Accepting Death...

The title says it all. As you probably guessed already, Jeremy and I need your prayers to give us strength and wisdom.

We have found over the past 3 days here that death is viewed quite differently than in the US. We have come to the conclusion that death is seen more as a routine part of life, and is no real surprise or emotional event when it does occur. This has been an area in which we have had to adjust our own practices and realize that we do not have to always do "everything possible" for a patient, especially if it is not going to do much to prolong or improve their life.

Here are just a few cases I will share from our first 3 days.
First, the gentleman Jeremy wrote about in the last post passed away only a few hours after we had initially met him. Despite our best efforts in this hospital setting, we were not able to change the ultimate outcome. While it seemed to bother us quite a bit to lose a patient, everyone else seemed to go on like it was an everyday routine.
Second, this morning I was rounding on the pediatric ward, and noticed a young child with a seizure disorder who had been very ill recently with uncontrollable seizures was no longer there. I later learned she had passed away during the night last night. I felt sad inside, but I also know that we had done all things possible for her prior to her expiring. In fact, as I look back today, she is probably better off, because the possible outcomes for her were limited.
Third, we had a patient with tetanus here in the hospital who passed away overnight as well. He was not my patient, so I don't know all the details, but I basically know he was in very severe condition upon arrival to the hospital, and was not responding well to the medications.
Finally, i have a very sad case from today. During clinic this morning, an OB/Gyn resident came to find me and get "a NICU consult." She had just delivered a full term baby by C-Section but the baby was not doing well. He had required some bagging and suctioning in the OR, and had been brought to the mother/baby ward. After discussing the child's condition with her, I promptly went to examine the patient. When I got there he was breathing only a few times a minute, very cyanotic (blue), had a slow heart rate, and very poor muscle tone. We opted to take him back to the OR where we had suctioning available as he had meconium aspiration in utero and had only received bulb suction at birth. In the OR, we had to improvise and use a nasogastric feeding tube because it was the only one small enough to pass through the nose into the airway for suctioning. We also had to struggle to get oxygen available. We bagged the baby for a while, his color improved, and he opened his eyes and was crying, so we took him back to the ward, and started him on some IV fluids and antibiotics due to our concern for infection. Later when I went to check on him, he was the same as when I first met him. Despite multiple other interventions, and several prayers over him, he passed away later this afternoon. I feel we did everything possible to help him in our setting, and I honestly don't know if we could have done any better at home, but it is always a struggle to see such a new life pass away. I must have run through my head 50 times anything I could have done differently, I have reviewed neonatal resuscitation, and I have come to the conclusion that we did everything correctly, but ultimately God had another plan for this little boy.

Preparing for death is yet another issue we have come across. In addition to the children, I also see a few adults each day to help out with clinic flow. (by the way we see 500 patients/day on Monday, Wednesday, and Friday in clinic in addition to the inpatients). Today I met two older women, both of whom likely have cancer and will die soon. One I talked with the family regarding her poor prognosis and just provided some pain medicines for her and referred them to the chaplain. (Here you break bad news to the family, not the patient). The other had a large mass sticking up in her abdomen, likely a uterine or ovarian tumor. She is going to come in and have it removed by the OB/Gyn doctors, but likely she will not have a good prognosis either. Hopefully we will be able to take away some of her pain by getting rid of the mass, and let her have some comfort as she lives the remainder of her life.

Now for some more positive stories!
I think Jeremy and I are getting more comfortable with the system here. We are actually working together in an office room, sharing an interpreter. It is really great because he is teaching me many things I have forgotten (or should we say stored so deep within my brain they are hard to retrieve!) and I feel as though I have also shared a few pediatrics points with him as well. The staff here is also very helpful to guide us if we are unsure or if we need to do something more the "normal way" for here as opposed to our US ways. Today we each sort of had the opportunity to work in our comfort zones, mine in the pediatric ward, his in the adult wards. It is kind of strange to think I am seeing most of the kids here myself and treating illnesses I have never seen, but I know a power far superior to me is guiding my thoughts and hands!

There are also a lot of procedures to do here. Today alone I did a paracentesis (drained fluid from the abdomen), and sutured up a finger. Yesterday I helped to fix a fracture and cast a child's arm. We also do a lot of ultrasound, and OB/Gyn related procedures here, which I personally don't care to do a lot of, but having a good knowledge base is always beneficial.

We start taking call for the hospital tomorrow. I am on tomorrow and Jeremy will be on Friday. One of the other residents here is leaving this weekend, so call will be every 3rd night, but it is from the house, mostly for emergencies or lab results, etc. We are lucky to have good attendings here, who are available if we need them. We are also the distributors of snake venom after hours when pharmacy is closed, so that should tell you how common carpet vipers and spitting cobras are here.

I know this is long, but I want to leave you with our schedule, just so you are familiar with our routine.
Monday, Wednesday, Friday: Hospital Rounds at 7:30AM, start clinic when rounds are over until 9:30, then break for patient devotional from 9:30-10:00. Resume clinic at 10 and go until 12 or 12:30. We then go to Theatre (OR) to do any procedures from the morning. Lunch is for about an hour after procedures. We then return to clinic and see patients until all are seen which is usually around 3 or 4PM. Finally we again go to Theatre and complete and remaining procedures for the afternoon. Then home to dinner and rest.

Tues, Thurs: Rounds at 7:30 until finished. Then to Theatre for any scheduled elective procedures or surgeries. Work until those finished then we are free for the afternoon.

Sat, Sun: Rounds at 8:00 until done. Then to Threatre if any procedures need to be done, otherwise done for the day.

The only exception to this schedule is when we are on call. We then round briefly at around 5pm and then again at about 8:30 or 9PM just to make sure everything is taken care of and no new concerns or problems have come up.

Ok, so this chapter is complete. I could type a ton more, but I am afraid the internet connection may not last, or you may soon fall asleep reading.

Thanks for following along and thanks for your prayers and support,
Steve