Death

A view from the hospital to the front gates

As a surgeon, I am no stranger to death. It is an unavoidable part of the choice you make when becoming a doctor. ‘Part of the Job’; albeit, perhaps, a very hard one. I have seen death in many guises throughout my career; old, young, some terribly sad, some heart-breaking, some anguished, some expected, some peaceful, some wanted, some lonely, and there are some that catch you completely unawares. It is not that you ever get used to death as such, but as a doctor you learn to develop a certain emotional detachment that allows you to perform your job (sometimes in very extreme circumstances), as well as to protect you from what would otherwise become overwhelming. And of course, one of the ultimate roles that we sometimes play as doctors is to help a patient’s course veer away from its clutches. A true privilege when it happens and goes well.

Death here seems much closer. Life hangs on a much more tender thread. Things that would rarely happen in the UK and seem tragic, are met with an almost acceptance, within the spectrum of ‘normality’. Maternal and infant death. Children. Young adults. Mothers. Fathers. Friends. Family members. It happens much more frequently here. And despite the herculean efforts of the staff, the simple fact is that much of what modern medicine can offer is just not available.

The four bedded ICU

Last night I was called into the hospital to see a man in his 40s. He’d been admitted for 2 days already and had been transferred to ICU (the Intensive Care Unit) as he was deteriorating. It is important to highlight what ICU means here – it is a 4 bedded ward with one trained nurse allocated exclusively to these four beds (although not always present). There is no monitoring as such, but it does house one of the hospitals saturation monitors, a blood pressure machine and one of the ECG machines (I think there are two in the hospital). There are a couple of oxygen concentrators available, although these seem to alarm incessantly; complaining that they are not delivering as much oxygen as they would like to. It is a world away from what we would consider an ICU at home.

As I laid eyes upon the man I had been asked to see, I knew his tender thread was desperately bare. Without some significant change to his current course, he was not long for this earth. He was barely conscious, his breathing ragged and looked ghastly. His wife was holding his hand, willing her strength upon him. He had IV fluids running,  a nasogastric tube and a catheter. A surgical review had been requested as somewhere along the line a working diagnosis of peptic ulcer had been made (and, if perforated, was something that an operation could potentially solve). My immediate thoughts as I approached the bed were that we would need to get him to theatre immediately if he was to stand any chance. I was slightly irritated that things had been left so late before involving us. However, as I assessed him, things did not add up. The history was confusing, albeit third hand – his wife talking to my colleague, talking to me. Yes abdominal pain had been a feature, but the sweats and rigors (uncontrollable shaking that occurs with certain infections) were far from typical. And as I laid a hand upon his belly I knew there was nothing I could do surgically. He was roasting, truly burning up in front of me. His body was gripped by some infection and his abdomen was not ‘a surgical one’. There are certain signs in patients with an ‘intraabdominal catastrophe’ (potentially salvageable with surgery) that could conceivably generate a similar clinical picture that guide you towards the belly as the cause. He had none. I would go so far as to say his abdomen was blameless. His saturations were dangerously low and he did have some signs in his chest (but it is difficult to know if these were cause or effect of his illness).

I withdrew to the office to consider his predicament. I was sure that he had overwhelming sepsis of some sort, but the cause was far from clear and any number of sources could be harbouring his demise. Antibiotics were a must and we started them immediately. Fluids were running, but clearly they alone were not enough to support his failing organs. The inequality in healthcare was starkly apparent. This man in the UK would be on full monitoring including tubes into arteries to give beat by beat readings of his blood pressure. He would likely have his breathing supported and possibly be given medicine to improve the functioning of his heart and blood flow. He would be stabilised for special investigations (such as a CT among a myriad of potential others) to try to find the cause of his trouble. He would still be desperately sick, but he would have a chance. Here, the only tests available beyond clinical acumen are a haemoglobin (not even white cell count), bedside HIV and Malaria testing (both negative). We could not check his liver function, nor kidney function nor even do blood cultures to try and narrow down the source and target antibiotics appropriately. X-rays were not possible as earlier in the day the power was not sufficient and now he was too sick to be moved. So it was antibiotics, fluids and hope.

This morning he was worse.

Hospital Corridors

Around 12 midday a guttural, agonised cry ripped through the open-air corridor between theatres and ICU causing every head to turn. His death was announced by the grief of his departing wife.

This is healthcare in Africa.