Blood
Every year,millions of dollars are spent by African governments and international research, aid, relief and development agencies to combat the enormous burden of disease perpetuated by the very small, but ever virulent, mosquito. Malaria is endemic in much of the world; people living within the highlighted red belt that shows up on all CDC or WHO maps as a “malaria risk zone” experience malaria infection and symptoms frequently during their life time.
For much of the world, malaria remains a resource drain, a nuisance, a fact of life. Depending on the strain of malaria and the level of infection transmitted, and the preexisting health status of the “host”, malaria can progress from an inconvenience to a dangerous medical emergency. This all too common illness remains one of the leading causes of death for children under five years of age around the world.
Severe, or “complicated” malaria, is distinguished in the medical community by the degree to which it ravages the body. Associated symptoms beyond just fever give us an indication as to the degree of destruction that is being done. Frequently we see women with dark skin but white palms and jaundiced eyes, children who arrive to us semiconscious, their eyes rolling, old men that have experienced malaria bouts frequently in their lifetimes, but who suddenly succumb this time, their skin radiating heat like an iron press, fresh off the cook stove. Malaria in pregnancy particularly pains me; the mere thought of blood circulating into a developing fetus that is plagued by the parasite, gobbling up all the nutrients and oxygen that belongs to the developing child, robbing them of their very first right.
Every single day at the hospital, I have patients and care givers of young patients telling me “skin gets hot, very hot at night”, “head hurting” or, “mouth tastes bitter”. I ask more questions and begin an exam. I want to know, early on, whether or not symptoms have progressed to include “body jerking” or, seizure activity. Has the malaria crossed over into the brain? I especially want to know this for young children.
Being a common ailment throughout the continent and around the globe, one would think that management of this disease would be cookie cutter standard. In fact, the opposite is true. Complicating factors such as limitations in reliable testing, and medication resistance, produce ever changing protocols and guidelines for treatment. For western medical providers who arrive in country with books, and a pharmacology matrix, those of us who like to rely on “evidence based” medicine, the conundrum of malaria unfolds slowly. The sheer number of patients, all with the same somewhat vague seeming symptoms, leads us initially to press harder for differentiation. Not every fever can be explained by malaria. We know this, and push for The Answer. And then, there is the question, what about the blood?
As they say here in West Africa, “Malaria eats the blood, blood gets TOO low”. Many people here suffer from chronic anemia. When we note the classic signs-pale skin to the inner lower eye lid and palms, weakness, fatigue, sometimes shortness of breath we suspect anemia, or “low blood”, and begin the process of cajoling the lab for a hemoglobin level. Then, if stars over the bay of Benin align and the hospital actually functions somewhat smoothly, a young kid sitting in a small lab room fires up the small generator, pulls a white coat on over his Akon T-shirt, locates the necessary items, and appears at the bedside where you have requested him. The blood sample is obtained by holding the sweating, squirming hand of a wailing infant while nurse and lab tech together prick the tiny finger, and try to soothe the terrified mother, who no doubt is second guessing her choice to bring the child to the hospital instead of to the traditional healer for “country medicine”.
Hemoglobin, the value used to determine the number of oxygen carrying red blood cells circulating in the body, should be between 11-17mg/dl in a healthy person. Women tend to have lower levels than men, children slightly lower than women. Regardless, when hemoglobin levels get too low, the implication is that the blood being carried about the body does not carry enough oxygen, carbon dioxide is not being removed, and that organs, cells and tissues from toes to brain are not getting what they need.
In emergency departments in The States, we often transfuse patients when their hemoglobin level drops below 10mg/dl, and we do it with a sense of urgency. At St. Timothy Hospital, the cut off for transfusion is a hemoglobin of 6mg/dl. We transfuse kids almost every day, often 24-28 hours after their arrival to the hospital in a state of weakness and fever, after the IV has already delivered 2 doses of liquid Quinine for malaria treatment. The delay occurs as we implore the patient’s family to find a compatible donor, because without 24 hour electricity, the hospital is not able to maintain refrigeration for a blood bank.
At home in US hospitals, we order up blood “STAT”, and wait anxiously at the tube station for the red, highlighted, container to arrive with meticulously printed product information on the bags of blood and professional grade tubing. At St. Timothy, we have to place the responsibility on the patients’ families. These young girls, mothers, barely look at us when we round. They hold their infants arms while we stick and prod to place IVs and obtain blood samples, not understanding a word we are saying despite our attempts and efforts to smile gently. They blindly trust us, and expect that we can make their children well. We explain that we need to put blood in, that only with blood will their child be playful, energetic, and able to work or go to school, or even eat again.
Often, when the delay goes on too long, the Liberian nurses become more stern in their imploring. “We told you this baby needs blood, yeah? Where the family? Who is coming?” The mothers or grandmothers pick at their children’s hair twists, are silent in response.
“Can they find someone?” I ask, nervously eyeing the pale child next to them. The Liberian nurses shake their heads in frustration.
“She say she call the baby’s father, that he has to ask his friends. I told her to buy it, but she say she have nothing to buy with”.
Outside of immediate family or the occasional kind soul, it seems that blood selling is one of the few thriving industries in town. If they can past the lab screening tests-no HIV, Hepatitis, or active case of Malaria, and if their blood type matches that of the small child in need, young men with pipes for veins, muscular despite the fact that they do little all day except pull a fishing line at sunset or engage in a football match, can make 10-20 US dollars for a 200ml bag of blood. Perhaps they use that money to provide for their own children, scattered about town. Perhaps they are purchasing mosquito nets for their families to sleep under at night. The big question is, will those same donors be available the day their own infant, or mother of their children, sends someone down the hill from the hospital on a blood hunt. Would they spare some, free of charge, to a friend’s child? These are questions that seemed to have no answer for me, white nurse woman. I keep asking.
I crouch down in front of the young girl, mother, or put my hand on the old grandma’s leathered hand. “Mama, no medicine can help now. This baby need blood, today, now. You have to call your people”. I’ve seen funerals here, how the entire town is family. But when it’s time to give or even sell blood, suddenly, people don’t seem to know eachother.
So, we wait. And really, perhaps it’s just the knowing of the level that makes us, westerners used to immediate response and gratification, frantic. It took me longer than just a few days to get over the reality that these kids are walking around with hemoglobins of 5, 4.7, 4.3…what is sustaining them?
As time goes on, managing malaria does not become much more clear. How to decide between uncomplicated and complicated cases, how much weight to give the patients recall of symptoms versus their actual presentation? What if they were started on one drug, and still have symptoms? While on an academic level, the problem seems to become more and more compounded, somehow, our reasoning, or perhaps what is known as “clinical judgment” emerges.
We treat broadly and quickly for malaria, unless we can strongly justify otherwise. Because the likely hood that malaria is a problem, if not the problem, persists. And the risk of missing the window to prevent the progression from an uncomplicated case to a medical nightmare haunts us. This part of clinical judgment uploads pretty quickly. Unlike adjusting to these abnormal lab values, the reality of someone’s child seizing endlessly on your ER table, beginning the progression down hill towards respiratory arrest, while a bewildered family looks on, is enough to motivate any clinician, any person for that matter, to stop this train well before any impeding derailment. We all learn this; the way it happens often becomes transformative.
Prince, a child from a Mende speaking family, came to St. Timothy hospital just after dark one evening. He was brought by his grandmother, a weathered faced woman who wore no shoes, who had noticed “baby was jerking”, in his sleep. Round cheeks and fleshy limbs made Prince stand out compared to his skinny peers. His little body was so hot that holding him felt strange, almost painful. His brown eyes appeared vacant, with boggy, dilated pupils, his lips were parted with sloughing skin; he was technically awake but lying far too still for a two year old on his hospital bed.
I had arrived to the hospital alone, preparing to observe a C-section. One of the laboring women from the morning OB rounds was not progressing despite a long attempt at laboring through, and the Liberian GP and anesthetist were prepping her for the procedure. The nurses greeted me in the ER room, where a newly arrived patient was being triaged. Glad for the opportunity to work with them to teach and facilitate rapid assessment, I detoured and found what I guess in one perspective could be described as a great teaching opportunity.
Sadly, a grandma with a lappa wrap covering only her modest parts lay slack jawed and minimally responsive before us. Her IV line was infusing, they were taking her temperature. The Liberian PA was writing orders for malaria treatment. The nurses aid reported a blood pressure of 190/116. One quick glance at her pupils…the right wide, the left pinpoint, the story that she went to bed after the afternoon meal with a “strong headache”, gave me enough final information to redirect the activity in the room.
“This woman’s blood, the pressure is too high, I think her brain is hurt because the pressure might have torn a hole in her brain blood vessels. Everyone, listen, we can treat her for malaria, but see how she is not responding to us? See how she moves her left arm a little when I pinch her nail beds, but not on the left side? She how her lips are drooping and she is drooling”?
We transferred this patient to the ICU room, designated as so because it housed one of two oxygen tanks in the entire hospital, the other being in the OR. We practiced transferring a patient from stretcher to bed using a sheet to slide the patient smoothly, instead of relying on family to pull and lift her by the arms and legs, like a sack. We practiced starting oxygen immediately, and keeping the oxygen in place until a decision could be made.
During this process I began to discuss with the nurses not only stroke but, given the lack of ventilator capability or any form of neurosurgery specialty in the entire country, I began to broach the issue of palliative care. Her prognosis was not a surprise to the staff. They were well aware of the signs of impending death. What, if anything, to do about it, how to handle this patient at a point of inevitable decline, was what I wanted to address. Often, such a prognosis was approached in silence, avoidance.
While I recognized that my way was not the way or might not be right for here, there was no denying the fact that this old woman’s husband and two sons were standing there; certainly with some level of expectation. Much as I debate, I still can’t see the harm in communicating, can’t see any cultural faux paux or damage done in updating a family as to a prognosis, offering them sympathy and respectful support. Tonight however, the process became a bit complicated. Tonight, the ICU was actually full.
We arrived to the ICU room and found two pediatric patients inhabiting the other beds. Momentarily I was confused because they had not been there this morning, and none of the nurses had mentioned the arrival of critical cases when I talked with them by phone about the scheduled C-section. Maybe they were not really critical? The smell of acidosis and sight of rapid breathing from the little girl in bed 2 verified what feared, and already knew.
As we settled the grandma in bed 1 and I made a display of positioning her so that the drool that was beginning to accumulate did not immediately result in aspiration, I noticed the boy in bed 3 seizing.
Thus began a three hour ordeal, the kind that at home would involve a critical care room, 2-3 designated nurses, a PICU fellow, pediatric specialist, a breathing tube, respiratory therapy, monitoring of every function of life, multiple medications infusing via pumps and calibrated machines, and a social worker for the family. The point is not so much that we have none of these things in Liberia, but that we were still getting a handle on how to effectively use the minimal resources that were available at this hospital. The biggest challenge was encouraging the Liberian nurses to be confident, to be empowered, to be proactive, and do something when these kids begin to appear, as we say, TOO sick.
The role that I had taken on here, both as clinical nurse and as teacher, “capacitator’ of the local nurses gave me two equally compelling priorities-the patient, first, of course, but also, to build up my colleagues, as they were the ones who would be doing this long after I was tucked back into my world across the Atlantic. As I lifted the child’s airway open and asked the family of the stroke patient to step out of the room, knowing that I was about to take the oxygen away from her and give it to the seizing child, I grabbed hold of nurse Amelia’s shoulder.
“This is your room, you are the nurse in charge tonight. Talk to us- me, Yatta, Esther, Howa and Zo…assign us tasks. Everyone in this room is sick, but what needs to come first, how can we work together?”
Amelia, a young nurse who had expressed interest in “being good and quick in the emergency role” smiled and lowered her eyes. I was pushing her outside her cultural comfort zone, asking her to assert herself over the group, and over me, a foreigner. Some might argue that imposing my own process was inappropriate, but since the defined job, as directed by the Ministry of Health and Chief Medical Officer was to transition St. Timothy towards more western style, emergency and critical care, and at this particular moment we actually had an ICU full of need around us, I was ready to blur lines and blow the status quo out of the water.
“Amelia,” I pressed. “You are the one in charge. You don’t have enough hands to do all things at once. Use your mind and your voice to move our hands…we are a team, but there is one team leader in an emergency. You can do this, who is sickest?” I eyed the seizing child, counted his respirations, gauging how much longer I could focus on the need to teach, before stepping in.
“The old lady is sickest” Amelia mumbled. My heart sank in frustration, yet… “But, I think that this baby needs our attention”.
“Yes! Why? You are right, but go on, why?” I waved my hands, motioning for more.
“Because, he is convulsing.”
I waited, holding my breath., then pushed one last time.“We don’t know why the child is convulsing in this very moment, but perhaps if we support him through it, he can recover and have a good chance for life. Yes?’
“Yes”. Amelia nodded. “And the old lady, I think she will be gone from us soon.’
“I agree with you. We have to consider what we can do, for all our patients and I think we are doing the best that we can for the lady. What does the baby need most at this moment?” I was already lifting the nasal cannula off the older women, and looking for something, anything, to vaguely wipe off the prongs.
“Diazapam?” Amelia stared at me, intently.
“Yes,” I agreed “We need to stop the seizure. But what is the first thing, always the first thing we think about?”
“For the person to breathe?”
I almost cheered. We placed the oxygen line into the infant’s nose, got the dose of diazepam injected into his thigh, and I watched his little body relax. His snoring seemed to ease his grandmother, who began to wipe sweat and urine from his little body. As I listened to his lungs and lifted him to move him up in bed, I noticed that his right arm was swollen, just above where his IV line was taped. Half his dose of Quinine was drained from the hanging bottle. How to tell how much of it had been received to his veins and was circulating to kill the malaria parasite, and how much had leaked through the side of his infiltrated vein and was now pooling in the space between vessel and deep skin tissue. Great. Some days it feels like all we do is replace IVs on these kids.
By now my US colleagues had arrived to the ICU room, two doctors specializing in ER medicine who were also planning to watch the C-section. They surveyed the scene, taking in the obvious degree of acuity in the room. We all three looked at each other. Questions: How long had these kids been here? What has been done for them? If the Liberian MD and PA are prepping for a scheduled C-section, do they consider these kids stable? Is it just up to the nurses to sort out what to do for them? We grabbed their charts and began to try to glean the story, put the pieces together.
Doctor Steve rubbed his forehead. “The boy has a hemoglobin of 4.3. Is that even possible?” I shook my head, mildly surprised that we actually had a lab value this early in the game. Doctor. Rob was at the bedside of the small girl. He held her wrist, felt her pulse, and watched her breathing.
“Antibiotics would be a step in the right direction” He began to write orders, and then held the girls small arm while I placed a second IV. The skin was loose, did not pull tautly against her muscle, but stayed stretched when I removed the tourniquet. We call it skin tenting. It means severe dehydration.
We fell into our roles, and drew the Liberian nurses in with us. I continued to press Amelia toward management and delegation, and pushed the doctors to communicate their thoughts and plans with her. Six of us worked together for hours, placing IV lines, mixing and hanging medication, alternating oxygen between the sick boy and girl, talking through a decision tree of what to prioritize, how to proceed. The old woman labored to breathe behind us, while the sick children mewed like kittens, the only response they could muster in response to the poking and prodding we were imposing.
We talked to each family, explained what we thought was wrong, what we were doing, what we hoped to fix. The family of old woman were incredibly gracious when I explained taking the oxygen for the children, and when the doctors explained that even with the best technology in a hospital across the world, that their mother’s brain was likely irreparable. They encouraged us to work for the children, then went outside, to the front courtyard steps, to sleep under the stars, and wait for her to die.
By 12am, Prince, the seizing, anemic boy in bed 3, was emerging as the most difficult to resuscitate. He needed blood so badly that it was hard to tell if the seizing at this point was directly due to the malaria parasite, or if his blood was now so low that it carried an inadequate amount of oxygen to his brain, and was therefore seizing due to hypoxia. Blowing oxygen into his nose through plastic tubing would only help to a point. He needed more red blood cells to carry the oxygen around his small body. Plus, we could not, could not, get an IV re-established.
His grandmother stood at the head of the bed, an old woman wrapped in a towel against the believed to be poisonous night air, in which we continued to sweat profusely. She watched silently as we pricked hands, arms, wrists, legs, feet, then moved to deep vessels at the groin, even the neck. I feared she believed that we were torturing or experimenting on her child, that she would call us white saddists and carry the child into the night in fear and horror. I cajoled the nurses into translating for me, even in the midst of our frantic work, to explain.
“Old Ma, we are trying, we don’t want to hurt the child, we want to help him. And, then the favorite conversation. “This boy needs blood. Who is looking? The boy will not be alive in the morning, someone needs to go to town tonight.
While we waited for the miracle of a blood donor to appear, we continued to try to find a place for a portal to infuse it. At one point, I held the child’s arm tight as I tried to work an IV into the bend of his elbow. It gave me no blood return, and as I let go of the site, I saw that the child’s arm remained ridged. I tried to move his arm for him, and became momentarily nauseas. Had I dislocated his little elbow in my efforts? Strange, to feel relieved from one bad possibility by the recognition of another. Dr. Steve pointed to the child’s vancant eyes, and we both realized that the child was seizing again. While not enough to move his whole body, Prince involuntarily made his arm rigid and arched his back. We injected more diazepam into his sweat drenched leg muscle, he relaxed and his arm was mobile again. I hoped that his respiratory drive would not be depleted by the frequent dosing.
Finally, Doctor Rob broke the tense silence, drew us from the microlevel of focus needed to methodically hunt for a possible place and try to coax a catheter into any hint of a vessel. Doctor Steve and I looked up, from where we were again attempting to access the deep femoral vein.
“Do you want to try an EJ again ?” I asked, and began to expose the child’s short neck.
“No, I want to stop messing around and get a line in now. I want an 18g needle and some Betadine”. It registered and I inwardly nodded in agreement, in thanks. He was right.
I translated for the other nurses, explained that we were going to put a needle into the boys leg, not into a vein, but into the bone. I showed them how to help prep the site, explained as the doctors palpated for the right place, at the top of the shin bone, avoiding the growth plate. Doctor Steve and I held the leg. Doctor Rob guided the needle delicately through the boys flesh, then put his own weight behind it and began to bore the needle in a clockwise motion, searching for the space where bone tissue gave access to circulation and we would be able to bring fluid and new blood. I braced myself for the sound of the signature pop, which offers some relief that the line would be in, but seemed still seemed unnatural. It came, and we connected the IV fluid and resumed the Quinine infusion.
I looked at Rob's strained face. In the medical world, we care for and give care to people, on many levels. We each are individuals, good at caring differently. I knew that in a moment like this, this way was the only, necessary, way. In a rare moment, I acknowledged this type of caring as something unique, in line with but separate from my own capacity. Beyond just the skill, it was the decision, the timing. I saw his caring, and it resonated deeply.
We left the hospital, knowing that there was little else to be done until blood was actually available. The grandma assured me that the lab technician was finding a donor in town. She had given him the equivalent of 20 US dollars. The nurses assured me that the lab tech knew who to ask, that it was a separate matter, a side business. It’s the business of getting blood in this town. We had reached our point of being able to do. The old grandma in bed 1 continued to snore agonally. Every now and then we rechecked her vital signs to gauge how long it would be. We wiped her chin and smoothed her hair.
I reviewed the use and care of interosseos needles with the Liberian nurses, we discussed step by step plans for what to do if the boy were to get worse. Seemed ridiculous to be saying if worse, but here, everything is about degrees of severity, perspective.Just before we walked down the hill towards house, and bed, I glanced at Prince’s chart. His blood type was marked in large script, B positive.
Momentarily, I was transported to a hospital room, worlds away, where I was the patient, surrounded by lights, feeling small within a white room. Specialists surrounded me, they were discussing blood that day as well: blood type, needing more blood to analyze, and the infinite amount of helix contained, coded information,that a sample can convey. I learned that day that my blood type is B positive. I know that my blood might not be good for all children, but as I stared at Prince’s soft brown eyes, temporarily focused and slowly following movement around him in between seizures, I realized that for this boy, it might mean life.
With a ringing in both ears, I offered. The nurses assured me that blood was coming, that I didn’t need to give my own. They shook their heads and protested “You have to be strong, to treat all the patients. You don’t need to do it. It’s the family’s responsibility”. Tempered by the thought that foreigners offering up a solution to a problem meddles with the process of a long term solution to blood scarcity in this community, and with the practical belief that local blood might deliver less unfamiliar antibodies to this child, I did not push the idea. Still, as we left the ward, I found nurse Ahmi.
“If anything goes wrong, call us, for any small thing.” She nodded, understood. We were on call that night, the Liberian MD and PA had long gone home after the C-section. I had heard the child born was a healthy girl.
“Anything Ahmi, I know the IO needle is a new thing, I don’t want any nurse feeling uncomfortable. You call us for anything. And Ahmi”, I hesitated, watching the boy through the doorway. As his grandma sponged off his little brow, he curled his pale nail beds around her lappa cloth skirt; an encouraging sign. “Ahmi, if no one brings blood within an hour, wake me. We are both B positive. Please”. She agreed, nodded again.
What felt like only minutes, but was apparently 2 hours after I had hit the pillow that the radio erupted static through the darkness, and I resurfaced, knowing immediately. Nurse Ahmi’s voice confirmed that they were coming for me, for the blood. I climbed into the land cruiser for the 4 wheel drive ascent up the hill, noting the rarity of coolness in the air. I was not sweating, and actually had goosebumps. The stars above were majestic.
Ahmi rode beside me in the ambulance truck. “They didn’t come?” I ventured. Ahmi shook her head, looking distressed more than I ever remembered seeing her seasoned self to be. “The lab tech is drunk. He took the money. We went to find him, he drank the baby’s blood money.” It was not the time, or necessary, for us to confirm what we both knew was an excessive degree of wrong doing.
On arrival, I went straight to the lab. In my half awake state I stood in front of the lab tech, not the one who had been on shift earlier, who had presumably gone into town in search of Prince’s blood donor, but another, older man, who worked the graveyard shift. As always happens when on the other side, I suddenly was a bit unsure of how to proceed. The man motioned me in, told me to sit, introduced himself while he began to methodically lay out his equipment, donned gloves, palpated my tanned but in comparison light hand.
“My name is Fortune” he told me. “When is the last time you gave blood?”
“Not since high school” I admitted. “They won’t allow me to give it in the US anymore…’
“Because you spend a lot of time in Africa?” he finished for me.
“Yes.” I watched as he performed text book perfect venipuncture, then deposited a small sample of my blood onto 3 slides, and into one tube, to begin the screening process.
“Well,” Fortune concluded, as he attended to his slides, “We are thankful to receive your second quality blood tonight”. We grinned at each other and I realized, under the dimly lit bulb that was attracting bugs, to swarm around the ceiling, that Fortune was well educated. Beyond meticulous technique in his trade, Fortune possessed a worldliness that indicated life and learning beyond Robertsport. Appropriate use of sarcasm is always a good clue to this phenomenon, I am finding.
The man’s name must have blessed me, because all my screening tests came up negative, my typing was correct, and we were able to move on to the collection process. A 16g needle is a large one; I felt the pinch and burn in my right arm and made a mental note to reiterate to the nurses why we put such large IVs in trauma patients, because they allow the blood to infuse in, or in my case here tonight out, quickly.
It took about 20 minutes, from start to finish, for Fortune to drain and collect blood from me, destined for Prince. During that time I sat very still. It seemed like the first time I had been awake and still in quite a while, certainly since I had been here in Liberia. I periodically squeezed my fist to coax it down, watched the color darken in the tubing from red to deep purple. Outside, the roosters were already crowing, but other than that, it was quiet. Fortune talked to me, told me stories about the hospital and the war, recorded my name in the donation log, along side others from Robertsport and Grand Cape Mount County. His block pencil letters cautiously spelled out my name, Kathryn, next to countless Massas ,Howas, Sonny Boys, Juniors and Alfreds. Under address, he simply put, America.
I thought about a lot of things during this time. Some had to do with this hospital, some had to do with others; different times, different places. I thought about blood- how it restores, how it can kill. I watched Fortune open each piece of equipment from a sealed package, was thankful for his professional technique.
Finally, it was done, it was time. In slow motion I stood up, and changed roles. Fortune passed to me the bag of blood, labeled with a black marker to bare the all important B+ marking. It was still warm, and yes, it was strange, to consider that I was holding my own. As I turned to leave the lab and run for the pediatric ward, I turned to Fortune, to shake hands. He thanked me, and then paused. “Can I ask just one thing?”
I was startled. “Of course.”
“Tell me honestly. In the United States, do they have the cure for AIDS in their laboratories? Do rich people die from AIDS?" The weight of what he was shyly, politely asking, the implications, hit me like a truck. I chose my words carefully.
“Fortune, I have worked at what is considered the best hospital in the entire USA. I have taken care of many rich people, and many poor people. I promise you, I have never heard of any cure for AIDS. Scientists are searching, everyday. We have medicines that can allow a sick person to live longer, live better, with AIDS. Many of those medicines are the same ones people can get here, at St. Timothy. I look at the packaging, they are here."
I wanted to grab his hand, to emphasize what I was saying, but my hands were full, holding the body temperature bag full.
“But no one, no one anywhere, is considered cured. Everyone dies from something, and people with the virus will eventually die because of it”. I looked into his blinking, bespeckled eyes, trying to ascertain if he believed me. And then I took, what may be, a personal liberty. Sometimes we have to say what we believe, or want to believe.
“If and when they find a cure for AIDS, the West will not keep it from Africa. It will be for all people, rich and poor”.
Fortune nodded, thanked me again, told me to call on him if I needed anything. I ran down the hallway, because Prince was waiting.
The rest of that night and early morning dragged on, full of efforts to again establish IV access to infuse my blood into Prince. The boy now lay very still, even when we pricked and eventually cut through his skin, in search of a vein. Needles in the bone are good for fluid and medicine, but it’s difficult to infuse thick blood through them. They clot, back up, and at one point the nurses and I saw the wall behind Prince’s bed splattered red…the line was clotted and when we tried to flush it, the back pressure caused the syringe to burst and the blood hanging in the tubing meant for Prince sprayed everywhere.
The act of sticking and manipulating Prince’s flesh was enough, now the room looked even more like a butcher shop. We were all horrified, and in a visceral, self protective way, I rationalized that at least I knew the blood that was now everywhere was my own, and that it shouldn’t hurt anyone, because it was screened to be ok.
We cleaned up the mess, and I taught the nurses another lesson I had learned in my practice; when to call the doctor, when to call on others for help. Perhaps we could have kept going, kept sticking, but I had a growing sense that this child was, as they say, moving away from us. Calling for help earlier rather than later was what I wanted to invoke in these nurses. And perhaps, I didn’t want to be the lone, outsider practitioner here at the bedside, if after all the things we had done to his small body were suddenly viewed not only as strange and fearful, but perhaps wrong, a likely scenario if the boy was to die.
Nothing else we could do would matter without a portal to infuse blood into. It had been over an hour since we had tried to push the blood, using a pressure bag, through the interosseos needle. We could get fluids in, pushed them syringe full at a time, but not blood. Despite some improvements in hydration, we still couldn’t get a catheter to thread and hold in Prince’s arms, legs, or even scalp. We were getting nowhere, but I wanted them to see that all this meant was it was time to switch gears. Leaving this child’s bedside, waiting the night away, was a choice that was sure to produce more of nothing.
We woke up my American colleagues, and together, after more failed attempts taking us to the edge of our practice experience, we broke the call schedule rules and woke up the Liberian doctor, to do what we call a cut down. A small incision, retract the skin, hunt deep in the flesh below the deep veins that we usually can search and palpate for from above.
We found it, just as the sunlight broke through the windows of the hospital. The Liberian Doctor, Dr. Garlo, made the cut, Doctor Steve retracted the skin, together they exposed a thin white string of a vein, and worked to thread the catheter. We nurses flushed the lines, held them in place for suture, milked and connected the blood tubing. We all held our breath and watched as nurse Ahmi released the roller clamp, and the blood began to drip, drop, into the chamber, a steady flow, into Prince’s tiny, surgically located ankle vein.
Doctor. Garlo sighed, “Praise God”.We cheered and highfived in relief, but the celebration quickly became subdued. Doctor. Steve showed us that right about the time that the much waited for blood began to roll down the line into Prince, that the Grandma in bed 1 was laboring over thick mucus in her mouth and throat, and then lay completely still. Her family, no doubt roused by the rising sun, was standing just outside the doorway, watching.
While Doctor Steve and I verified that Grandma had passed, and talked with the family, the Liberian nurses tended to Prince, to the small girl in bed 2 who was now awake enough to be propped up and hold a small cup to her dry lips, and began to tidy the room. The place was littered with what seemed to be every medical supply we must have in the hospital. Death was something these nurses were well accustomed to. They cleaned, sent for the things to prepare the body, working silently, efficiently.
Outside the hospital, patients were beginning to line up, registering for the outpatient department. The old man was sweeping the floors, directing people to stand on the unswept side until he was finished. Before I started down the hill toward sleep, I checked on Prince one more time. He hadn’t seized for a while, his vital signs were stable. The blood was still running. I examined the cut down site, the suture dressing, and noted that we might soon be able to get a line into his scalp. If we needed to, we could keep trying.
I recognized that I had become rather attached to this child’s outcome. Despite my better judgment, I was falling prey to the buzz of emotion in the room around me. Prince’s grandmother was thanking me, holding my hands. Now that the old woman who had passed was removed from the room and the family gone to make funeral preparations, the nurses were joyful, and teasing me.
“That’s a black baby with White Woman blood” they giggled. “ The old lady”, they motioned to Prince’s grandmother, “She say you are family now”.
I smiled at the woman, thankful that she was satisfied, and not ready to send the community after us in anger
over an entire night of invasive procedures. I squeezed Prince’s little hand and he sucked at his lower lip, finally resting, ready for comfort. Family. I remember once reading the sentence,
“Wasn’t that the definition of home? Not where you are from, but where you are wanted?”(Abraham Verghese, Cutting for Stone).
“Ok then”, I said, “When am I invited for dinner?”
Prince was discharged from the hospital, and returned to his town, just next to the border of Sierra Leone. Before he left, I was able to meet his mother, who was sent for in a bush taxi during the whole ordeal. She arrived from Monrovia, where she had been looking for work. She shyly thanked me, on the road up to the hospital one afternoon. Together we went to see Prince, and I was thankful to be able to point out good signs indicating that her boy was recovering.
The hospital refunded the money that was stolen by the day shift lab tech. It was a sad affair for this close knit community of staff. Dr. Garlo had been furious when nurse Ahmi reluctantly informed him of the deceit that had gone on that night. The tech was fired, kicked out of his home, which was hospital property. All the gossip and layers of feeling surrounding this event were not to be our domain. Like many things here, it was pushed into the periphery, like the war, the endless dying, the fact that many hospital staff steal supplies for their own, home based, fee for service practices, or directly charge the patients despite the banner sign at the hospital entrance that proclaims, “No money business here”.
In Africa, as in the rest of the world, everything is money business, even blood. The staff at St. Timothy have not been paid for over 3 months. At times, look the other way is accepted as part of survival.
But, as nurse Ahmi remarked, in rare moment of direct contemplation, “The man stole from the old woman, from the boy, the man went too far”. The doctors and myself were relieved that the response all came from the Liberian staff and the hospital, that the outsiders were not the ones to initiate anything punitive. It would further complicate dynamics, pressing issues that at this time we felt were stretched taught to their limit.
Two weeks later, I got word from one of the nurses that they had seen Prince in his home village, that he was being carried by his grandma in the market. They recognized him by the scar to his leg, where we had cut deep, for his blood infusion vein. They reported that he ‘was trying”, which means, “getting along well”. Apparently, it is now said that Prince has two mothers, his Liberian family, and “the White Woman”, “the B positive”.
Hearing that Prince is out and about and “trying” of course felt good. Hearing the nurses explain to eachother the use of interosseus needles for short term hydration and emergency medications, seeing them excited about a new procedure that gave them options when their patients were critical, felt pretty good too. Knowing that my blood screened negative for malaria was an added perk of whole bizarre event. My conversation with Fortune, while holding a warm bag of my own blood, pulls at my heart.
At night, mosquitos continue to whine, and during the day, I continue to counsel mothers about using nets over their children’s sleeping mats. The hospital still doesn’t have electricity for refrigeration, and we continue to receive semiconscious children with “hot skin” and reports of “baby jerking”. Aside from my work in this hospital, any hospital, I know there are innovative, and successful ways to impact the terrible burden of malaria that Africa suffers. I pledge that my work will be in conjunction with these efforts, in different ways at different times. We don’t have malaria to speak of where I come from, but I will work alongside friends and colleagues who do. It’s in my blood.
