I vaguely register the old lady as I walk past the triage desk. I hear the triage nurse talking to her son “…for four months?” whilst I catch sight of the normal vital signs and carry on walking. When I walk back, the doctor is examining her in the corridor. She looks pale. Tired. The doctor is worried and I see why.
The woman is moved to a bed where she is immediately assessed. I sense the doctor’s increasing concern as I explain to the visiting communications officer that she may not see much of interest today.
By the time she has been moved, her heart has stopped
The communications officer is there to understand how the emergency programme runs, but there has been a nursing strike for the last three months and the number of attendances has dropped by about two thirds. We can’t admit patients here and they know it, opting to either take their chances at home or take themselves directly to the one public hospital in Nairobi with a functioning inpatient unit. It’s not an irrational decision – about a quarter of the patients we see here end up being sent there via an ambulance that costs them 1,000 Kenyan shillings (KS) – more than a week’s wages for many.
Photo: David Kariuki / MSF.
The doctor has decided to move the patient to the resuscitation area. I stand on instinct. I pull the bed out to transfer her. By the time she has been moved, her heart has stopped. The rest is reflex. Oxygen and ventilation bags appear on command and chest compressions start. The ABCs of resuscitation are started. Two minute timers are set, adrenaline is drawn up and given, the heart monitor is found and attached. As the only doctor with specialist emergency training, I take the lead by default - though I’m standing in the wrong place. An old instinct won’t let me leave the airway until there’s a tube in it. Intubating in this department with the resources we have often causes more problems than it solves so I hold back and hold her airway open with my hands.
The whole department is now focused on keeping this one patient alive
The doctor reads out the blood results, tells me the history. She’s 76 and has been severely anaemic for months - diagnosed at a private clinic and not followed up as there was nowhere affordable for the family to take her. She has had chronic diarrhea and weight loss. I guess at an undiagnosed cancer, now reaching the end of its hold without ever having been pulled out into the light.
As is usually the case with a cardiac arrest, a switch flips and the whole department is now focused on keeping this one patient alive. I’m vaguely aware of two sets of eyes staring into our cocoon. The son is watching intensely from the corner. I expect that he knew this was coming long before we did. He’s calm – at least on the surface. I want him to see we’re trying. I’m also aware of the clicking of a camera - an experience that makes me uncomfortable at the best of times. For a flash I see myself through the lens – exactly the kind of image I told them they wouldn’t get today – action packed photographs of fighting death and saving lives. I know the truth is different, it feels dishonest.
Photo: David Kariuki / MSF
Miraculously we get a pulse back and she is breathing. I recognize the breathing pattern. It is not one that lasts long… It’s time to make some decisions.
We have just enough time to discuss the alternatives to the inevitable – are there intensive care facilities nearby? Where are the ambulances? Can we transfer? – before the heart rate slows and stops again. CPR is restarted.
Some battles weren’t meant to be won
News comes back that there are no Intensive Care Unit beds available. At this point I speak out the decision I have already made. This is an elderly woman at the end of her life. Sometimes medicine is about acknowledging that and letting go. One more adrenaline and two rounds of CPR. I check the pulse. No miraculous return this time. We “call it”. 1017am.
It’s always sad and a little deflating call a death after an arrest. Time teaches you that some battles weren’t meant to be won.
Throughout my childhood and beyond, my father told me to pick my battles. I always thought it was advice designed to protect his intense little daughter who railed against the injustices of poverty, homework and bedtime with equal force, against burning herself out. As well as, I assume, buying her long suffering parents a moment or two of peace and quiet.
Photo: David Kariuki / MSF.
I have thought about this advice throughout my medical career, especially when I have got it wrong. The argument over a referral that did more harm than good, the tubes and lines that went into patients which served only to deny them the peaceful death they were due.
What I won’t fully realize until the next day is that this little skirmish against the inevitable would feel like the less important of two losses.
I needed to make a decision
The following morning the nurse approaches me with a card in her hand and I feel a sense of urgency under her characteristically friendly and laid back demeanour. She wants to talk to me about a 14-year-old girl I had seen shortly after the arrest. She had been carried in in agonising pain with a crisis caused by her sickle cell disease and I had quickly prescribed her medications and ordered her blood tests whilst dealing with the aftermath. When I eventually came to see her, her pain had settled and she was sleeping. I reviewed her blood tests with the doctor on duty. She had some signs of a chest infection and her bloods were slightly worse than what you’d expect.
I needed to make a decision again. This one was deceptively quiet and routine. In fact, infinitely more complex. At home in the land of free healthcare I would bring her in for admission and a battery of tests without a second’s hesitation. Here,within the Kenyan public health system, patients get treatment only after they have paid, although, a waiver system is applied on a case by case basis.
I am not equipped for this. I speak to the doctor on the afternoon shift. I admire her more than I can say.
Medicine is full of difficult decisions. Even with access to all the knowledge and all the tests, there is often a degree of crystal ball gazing when deciding what your patient’s disease will do. Deciding to admit in Kenya’s healthcare system during this strike means weighing up a whole extra set of impossible unknowns. As well the medical issues, you need to weigh up the financial consequences to the family of stumping up fees for transfer, registration and treatment at the receiving hospital (will her sisters be able to eat? What about the next time when she’s really sick?). On top of that, you need consider the chances of them making their way through the hoards of patients currently pushing the national hospital to its limits to become one of the lucky ones seen and treated in a timeframe that makes the whole exercise worthwhile. I am not equipped for this. I speak to the doctor on the afternoon shift. I admire her more than I can say. She has been navigating this grueling terrain her whole career. The camera has gone now. This would be invisible to it anyway.
This war is more brutal than the one I am used to
Together, we make the decision to treat her with antibiotics and let her go. The security deadline for leaving at the end of the day is pressing down so I follow the MSF team home. After I have left, the doctor explains the plan to the parents and watches her walk out.
Her father carries her lifeless body back to the department just a few hours later. When the friendly nurse tells me about it in the morning it hits me like a punch. I can’t hide my response – I’m still soft and weak – this war is more brutal than the one I am used to. I sit silently, unnerving those around me. I haven’t yet got the hang of the well-practised stoicism and optimism that calms the deep tides of emotion that run alongside the suffering here.
Photo: David Kariuki / MSF
The rest of the shift plays out like an attempt to drive the point home. A woman bleeding following a miscarriage who can’t afford the medical kit required for the simple procedure to help her, the man with an overwhelming infection diagnosed with HIV who walks out after the antibiotics and fluids we provide him for free from the MSF supplies. As I have grown up I have realized that picking your battles doesn’t just help you make peace and save the energy spent on unimportant and unwinnable causes, it galvanizes you for the real fights. I picked this. This battle matters.
It’s the real trick to living a meaningful life. The problem is that the real battles, the important ones, the heroic ones, are often quiet and invisible, sometimes even to those fighting them.
A song by my father’s favorite band runs through my head as I take a phone call over the weekend. It’s the doctor I discussed the young girl with. She’s back at work and wants to discuss a patient. The man with HIV survived the night and has returned with some support and has agreed to be admitted for treatment.
You can’t always get what you want. But if you try sometimes, you just might find,
You get what you need.