Left To Die On A Tile Floor

“Dr. SW101,”  said Father Larry, “There’s a woman lying unconscious in the church courtyard.  Can you go see her?”

With little more than a quick nod, I grabbed my interpreter and headed out the door. How, I wondered as harsh sunlight spilled into my eyes, is a doctor supposed to help an unconscious patient?  In Haiti.

I tried to think of all the reasons a woman might collapse, and what sort of assistance I might be able to offer.  Again…in Haiti.

Quickly, I reviewed ACLS in my head.  I tried to revise the arcane algorithms based on the fact that we probably did not have ONE SINGLE med used in a typical code.  I thought through hypoglycemic coma, and stroke signs and symptoms.  I tried to recall how I might distinguish between ischemic and hemorrhagic types (and would it help to know the difference?).

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Our team working on the patient

Also on my list of worries were seizures, pulmonary emboli, electrolyte disorders, dehydration and the difference between heat exhaustion and heat stroke.  Distantly, I pondered the probability of this being a simple “waiting delirium” where people fake a collapse to get to the front of a line.

I approach what must be the patient but of course I can’t see her.  All I see is a giant throng of people hovering in a circle; a shark frenzy of curiosity.

My interpreter helps me push through the crowd to a thin elderly woman lying with eyes half closed on a tattered blanket.  She was placed in the half-shade of a skinny, leafless tree on dusty cobblestones just outside the church offices.  People are yelling and pointing in all directions.  They give me space grudgingly.

I learn that the woman had a seizure sometime in the night, passed out, and has been seizing regularly ever since.  She is completely unresponsive.  Someone tells me she’s around 70 years old.  Someone mentions that she’s a grandma.  Someone says it’s hot out.

After a brief exam, I have her brought into our clinic and placed her on a army-issue stretcher.  I rummage around our supplies with the help of a spectacular nursing student named Kim.  Together we come up with an angiocath (for IV’s), a bag of normal saline…even some gauze.

We place the IV and get some fluids running to treat possible dehydration.  Kim and an OB nurse place a foley urine catheter we happen to have too.  Clear urine runs into the bag, ruling out dehydration.  We find urine test kits and note that there is no blood or glucose in the urine, thus arguing against diabetic problems or UTI.

The immediate problem was the seizures.  And we had no medicines we could give a patient who, every 15 minutes or so, had a full seizure on the entire left side of her body.  Kim and I riffled through the meds again and found some dilantin (good for seizures)…but in pill form, which made them totally useless.

Knowing the patient would die in her current state, I wrestled with the problem of how to get some sort of sedative – ANY sedative – into her tortured body.  At one point a group of us seriously considered IV Haitian Rum.  I thought about crushing up the dilantin and trying to trip a slurry down her throat, or pushing it rectally.

We eventually found liquid dilantin; made for oral administration.  The discovery felt like a ray of sunshine in a mausoleum.  Now all we needed was a naso-gastric (NG) tube.  Gotta be lots of those lying around, right?

None.  The patient is seizing again, Dr. SW101.  The family is getting frantic.  People are looking in at the patient through every window.  What do we do?

Kim and I did find a feeding bag. Looking at it, I envisioned how we could fashion some version of an NG tube out of the tubing from the bag.  I talked up my plan to Kim.  Seeming like this kind of thing was a daily occurrence for her, she retrofitted the tubing, reversed the adapter connections…lubed the thing up and slid it right down into the patient’s stomach.  Perfect.  I had my tube.

I dose out my best guess for the patient’s weight, not knowing her renal function, her hepatic status, her chronic diseases or her current metabolic state.  I gave it my best guess – shooting for safety and efficacy – and we started a regimen of dilantin.

Along with trying to treat this patient urgently, we knew this woman needed to be in a hospital, and Father Larry had been working on the weirdly complicated logistics of transporting a critical patient to General Hospital in Port Au Prince.  Father Larry also supported my desire to stay with my patient to make sure that someone on the receiving end knew the story and could adaquately take over for us.

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Our best effort at an ambulance

Not ungently, we put the woman in the back of a tough Isuzu jeep and then blasted out of Thomaseau over rocks and roots and dusty country roads, headed for the thriving city of Port Au Prince.  Nearly 2 hours later, sweaty and dusty, we pulled in through the hospital gates.

My driver and translator is something of a celebrity in the village and knows many people in Port Au Prince also.  He did some quick talking at a back entrance to the ER, and ran back to our car and told me to, “help me pick her up…quick!  They’re letting us in the back.  Otherwise we have to go through the front and it will be at least 8 hours until she is seen.”

We carry the woman through wards teeming with people.  I sense many stares as I pass as quickly as possible through hordes of sick patients, family members, hospital staff and equipment.  We enter an austere room made of tile and bricks, with windows high above us grudgingly tossing some light to the floor.  A kid of about 15 is walking back and forth, tears streaming down his face as he intermittantly screams and jams his hands down his pants (psych?  testicular tortion maybe?).

“Lay her here.”  Instructs Bobby, my interpreter, the celebrity-guy.

“Right here?  On the tile?”  I reply, looking around anxiously.  “Where’s the bed?”

“No beds.  There won’t be one for hours.  Maybe days.  It’s leave her here or we take her back.”

We lay her on the floor.  Two of her family members that came with us huddle on the cold linoleum next to her.  I tell her story to a bored and tired looking orderly.

“Ok.  They’ve got it from here.”  Says Bobby, already heading for the exit.  “Stay any longer and they’re going to demand more money to keep her.  We need to get out now while we can.”

Fighting a sense of revulsion at the place where I’m leaving my patient, and vicerally wrestling with nearly-overwhelming waves of guilt for abandoning her, I snap a quick photo and leave.

As we walked away, I knew she would die on that cold, lonely floor.  Her family trusted her to me, and I left her lying in a tile grave.

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Her Final Moments

Not long after we returned to Thomaseau, after a harrowing drive through some of the worst slums in Port Au Prince – and in the entire Western Hemisphere – after hours and hours of efforts to save a life…she died.  Probably from a stroke that occurred before we found her in the courtyard.  Within 2 hours of our return to the village we were notified that the patient was gone.  Please come collect the body.  We wouldn’t have given her a bed in the hospital anyway because you didn’t pay for food and supplies.

We did calm down the seizures, by the way.  By the second dose of dilantin, the repeated convulsions faded away and our patient clearly became more peaceful. 

A small consolation.

The news of this woman’s death was somehow devastating to me, even though I knew she had no chance.  I couldn’t help but get emotionally involved in something that required so much effort and focus. 

And for all that work, I ended up with a dead patient; her last moments spent in squalor, destitution and abandon. 

I have now spent hours trying to frame this experience in some sort of meaningful context; actively resisting raw emotions of fury and hopelessness and sheer nhilism.  So far, I know only this:  all I can really do for Haiti, is care about the suffering there. 

And never, ever forget…

Swearing at the Chaplains

I have a hard time connecting with our hospital chaplains.  Something about their collective personalities, I guess.  I’m inclined to say that they’re just generally weird but I suppose that would be arrogant.  In effect, I’m saying they’re strange and I’m normal.

But they are.

Strange.

I can’t shake the feeling that the chaplains are working in my hospital because they’re winding down a career – the semi-retirement of the Godly set.  I often catch myself thinking they’d be on the proverbial golf course if they could make the numbers work.

I can never find them when I need them.  I never hear my patients asking for them or expressing gratitude that the chaplain stopped by.  They don’t help with cases and in my 2+ years in this hospital, I’ve never worked with one chaplain on any case – dire or otherwise.  I’ve gotten to know janitors, administrators, transporters, most of the switchboard operators, librarians, at least a sampling of nurses on every floor and virtually every nurse in OB.  I know most of the social workers, some of the PT guys, a couple of dietary folks, two coffee ladies, the head IV therapy nurse, the wound care people, some of the security guards and the guy who heads up the hospitality service.  Heck, I even know the ladies in the post office.

But I don’t know a single chaplain.  Not one.  They drift through the hospital like druids floating around looking for sacred mushrooms to grind into some acrid concoction of God, but they sure don’t talk to me.  Given that when working in the hospital, I’m seeing people at death’s door every day, I can say that if they’re ushering people into the heavenly realms, they’re doing it when I’m not looking.  More than once, I’ve wondered if they’re out back smoking the nargila and waiting for their retirement to kick in.

The other day I had a patient ask for her pastor to visit her.  We were discussing that the end of her life was near; it was time to consider switching from care for cure, to care for comfort.  In other words, it was time to pull out the catheters.  This was an emotional discussion for both of us, as we’d made an early connection with each other and I really enjoyed her acerbic wit coupled with a clear love for the act of living.

“Before we start pulling out tubes, I need to pray with my pastor,” She told me, between gasps.  “I’m scared to make this decision alone and without some prayer first.  His name is Pastor Jarrod and he’s with the Community Grace Church downtown.  Please find him.”

You can imagine that this sort of plea wasn’t taken lightly.  If you really think about what it might be like for you to die, GENUINELY mull the idea of your own demise around in your head for awhile, I think you’ll find the idea a bit unsettling.  Most humans innately fear the unknown, and even if you have an enormous amount of faith that you are to be saved from the ill-effects of death, crossing the actual threshold should stir up at least a little consternation.

So, I moved quickly out of her room and attempted to contact the pastor of my patient.  After 3 or 4 phone calls, I’m successful only at leaving messages at various destinations.  Then I remember, “Hey!  We have a chaplaincy here!  I’ll just call one of them.  They can spend some time with her, pray with her, encourage her and fill the void until her pastor gets here,” I figure reasonably.

I stop to think for a moment and realize I have no idea how to even call for a chaplain.  This is understandable, given how infrequently we even use their services.  So I look them up.  Calling their office in the dead of the business day leads to a voice mail.  They offer an “Emergency Line”.  I call that.  Voice mail.  I page overhead.  No answer.  I leave my cell phone number, pager number and numerous voice messages.  No return call.

An hour later, I get word that my patient is exhibiting agonal breathing.  She has reached the end, and I failed to bring a pastor or chaplain to her side.

“Godd*&m, f&c$ing chaplains!”  I scream to myself, “I can’t envision a more worthless excuse for spending hospital money.  What the hell do these people even do?!”

So, the title of this blog is misleading.  I didn’t swear at chaplains, thank God (no pun intended).  I swore at the idea of chaplains.  They could play such a huge role in the lives of people in our hospital, but from my perspective, they don’t do anything of the sort.  It could be that we’ve just been ships passing in the night for all these years.  But why do I see the maintenance supervisor about every other day, saying hi to him and laughing about how I messed up his wax floors last year, but I couldn’t find one of our drifty druids if someone’s life depended on it?

Turns out this lady’s personal pastor did get my voice message and rather than waste time calling me back, he made a bee-line to the hospital.  He held her shaking, fearful hands and prayed deeply and intently with her.  He reminded her that according to her Christian beliefs, she has power over the eternal effects of death as well as the fear of death itself.  He reiterated that Jesus has wrapped her soul in love and freedom from darkness.

Shortly after this prayer, he told me later, my patient sighed peacefully, looked out the window and whispered, “Lord, I’m ready.  Take me home.”  And then she died, her face still and peaceful;  probably much like she first looked when she was a newborn baby, asleep in her crib.

Perhpas I’m being too critical of the hosptial chaplaincy and one day will wish to change my assesment of them.  But for today, as my mind and heart still reel from the loss of such a beautiful person who almost faced the end of her days in needless fear, our chaplains leave a lot to be desired.

Ode to McDonalds and Cigarettes

You can say you saw it here. This family medicine doctor – supposed bastion of all that is healthy and wholesome – recently found himself encouraging a patient to keep up the McDonald’s and smoking. Instantly after proclaiming my support of these two great sins of the developed world, I heard my program director’s voice in the back of my head saying not unkindly, “Nice job, doctor, good work…we’ll most likely kill you in the morning.” Although never tempted by cigarettes, I frequently fight the urge to hit a McD’s and constantly rail against both as all that is disjointed and wrong with our society (celery is another problem, IMO, but that’s another discussion entirely).

I saw a patient this weekend who unabashedly describes smoking about a half-pack of cigarettes a day, and has been doing it for “goin’ on 50 years now, and I ain’t quittin’ no matter what you tell me.” The patient is 78 years old with advancing COPD. When she inhales, the wispy flimsy breath she drags down into her rapidly deteriorating lungs rattles around aimlessly like a blind baboon in Grand Central Station. She then forces the air back out; little of the oxygen actually used. She is on 14 medications to treat everything from her diabetes to the high amounts of fat in her blood.

“Smoking makes me feel…” She closes her eyes, her face taking on a distant, faraway look as if she just lost herself in recollections of her torrid love affair in Paris on a college philosophy tour, “like I’m surrounded by friends when I’m actually all alone.” How can I beat that?

This patient lived a full life, been smoking for a good majority of it. Now she is stuck in that impartial vice-like vortex of half-life and half-death that American medicine has so expensively provided us. Historically, people just died when they got as sick as her. Today, people linger, in a sort of daily, living suffering. The institutions they inhabit have innocuous-sounding descriptions like “assisted-living communities”, but everyone knows what they really are. Places where the clock of mortality hangs largest on every wall, where the clanging metal hammer pounding on anvil cannot go ignored, but can’t be rushed. It pounds in measured, inexorable rhythms, indifferent to anguish it causes. Hundreds of thousands of Americans waste away in these communal halls, most abandoned by their families, waiting for that final insult and staring droolingly at the wall in the meantime. But when this insult finally does arrive – a heart attack, hemorrhagic stroke, maybe a pulmonary embolism – it shows up with a slouch, hands in pockets, irresolute, nuanced and often as slow as a sadist. These days, the Reaper arrives in a robe of gray, eschewing the dramatic and abrupt pitch black somewhere around the time we invented beta-blockers.

So, go ahead, lady. Smoke to your heart’s content (or infarct). The damage is done, really. If you did stop today, the additional few weeks or maybe even year would be so miserable for someone who loves smoking this much it wouldn’t do much for you. Mortal time isn’t everything. There’s such a thing as life quality, too.

“The other thing I love,” She continued, “is Saturdays.”

Her face, looking like gravity used physical hands to pull her face to the ground for the past 200 years, suddenly filled with a smile. Her losing battle with age suddenly clamoring to a standstill. “My wonderful daughter comes every Saturday and brings me a McDonald’s egg McMuffin sandwich and coffee. I just love that. I look forward to it all week. Say, what day is it? Maybe she’s coming today. Do you know?”

“Well, it’s Saturday night at 11. Maybe she came earlier before your care facility staff thought you needed to come to the hospital.”

“Yes. This could be. You see dear, I can’t really tell the difference between days and weeks and months and years anymore. They’re all sorta the same to me anymore. I just know my Jerry comes on Saturday and we have breakfast together. And you know…that McDonald’s does a lot of good for other people, too. They hire young kids, old folks…give people a start in life, or help them do something worthwhile. The buy all kinds of ingredients from local grocers and farmers. Why, when they moved in here 30 years ago, my son was one of the first they hired. He has his own business today. Employs 30 people.”

“Wow. I’ve never thought of them that way.”

“And them McMuffins…ain’t so bad for you, either. They fill you up, keep you fed through almost a whole day. It’s good food.”

By any primary health care measure, someone who smokes daily and eats fast food at least once a week, is not healthy. But exceptions to every rule emerge in unlikely places. This woman did not come to the hospital to make me re-evaluate my unbending belief in the immutable evils of fast-food and smoking. But her defense of their place in her own life was unassailable. This woman won’t live to be 90 years old. The end may come in the next few days, in fact. But this is true for all of us. This very moment, our lives could be required of us. Should this happen, could you depart with the same gentle serenity?

If deprived of her simple vices, could she?

I found myself answering no to both questions. So this family doctor ended up departing the room, encouraging an overweight patient with COPD and hyperlipidemia to “keep up the smoking and enjoy your McDonald’s.”

I’ll start typing my resume. I hear there’s good jobs in the restaurant business.