Monday, April 23, 2012


I have rarely seen anyone so pale.  Lips grey brown, tongue white with only a hint of pink – like he had stuck out his tongue to catch the snowflakes.  White fingernails.  White conjunctiva.    Tachypnea.  Pulmonary edema.  Tachycardia. 

He’s dead now. 

After getting a pouch of whole blood from his father – after they went out to the village to try and find the money for a quinine perfusion that he should have received earlier. 

When I got to peds this morning, I was cleaning off the supply cart when I this labored dyspnea slowly sank into my consciousness.  I followed the sound and there he was.  Bed 16.  Looking horrible.

He is better now, the nurse on guard shift said.  Better?  I wondered what he was like before. 

Look at how pale he is. 


Oh yeah, I guess he is pale.  Okay, bon travaille!

And then she leaves

And maybe he would have died anyway.  Maybe so.  Maybe all the appropriate interventions in the world wouldn’t have worked for him. 

But he was only 4

But we should have started IV quinine as soon as he came in.  He should have been transfused earlier. 

And its easy to diagnose in retrospect. 

But there is no excuse not to assess the patients.  None. 

You don’t even have to be smart. 


And yeah, I think I’m pretty rock and roll.  Sometimes.  I think that oh, if I was there, this, this, this, wouldn’t have happened.

And that’s not really true.  Pretty much, here, you either die or get better, and I make mistakes every day.  all the time.  I just don't love admitting it.

And an hour before he died

They asked how much should they feed him.

A little bit of bouille?? How often??

People always fixate on something.  Someone can be pretty much coding and the family member will be all torn up about whether or not his tube feeding is at the correct rate or if he received his glucerna shake. 

Or how the patient has slid down in the bed or how the pillow is wrinkled.  And usually the things they desperately grab onto have nothing to do with how they really are doing. 

When my grandpa died, my family did it too.  We must have been the nightmare family.  5 nurses in one room.  The rest doctors.  And what did they do??  Did he get his beneprotein in his tube feeding?? He needs his protein……

We have had 15 kids die this month.  I’ve seen more death this month than in a long time.

But I’m either getting jaded or will completely lose my mind over something very simple frivolous and non related.  I suspect the latter will happen soon. 

In fact, I’m bothered by the fact that I’m not that bothered.  Or maybe I am, or I wouldn’t be writing this. 

It is just hard.  To see the tears streaming down the parents faces.  To see the hope. Hope until the very last minute.  Spending all their money.  Trying.  The next kid, will they take him to the hospital??

And they close the eyes.  And cover the face.  And I take the IV out.  And the mother, she just crumples.  And then they walk out.  And then we go eat. 

And I think I have a lot of misdirected anger at the nurses here.  And I may have taken a bit a self-righteous stance.  I am expecting the other nurses to view nursing through my eyes, to have my same world view.  They have less education.  They have no experience in an American hospital.  They were not trained in their departments – no six weeks of following someone that knows what they are doing – no formal orientation – just thrown in, sink or swim. 

And they do a little of both.  There isn’t a lot of admitting you are wrong here.  Do you know how to put in Pediatric IVs?? Oh yes.  Yes.  You have done it before?  Yes, I know how.  Okay, you can do this one.  And his hands are shaking.  And he cracks the needle.  And it’s obvious he’s never done it in his life. 

Do you know how to give this medicine?  Yes.  And then drawing it up wrong.  And giving the wrong dose.  I don’t know what that’s all about. 

But, when I was a student, if I was just thrown out there, I wouldn’t have done well either.  If no one had explained things to me, been patient with me, and watched my hands shake as I did everything for the first time, how would I have learned??

But we put these people by themselves right away – and then we expect high quality work when they never had the opportunity to learn??? 

But everything is complicated here.  This hospital has been in very competent hands the last 8 years.  Change comes slowly here.  I think I have the answers.  But I don’t.  Not even a little bit. 

The wretched part is just how preventable it all is.  No oxygen. No life support of any kind.  When they die, they die.  Now, it’s laughable that I printed out ACLS and PALS to take with me and had a special notebook to put it in.  I had every protocol for every scenario. 

It is just terrible to see children die on your watch when you know that ANYWHERE else…..they would have had a fighting chance. 

And they would have had people that fought harder for them. 

And then they might have made it. 



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