened, and soon there was fresh blood in her stool too.  She had been taking a lot of ibuprofen for some joint pain, so this was the likely cause. All we could do was wait it out and keep giving her blood to replace the blood she was losing. Now, there is no Red Cross blood bank in Nepal. There is a small reserve of blood in the hospital, but each unit that is used by a patient, must be replaced by a family member. So in order for this woman to get blood her family would need to donate. The ideal situation is to give the blood as soon as possible since most of the clotting factors (which she desperately needed) were most active at that point. However, her brother and his wife did not seem all that interested in donating blood.  Maybe they were scared, but it came across that they were disinterested. I became upset over this, and in my best broken Nepali expressed “this is your family, you need to give blood!” That did squeeze one unit of blood out of the two of them, but that was it. Later that day they told me they wanted to take her home. This basically means that they think she is going to die, and they would rather have this happen outside of the hospital. I think the two reasons for this is to reduce further hospital bills, and it is much cheaper to hire a taxi to transport a live person than a dead one. I argued with them that there was a significant chance she would recover if she were to get the blood she needed. But the family would not budge. I then told them we would give the blood she needed from stock (without having to be replaced) and would even have our social services visit them to see about covering the cost of the hospitalization. For reasons I still do not understand, they refused. The patient that day became extremely withdrawn, and wept quietly to herself and refused to answer questions.  It was as if she felt her family had abandoned her, and from my perspective it seemed she was right. From that point she gave up, and the family delayed taking her home just long enough for the patient to die on my ward.

Story 3: 4 dead kids in 3 hours.

This was the most devastating day since arriving to Nepal. I was already tired going into this call, and these few hours pretty much took me out for the rest of the week.

Child one: 9 years old. Did not wake up that morning, and was transported to our hospital over 8 hours of dirt roads, only to die 30 minutes before arriving. The mother screamed “my baby girl” over the body for an hour. We never found out what the child died from.

Child two: A woman tried delivering her baby in a remote village. The first signs of a problem was that the midwife in the village refused any help to the laboring mother, and told her to go to “Mission,” as our hospital is referred to. Her exam showed the babies arm presenting, and not the top of the head as expected. The full term baby was already dead. Since the baby would not come spontaneously arm first, a cesarean section surgery was required to remove the dead baby that this woman had been expecting to be mother of for the last 9 months.

Child 3: This baby died while I was caring for child 4. She was a pre-term baby, born to a 14-year-old mother out of wedlock who had tried aborting the baby late in her pregnancy. The family had abandoned the mother, and she would now have to transport her dead baby’s body, to who knows where, all on her own.

Child 4: A 20 month old girl who looked remarkably like my daughter. She smelled strongly of wood smoke used for cooking. The baby was not responsive, but breathing on her own. Her condition deteriorated, and soon she was not breathing on her own. We ventilated her for an hour with a bag and a mask, but she would not recover. As I lifted the limp toddler it felt so much like lifting my sleeping daughter, and I started to break.  This baby did not to wake up. The mother was crying next to the bed throughout the last hour, and I could not look her in the face. This was too much. I’m sure the residents and staff all saw me losing it as I ran for the door. I cried harder than, well I can’t remember when. I tried to find a dark secluded place on the hospital compound, but I’m sure my sobs could be heard over quite a distance. It was all just too much.  There were 4 dead kids, 3 of them under 2 years old. And it all happened between 8 and 11PM.

I always wish these blog posts wrap up with a neat bow or an important life lesson learned, but they don’t.  I don’t do dead babies and children very well, which is probably why I avoided pediatrics in my medical training.  I know this world isn’t a good place, sin nature, fallen humanity and all that, but what did these babies do wrong?  Maybe we can blame it on greed and poverty, too much money and resources some places and not in others, like Nepal. I’ve got no good answers, but it’s made me feel better getting it all out.  Perhaps I’ve made you feel worse, but that wasn’t my intention.   I’ll try to avoid kicking the hospital hornet’s nest and post more often so as to not drop all the ‘worst of the world’ stuff all at once.