27 de Enero, 2012
A young man lies quiescent in the emergency room. He is painfully thin, no – thin does not even begin to convey it. He is so cachectic that every bone can be seen pushing through the fragile skin. His cheekbones seem close to piercing his face, his eyes are deep set and wounded. The only signs of life can be found in those eyes, and the faint movement of his chest muscles as he struggles to take in oxygen.
His family brought him in. Months and months of indeterminate fevers, months and months of blood tests – all to no avail. Night sweats, and a cough that just wouldn’t go away, and then the weight loss started… kilograms almost literally melting away before his family’s eyes. The doctors in the city had no answers to give, just more antibiotics, more treatments that might be the right one, and somehow never were. What led him to come to this little rural hospital in the wilds of Honduras? Was his family here? They brought him by boat from hospitals with far better resources than we can offer. Better laboratories, more tests, more scans, and updated machines. Certainly not better doctors, but doctors can only do so much with the resources they have.
I admit when I first saw him I had two completely different feelings at the same moment. I was filled with pain for his suffering, but I was also immediately intrigued. Possible diagnoses started rushing through my mind. The understanding of pathophysiology, the joy of medicine – of looking at the clues, the symptoms, and unraveling the mystery. Putting everything together and trying to find answers – oh how I had missed the challenge! In the Intensive Care Unit one it constantly analyzing and assessing, making minute by minute decisions and again analyzing the results. Here is Ahuas I have many tasks, and I am learning new things daily, but there has been nothing of the critical analysis and polymorphic associational thinking that I so love.
So, I began to think. What can cause dramatic weight loss, intermittent fevers, and nightsweats and not show up on a blood test? The immediate thought was TB of course, but he had had a negative tuberculosis test done in Tegucigalpa some months back. HIV? Malarial hepatopathy? Had they only done a sputum sample to test for TB? What if he actually had tuberculosis in some other part of the body – the abdomen for example – and it wasn’t showing up in the sputum? Some sort of immunological disorder? Dr. Ovelio was the doc on-call, and I looked over his shoulder as he ordered blood tests and xrays and discussed what more we should do. I looked into the young man’s eyes, and squeezed his frail hand and tried to convey hope. Perhaps we could find the answers.
Unfortunately it was both very simple, and not that easy. The tests came back quickly and positive. It was definitely tuberculosis of the lungs – quite advanced – and malaria to go along with it. We started the correct treatments, but his lungs were already so damaged, his body lacking any reserves. A day after arriving his oxygen saturation began to drop. He was placed on supplemental oxygen to no avail. The next morning I arrived at report to hear that his oxygen saturation was reading in the 50s. Dr. Ovelio and I went into the tiny isolation room where he had been admitted. Here there are no N95 respirators and negative airflow isolation precautions. Just a small “aislado” room kept apart from the rest of the hospital where a gaunt chest was heaving his last breaths. We tried to deep suction his lungs to no avail. His fingers were too cold for the pulse oximeter to read. His eyes were lifeless now, no longer seeing his father weeping beside him. Finally we stopped trying. His chest stopped heaving. He was dead before seeing his 30th year. We had all the answers – we knew what microbes infected his wasted body – but somehow the quest was no longer so intriguing. Analysis loses its joy when the answers fail to assist in any way.
Could we have done anything different? Probably not. It was most likely already too late when he walked through the clinic door. Yet it leaves me with a sense of futility and frustration – at the system, at a country where there is more need than can be sated, at myself, at the doctors from before who couldn’t diagnose him in time, at any number of things that are wrong with the world.
The struggle continues…
The struggle to find medicine and treatment for worldwide populations who cannot pay… The struggle to not just give up when you realize how little one person can actually do… The struggle to stretch resources to help as many people as possible without cheating anyone…
I held the father’s hand while the mother screamed. I stayed in the little room to see the body covered in a sheet and to hear the mourners begin to sing. The father’s sobbing slowly subsided, and then the day continued on. There were surgeries to do, and there was insulin to give, and student nurses to oversee. I don’t know why some deaths are so much worse than others, but when I first saw him, and he squeezed my hand, I saw the tiny glint of hope in his eyes – the hope that maybe we could save him. But we failed.