Great Highs and Great Lows

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This is a much more sober entry, so if anyone is reading these simply for cool, interesting adventure stories, this is not the blog for you. Skip it and come back next time.





My first patient died on me yesterday. True he was not technically "my" patient, I was hardly the responsible physician on call, but I was involved in his care, and I think I can call him "mine" in the sense any nurse could call a patient "his/hers."

He was a Tibetan boy (there is a Tibetan colony in Mussoorie, so we see quite a few patients in clinic) of maybe 10 - 13, wearing a bright red T-shirt with some American rock band name on it that I haven't heard of. He came in a couple of afternoons ago, and we all rushed away from our clinics to see him. He was moaning in pain, his entire body covered in a rash that looked something like folliculitus, and it was clear that every movement was painful for him. He also had tenderness in his thighs, but didn't present with fever or any other apparent symptoms. It was decided he must be having a bad allergic reaction to the Meningitis? medication he apparently took earlier, so we put him on steroids and I think, antihistamines. The next day at morning rounds his rash was gone, but he was still in pain. I can't remember exactly what treatment was prescribed at that point, but we still thought it was the original allergic reaction. Later that day (I missed it because I was in clinic) he suddenly started having problems, and they took a chest X-ray which I later looked at, showing it completely infiltrated with some infection. He was stabilized and put on antibiotics for both Meningitis and Staph (which can give similar symptoms). Apparently they hadn't thought it was Meningitis before, because he didn't have a fever. I didn't even know about any of these afternoon happenings until I was having 4:00 tea with the doctor on call that night, and a nurse rushed in saying something about dropping O2 stats and some other things, and the doctor ran from the room.

When I joined him, the boy's bp was 90 systemic on palpation only, impossible to determine by auscultation. They needed to put a new IV into him, but couldn't find a good vein for a good 5 - 10 minutes, not surprising to me considering he didn't have a dorsalis pedis, radial, or any other palpable peripheral pulse. The bottoms of his feet were a pale yellow, as were the palms of his hands, his finger and toe -nails were completely white, and when I pressed down on the ice-cold skin of his foot, I couldn't even see any blood return. They put him on Dopamine, which after awhile did help a little, but listening to his lungs was incredible. Incredibly labored breathing and if you ever wanted to know what secretions in the lungs sounded like, you should have listened to this. I could barely hear his heart over his labored breathing. His respiratory rate was something like 30/min (for you non-med people it's supposed to be about 12), his Hb was recorded at 9 while just earlier that day it was 13 (normally 12), and they didn't have the equipment to test his blood gas levels. Most scary for me, though, was that the doctor on call started asking advice from my rising 3rd year medical student friend. Not that it's the doctor's fault. In American terms, he's still applying for his residency, about the equivalent of 4th year, and in the Western world there's no way he would be on overnight call on his own in a hospital with no one to help him. Here, though, there are only 3 doctors, one of which is the head doctor who doesn't take call, so there are only 2 of them (the other guy's maybe the equivalent of a 3rd year resident) who take call every other night. There's no one else to do it, and someone has to. But it made me scared. When the doctor doesn't know what to do, who does?

When I left to take a dinner break the boy was still alert and conscious, constantly thirsty and trying to remove his O2 nose-tube, but was doing a little better. I could palpate an extremely faint dorsalis pedis, though still no radial oddly enough. They suspected an internal bleed, and he'd obviously gone into shock. When I came back and checked on him, he'd slipped out of consciousness and the doctor said they were going to ship him to a better-equipped hospital in DehraDun, but both my 3rd year friend and the doctor said that the prognosis was not good.

When I came in for morning rounds the next day, I found out he'd died during at 9 that night. Just a half hour or so since I'd stopped in to check on him.

The saddest part of the situation, besides the question of the medical care available, and whether anything could have been done if they had had better facilities or more experienced staff, is that the woman and man by his bedside who I'd thought were his parents all along, weren't. His parents were still in Tibet, having sent him and his brothers across the border illegally, like all the refugees in Mussorie, and there was no way they could possibly come into India to say bye to their little boy. Or would there even be any way to let them know? Are they still in Tibet now, dreaming of the better life they think they've given their children in India, thinking of all the opportunities and advantages they "must be getting"?

Earlier that day, just before lunch, I had seen a child being born for the first time. A boy, of what must have been a good 7 - 8 lbs, to an Indian woman having her third (and decided last) child. It was the most amazing thing I've ever seen, and it all happened so fast (probably because it was her third). It seemed like the head came out all in one smooth motion, the nurse suctioned, and about 1 1/2 seconds later there was a little crying baby, with a full head of hair, still attached by the white umbilical cord, lying at his mother's feet. The mother was so amazing, too, she didn't scream at all, but grabbed the handles and clenched her teeth, seeming to undergo much more pain when the nurse had to reach in to check her membranes afterwards then during the actual birthing process itself.

One life into the world, and one life out. I know it is the way the world turns, and if it didn't work this way the world would drown in people, but I couldn't help crying for the boy who died anyway.

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