Everyone Knew But me

The following story happened on my first day at the village clinic where I am working on the vaccine trial.  It has taken me a while to come to grips with it, hence the delay for posting.  Not a day goes by that I don’t think about the patient in this story.  I picture her face every time I see another one like her, wondering if it is her and that what had happened was some sort of bad dream or story I had read that happened to another doctor who had worked in Africa.  While the following story may seem frankly formulaic, like it was an amalgam of stories that you have read about elsewhere or had heard about on an infomercial for African children relief, it actually happened exactly as described.  I have often heard doctors describe that certain patients will leave an indelible mark on their lives, both as physicians and as humans.  For me, one of those patients will be Souleymane.  
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Patient #43 was a beautiful young baby girl, swaddled in colorful Malian cloth and lying rather quietly in her mother’s arms when they entered the small clinic room.  We had already seen about 40 other infants and young children just like her that day, my first in Doneguebougou as a “doctor.”  They all had the same complaint – fever – usually mixed in with some other common complaint (headache, diarrhea, cough, etc.)  In this clinic in this little corner of Africa, this meant malaria.  There was nothing to suspect that there would be anything different about this little baby girl.  

You could tell the mother was very proud of her baby in the way she held her head high up near her shoulder and cradled her carefully in her arms.  You could also sense that she was rather worried about her recent infection from the quiet concern I read from the mother’s face.  I remember the infant’s small, angelic face, her seemingly perfect dark skin, and the pink dress she was wearing.  I also remember seeing many small, handmade bracelets and anklets on her wrists and ankles, a sign that she had visited the traditional medicine healer in her village.  When I saw this little “perfect” infant as she lay in her mother’s arms, I knew something was very, very wrong.  

Her mother said her name was Souleymane (S.) and she was 9 months old.  They came from a village about 10 km (about 6 miles) away called N’gara.  She said S. had a bad fever and chills for a couple of days, and suddenly this morning was not responding to her when she tried to wake her. So, she begged her husband to accompany them on the walk to the clinic in Doneguebougou.  Neither the mother nor I have any idea what time she arrived at the clinic that morning, but it was already about 12:15 when we saw her, and we had been seeing patients since 8:00 am.  

At first glance, S. was not acting like the other babies I had seen before her that day and for that matter ever before.  She just laid in her mother’s arms, not moving and staring off into space with these deep, big, brown eyes that resembled those of a doll.  Within the first minute of arriving, the Malian doctor I was working with that day (H.) and I immediately had the mother lay S. on the exam table, the same table that was covered with an orange cloth that had already been drenched with the sweat, dirt, and some urine from the 42 earlier patients.  I recall thinking that it was not right that we place something that seemed so perfect on such an imperfect spot, but this was not the time to worry about perfection.  After we removed her dress to examine her, we took her temperature (40.5 degrees C, or 104.9 degrees F., a dangerously high fever for an infant) and did a quick physical exam, knowing full well that we probably would find nothing of significance but still suspected the worse.  We also noticed that S. was flaring her nostrils and using her chest more than normal, a tell tale sign that little S. was in respiratory distress.  I also moved her head from side-to-side to see if her eyes stayed fixed looking straight ahead (which is normal) or followed the direction I was moving her head (which is not normal); her eyes followed my movements, a very, very bad sign.  

H. and I had the same reaction to our brief exam and he anxiously told the mom to quickly go outside and wet her head wrap with the cool water from the spicket a few feet away from the clinic.  As she returned, H. called in the father to tell both he and the mother that their baby had to go to the hospital immediately because of the possible drastic consequences of cerebral malaria, of which this was most certainly a classic example.  

While he was doing this, I attempted to wrap S. in the cool head wrap.  As I supported her little head in my left hand and tried to wrap the cool cloth around her with my right, S. stopped breathing.  I felt her pulse and couldn’t feel anything.  I startled a bit and H. instantly looked at her and in a weak attempt at CPR, awkwardly pushed on her chest a few times, and weakly blew out air through his mouth in a way that made his lips putter, as if to help her breath from a few feet away.  He knew what had just happened.  The mother and father, watching everything we had been doing to their daughter, somehow both knew what had just happened, and started to wail.  For those first few seconds, I had no idea what just happened; everyone seemed to know but me.  

A few seconds passed before my instincts finally kicked in and I thought of the steps of CPR.  I knew that they had emergency drugs and oxygen in the clinic building next door that was to be used in case one of the vaccine trial recipients went into anaphylactic shock after receiving the vaccine.  I asked quickly if we could use that equipment to revive her, and H. told me no, that “There was nothing we can do.”  After he said this, I pushed him rather briskly out of the way so I could get near S., almost knocking him down.  My instincts now were in full gear, and I started CPR for the first time ever in my life on a live patient.  I had no mask to cover her face to prevent me from getting any infection she might have, but I ignored that small detail.  I put my lips over her little mouth and nose to help her breath, and did the breaths and compressions in the order that I had practiced up-teen times on a plastic dummy.  

At this point I was a machine, immune from everything occurring around me.  Neither the mother or father’s wailing nor H.’s staggered look fazed me.  I remember thinking “I don’t give a fuck if you say I can’t use the emergency equipment, I am going to use it anyway.”  After about a minute of altering breathing and compressions, I felt a tap on my shoulder.  It was H. telling me to stop.  I remember turning around and staring at him, tears slowly welling up in my eyes, tears of both anger and sadness.  The machine suddenly stopped whirling, and the human returned; I then realized that my attempts were futile.  Everything that I had ever been taught up to that point no longer mattered; I now knew what everyone else in the room had already known for some time.  

I looked down to the floor, and then back at S.’s naked body.  She still had the face of an angel, and the appearance of a life-like doll.  Her big, brown eyes were still open.  I will never forget the way she looked just then: at peace.  I reached up, and closed her eyes, like I had seen done so many times on TV and in movies, and never on a real person.  I remember her face and forehead were still warm, full of the warm blood of a life that was now suddenly and prematurely gone.  

The mother and father continued to wail hysterically.  H. scolded them (I think) for crying, and I yelled at him for yelling at them.  The tension and the utter reality of the situation hung thick in that small room for a few seconds.  I felt I had to do something.  So I brought the parents to the treatment room, and sat them down.  I then picked up S., wrapped her up in her mother’s cool, colorful cloth and carried her into the next room and handed her to her father.  I saw the father first proudly look at his daughter and then start sobbing hysterically.  Feeling invasive, I walked out quietly and closed the door, which shut with a loud thump, providing a rather grim tonality to the situation.  H. was silent, looking off into the distance.  I looked at him for answers, expecting my colleague to console me and tell me that I had done a good job.  Instead he looked at me and said “Wow.. . . .   Wow, wow, wow.”  

I was beyond myself at that point, and walked out the door of the exam room into the outdoor patio that serves as the waiting room for the clinic.  There waiting for me was a crowd of about 10 mothers with their children, every single one absolutely silent, looking at me in a way as if I were to blame for what they knew had just happened.  There I stood, in my newly ironed long white coat, as helpless as the little girl that had just died in my arms.  Not being able to communicate to them in their native tongue, I looked out across the dirt of The Compound and pointed to a tree that was far away from the clinic building.  They somehow understood, and one by one got up and walked in silence to the tree I had pointed to.  

After the last perspective patient had left the patio, I walked to the side of the clinic building, hidden from sight from everyone present.  I dry heaved, and then again, but nothing.  Tears welled in my eyes as I leaned against the side of the building and bent over, struggling to make sense of what the fuck just happened.  I began to curse my colleague for not allowing me to do more with the emergency equipment.  I cursed him again for what I perceived as his lack of judgment.  I cursed the family for not bringing their daughter in sooner.  I cursed the whole country for being so backwards.  And finally I cursed myself for agreeing to come to this fucking country and in thinking that I could actually make a difference; who the fuck was I kidding?  What the hell was I doing?  Why did I come here again?  Why did this happen at this time, in this place, to this child?

I sat there for what seemed like eternity, but in reality was more like a minute.  I got up, wiping my face as I walked back to the clinic.  While I was gone, H. had arranged for a relative of the family who lived in Donegue to come help them.  After about 5 minutes, the family left out the front door of the clinic and down the steps toward the main entrance.  The relative was in the lead, followed closely behind by the mother and father.  The father walked with his head down, holding his little baby girl tightly against his chest with both arms, her limp body covered from head to toe in the wet cloth that usually adorns his wife’s head.  The mother sobbed as she walked next to her husband.  I stood watching the unfortunate triangular group from the window of the very exam room where that family’s world and my world were forever changed.  

I stared at the family as they walked out the main gates and disappeared into the small mud brick huts of the village.  I saw the workers of The Compound gathered near the entrance look back in my direction.  I saw the looks of the mothers and of the infants and children who I had just instructed to move away from the clinic stare blankly back at the strange white man with the long white coat that was looking out the small window of the clinic.  To this day I can only imagine what they were thinking.  

When I turned around, H. was writing down S.’s information in the book that we use for record keeping.  I looked over his shoulder as he wrote.  When he finished, it looked like every other entry in the book, with the exception of an asterisk by her first name.  Dumbfounded, I asked what would happen next.  He said he would tell the team later what had happened, and that would be that.  I asked him if anything like that had ever happened before at the clinic, and he said no, that was the first time ever.  

We sat in silence for a few more minutes, both trying to make sense of what had just happened.  I breathed in deeply and let out a deep breath, and asked him: “Ready for the next one?”  

“Yepppp,” his lips puttering slightly.

Patient #44 was a . . . . . .