Little 6y/o Fernando dropped to the dirt floor of his house and didn’t get up.  His parents said he hadn’t been sick.  They debated for several (important) minutes and decided to transport him to our hospital.  Eduardo and I were beginning to attack the long line of waiting patients and our ED nurse interrupted me and said there was a “grave” new arrival.  I arrived to Fernando lying supine on a bed with vomit on his face.  I smelled discharged urine/bowel content (common immediate indicator of death) and looked at his chest and there was no movement.  An exam with my stethoscope revealed no heart activity.  The little guy was dead. 

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I asked his (now weeping) parents when they last noted any movement or breathing and they said at home, prior to their motorbike trip to Cavango.  They had loaded Fernando on the motorbike on mom’s lap, wrapped in blankets, squeezed between riders and they had assumed he had remained in this comatose (alive) state until arrival at the hospital.  There was no way of knowing when he had died during the trip and, of course, brain death occurs after only minutes without heart activity. 

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This “dead on arrival” diagnosis happens fairly often at our rural, bush hospital and, in this environment, because of the travel time intervals  (usually hours, minimally), we rarely attempt resuscitation to “restart” heart activity, though we consider it with every death.  We attempt the initial steps when we are certain that the death was recent or we witnessed the arrest, perhaps a couple times per year, but we have never had a successful resuscitation.

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I checked Fernando’s pupils and they were unreactive and I told Fernando’s parents that he had died on the way in to the hospital and that, after even just a few minutes, brain activity was irreversibly lost.  I got up to return to our long line of waiting (alive) patients.  For no apparent reason, with sympathy and tenderness, I touched Fernando’s mom’s shoulder and reached down to touch Fernando’s chest.  As I did so, some vomit trickled out of his nose without respiratory effort. 

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I had the intersecting thought, after sitting there for over a (precious) minute, that I really didn’t know when the child died and it might have been, however unlikely, right on arrival (now several long minutes ago), so it couldn’t do any harm to try a couple simple resuscitation treatments.  I sat back down, next to Fernando and asked for an ampule of epinephrine and it was drawn up by our nurses and I stabbed it into Fernando’s little chest and into his heart.  I calmly began chest compressions and told the parents what I was doing and that any success was unlikely but we wanted to do anything possible to be sure that Fernando could not be revived. 

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One minute, nothing… the same at two.  Ready to quit our brief effort, I touched Fernando’s chest and I thought I detected a heartbeat.  Another stethoscope check revealed a certain beat or two, but way too slow to sustain life.  I gave another shot of intracardiac epinephrine and more heart activity became certain. 

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I told Eduardo about the resuscitation attempt and he joined us.  I asked for oxygen to accompany the chest compressions and Eduardo began forcing air into Fernando’s inactive lungs via bag and mask.  A raspy breath escaped, then another.  I asked a nurse to begin an IV line but no veins were palpable.  We put a needle into Fernando’s tibia and gave more epinephrine, along with some IV hydration.  His heartbeat was strong and Fernando began breathing and I almost felt badly now because I was certain that Fernando’s brain was dead.  I checked his pupils and they were equal, of normal size and reacted to the light.  Perhaps…

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The IV line in Fernando’s tibia wouldn’t run so we put one in his femur and it worked for a while, but not well.  His heart was beating more strongly and we were now committed.  We went and got our portable ultrasound machine and, with it, painstakingly put an IV line into Fernando’s femoral vein.  Fernando was now breathing on his own and his heart was beating strongly, so we moved him to a bed and attached to him one of our new monitors.

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While this was going on, I was called to our delivery room, where a young, first-time mom had arrived during the night (with malaria) after suffering through labor pain for two days (!).  We checked the baby via ultrasound and he had a good heartbeat and was in good position.  Madalena’s contractions had, however stopped after her cervix had fully dilated (the reason I was called).  Our nurses have been trained to handle well most normal and uncomplicated deliveries, but they appropriately call us when labor has any appearance of variance from normal.   I had Madalena empty her bladder and ruptured her amniotic membranes (broke her water), and asked the nurses to begin IV medication to help strengthen contractions.  I was getting quite behind and “returned to work” on the long line of patients.  It was going to be a long day…

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In the afternoon, Fernando remained in a coma, unresponsive to any painful stimuli and we had begun aggressive treatment for malaria, his likely cause of death.  His heart was working well and he was breathing rapidly, but his blood oxygen level was quite low, even while on maximum supplemental oxygen.  He had surely aspirated his vomit/secretions at some point and now had pneumonitis, which we treated aggressively. I emphasized to the parents that we would continue to do all we could, but that a positive prognosis was unrealistic. 

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Madalena’s contractions had returned and she had been pushing for over an hour.  I began helping the baby out with traction, using a portable vacuum device.  After about fifteen minutes of work, a beautiful little boy was delivered, but he was not breathing and he had no heart activity.  We suctioned the baby’s airway, clamped and cut his umbilical cord, and aggressively dried and tried to stimulate him.  Still nothing.  I began chest compressions, hoping the heart hadn’t been arrested for long (it had been hours since we saw heart activity via ultrasound). I wiped the baby’s face of placenta, blood and mom’s stool/urine and began (unpleasant) mouth-to-face breathing. 

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This is one of those moments when, as a care-giver, one must decide if an individual person’s value exceeds one’s comfort level.  There are many such situations in our outback, low-resource, misunderstood (all modern equipment is foreign and strange) work.  I have stabbed myself with an HIV infected needle during a procedure, been treated for TB twice (we treat 300+ people with TB annually and do many procedures which can contaminate the care-giver), I’ve had malaria 30+ times (nearly died once, ending up in a South Africa ICU with ARDS), I’ve landed with MAF in severe storms and other risky circumstances, I remember a long night walking through the middle of desert-Africa-nowhere to a clinic of waiting sick people when our car broke down en route the day before, we’ve worked where there have been active land mines, we often work in 100+deg heat, etc, etc.  So many times awakened during the night because of an urgent need and rushing to a hospital without electricity (until recently)… I have smelled, touched, worn and, yes, tasted urine, vomit, stool and/or death hundreds of times… 

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Why?  For some sort of delusional narcissistic, personal glory?   So say some.  As I’ve written previously, I have recently been called “racist”, “colonizer”, “exploiter” and worse. Beauty and the eye of the beholder… When Paul chronicled his work and told his story, he was criticised in the church in Corinth for “boasting” and he responded by simply writing to them about cost. In his letter to the church in Galatia, Paul contrasted serving Christ with seeking to please men… We all must choose whom/what we will seek to serve/please. Why do we endure all of this and get up every day and do it again? Perhaps, because we choose to recognize the extravagant beauty and value of each one of these people (including Fernando and Madalena) as equal to our own while, clearly, few others choose to do the same. We have decided to live where they live… to serve them as they are… no strings… and to consider personal comfort and risk secondary.    I choose to measure love as Paul did and as Jesus does – in cost rather than sentiment…

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These posts, however, are not written to churches or to the public at large, but to you (few) who know us and join us in serving these beautiful, forgotten people, sacrificially sending your hard-earned resources to allow us to care for so many, and we are beyond grateful to be partnered with you in their care.  I hope you sense our Father’s pleasure, as we do, in both the pleasant and the unpleasant…  These stories illustrate a couple pleasant outcomes. There are so many of both…

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I do this messy “procedure” (we don’t have modern, “protective”, resuscitation equipment) perhaps 4-5x/year in similar deliveries and our success rate, when there is no cardiac activity, is maybe 20% (better when there is no breathing but the heart has some activity).  After about 3-4 minutes of slimy, assisted breathing and chest compressions (providing heart contractions manually to circulate blood), I detected a few (slow) heart beats, but no breaths.  Another minute or two and the baby rattled out a breath, then another, and his heartbeat became regular and fast. 

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We began oxygen supplementation, moved the now-breathing baby to another bed, and noted that Madalena was hemorrhaging badly.  Her placenta was slow to deliver but we wrestled it out and her hemorrhaging continued.  We began aggressive (and very painful) massage of Madalena’s uterus and gave her medication to help contract her tired and (too) soft uterus.  Over perhaps thirty minutes, Madalena’s hemorrhaging slowed and we were able to turn our attention back to her baby, who was breathing well, uttering soft cries, and moving all limbs.  There were so many patients who had been waiting all day to be seen…

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During the night, I was called because still-unconscious Fernando had developed repeated seizures, was agitated in between and couldn’t be calmed.  Good news?   Comatose kids with cerebral malaria will often have repeated seizures and agitation, indicating potential harm to the brain, which can indicate a poor prognosis.  But in this case, we knew that Fernando likely had brain injury, so might any activity be positive?  We administered a sedative to stop the convulsions and we would now wait to see if there would be further evidence of brain activity in Fernando…

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On our arrival to the hospital the following day, Madalena and her baby were both well.  Madalena’s hemorrhaging had stopped, she had eaten some breakfast, and she smiled a greeting as we entered her room.  Her baby had begun nursing and looked good, showing no signs of brain injury and, after full treatment for her (their) malaria, Madalena and her newborn, healthy baby will both return home well.

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Fernando had opened his eyes that morning and appeared to be able to track activity.  No way!  One side of his body, however, was flaccid, a relatively common symptom of brain harm after cerebral malaria and, which, only sometimes, resolves.  In this crazy case?

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The following day, Fernando was moving all limbs and swallowed liquids and a little food.  His breathing was still quite labored and he needed full oxygen supplementation via mask, along with aggressive breathing treatments to help open his damaged lungs. 

The next day, Fernando’s oxygen levels improved, he seemed stronger we found that he was able to sit up on his own. 

After another day, we were able to diminish Fernando’s oxygen supplementation and use a nasal cannula instead of a mask.  He accepted a sucker, sat on his mom’s lap and stood with assistance. 

The following day Fernando walked and talked with his family, while interacting, they said, normally. 

Today, we saw Fernando walking and playing outside and he will soon be ready to return home well!

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Worth the cost?