Sunday evening a couple of our adolescent patients had grown more acutely ill. One of our newer patients, Caroline, a 17 yo girl with HIV who had presented with diarrhea had continued to worsen with increasing abdominal distention, worsening sepsis, and delirium. Her mother had become increasingly worried that night and clung to my presence when I was at her bedside. I knew she was very ill but didn't realized she was facing the end of her life that night. About 1 am I awoke to a page from my intern that she had coded after a witnessed seizure. By the time I arrived she had regained a pulse but had no respiratory effort and minimal brain activity and was intubated. She ended up losing a pulse twice more. The third time we performed CPR for about 30 minutes and despite several doses of epinephrine, fluid, and other medications we could not revive her. We brought her mother in who made the painful decision that we should stop our efforts to resuscitate her. I had witnessed these types of scenarios various times from the outside as an observer but never myself had been the one to lead that discussion. After removing all of her lines and tubes, I actually was able to take part in wrapping her body for the mortuary, something I hadn't done in the US. In doing so I found myself reflecting on what a beautiful girl she was and how such a devastating disease had claimed this girl's life, not only the infection itself but the stigma of the disease which had led her to stop taking her medication and progress to AIDS. I prayed for her and her family as we gently wrapped her and I fixed the delicate white rosary that she wore around her neck. There was a special bond I felt among my intern and the nurses there who had all participated in her attempts resuscitation. I am so thankful to have had them there and not go through it alone. Thankfully, I suppose, I am one who can move on and continue work after difficult situations, and remain fairly disconnected from the emotion of death and dying. Being so intimately involved in the last seconds of her life was tough and I was physically exhausted after the code and emotionally stunned at what had happened. Most unsettling was not knowing the underlying cause for her sudden decline. Was it an infection/swelling of the brain, a heart arrhythmia, blood clot? Not knowing what the reason was and what we could have prevented or done differently is perhaps the hardest part.
Earlier that same day, one of our patients with presumed meningitis had started to go down hill after an initial very significant recovery. He slowly developed more confusion and headache after several days of looking great and being nearly ready to go home. On Sunday he suddenly had respiratory arrest likely due to aspirating on food. He was emergently intubated (thank God we have anesthesia here to assist with intubations!) and taken to the ICU. Unfortunately he was shortly found to be brain dead, with fixed dilated pupils and no corneal reflex. The following day I discussed with his family the prognosis after they talked with Chaplain and they made the painful decision of removing the breathing tube. He passed about an hour later. It was difficult to communicate indirectly with his family, especially his own mother, through the translator, not knowing exactly what his mother was thinking and feeling or how she interpreted my words. She was a single mother and had no funds to pay for his burial or funeral. I told her I didn't have the words to understand her pain nor could I ever understand what it would be like to make a decision to accept the death of a child and withdraw life support. I did feel that the Chaplain who was translating understood and communicated my deep sympathy and prayers for her. We all embraced in a circle and I prayed for her and her family, I believe she felt my prayers. I know God did. I praise God that she knows Him and that she can rely on Him alone for peace and comfort.
Just after that we ended up doing something similar for patient in the NICU who had gradually deteriorated over the last day. It was a baby with sepsis and renal failure who we had intubated for what we thought was only a temporary time while his kidneys recovered. I mentioned that he had been sustained on the only ventilator available in the hospital for babies. The machine had continued to alarm again requiring another re-intubation effort on Sunday. The next day he was very edematous (swollen) and he had lost all of his IVs. No one could place one and the surgery team felt it would be too invasive and only prolong suffering to place one in his larger neck veins. We discussed the prognosis with his family and after much though among all of his family and our medical team his family made the decision to remove the ventilator. His mother is single and this is her only child. I was very thankful that she had many supportive extended family members there. He passed a couple hours later. Although she had prepared herself, his mother was still painfully emotional. I felt privileged to be able to wrap up her baby and hand him to her while she cradled him in her arms for the last time, which she had not been able to do while he'd been critically ill in his bassinet. His family was so thankful to our medical team and were also so obviously filled with the knowledge of God and his peace and good will.
"You give and take away, you give and take away, my heart will choose to say, Lord blessed be your name"
The next day also started off on a sad note, getting paged that a baby admitted early that morning to the NICU, who I hadn't heard about yet, had stopped breathing. We had to initially CPR when we arrived to the NICU, but stopped after a couple of cycles and giving epinephrine. There was little hope of reviving the infant, who we noted to have had massive hepatomegaly (large liver) and profuse bleeding. It was suspected that he baby had liver failure due to receiving herbal medications, which I am learning is very common here and can have some devastating and unpredictable effects. It was still somewhat of a shock to me that the other physicians wanted to stop resuscitation so soon, but I agreed with their decision. They also knew that as part of the culture here, most individuals choose to avoid prolonged suffering and artificial life sustaining measures for their loved ones, even children. The mother's reaction, however, was so difficult to bear. I had never seen such strong, guttural, reaction. She was hysterical at hearing the news of her child and collapsed to the floor. I had no words to say to comfort her or try to understand her pain, but through the Chaplain I tried to convey my prayer that God sustain her and give her supernatural peace during this time. Dr. Terer, the wise supervising physician, was so sympathetic and caring and helped us to contact family members to support her during this time.
Despite the onslaught of trials over the past few days, I am nevertheless thankful for the opportunity to have such meaningful interactions with patients and their family members. There has been so much reliance on God over the past few days and I have been amazed at His ability to bring peace during the pain. I have seen the incredible faith and peace of the Kenyan people and have been privilege to be trusted by parents with the care of their children. I am also thankful for the supportive community here at Tenwek and the readiness of Chaplains and others to offer support for families. the ability to bring Christ into such difficult circumstances, and pray openly with the fellow staff members, has been so refreshing and a real privilege that I will surely miss when I return to the US.
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