The phone numbers in Kijabe are three digits. At 10pm my pager displayed “438 999” which means nursery—run! I had been home for a couple of cherished hours to have dinner with Bill and Liam during my Friday night call prior to this page. I slipped on my rubber shoes and ran down the dark dirt road holding my weakening flashlight trying to avoid an ankle sprain on my way to the hospital. I arrived to a grey infant, limp, being bagged by Julius. Lisa was standin’g by watching intensely. Lisa, who had admitted this three day old earlier in the day is the Clinical Officer on “first call” and Julius is the fantastic intern on “second call.” They called me to help them through this resuscitation. “See one--do one--teach one” has proved to be a reliable pattern for me here with only several exceptions of skipping either the first or second part. Our dying patient was the first born daughter of a young woman who sat nearby watching with glazed eyes reflecting the vast disparity between two possible outcomes. She had delivered at home with much joy and no reported problems. “It is cold these days and babies just can’t stay warm during these home deliveries” Julius says quietly. This little one came in with respiratory symptoms and a fever today and was started on antibiotics for presumed pneumonia—no CXR, LP or labs were done.
There is no way to know if anything would have changed if I had been called during the admission earlier in the day. Lisa told me the baby “did not look too bad.” Intubated, epinephrine, and 10 minutes of bagging generated a heart rate over 130 and shallow respirations that lighted the air in the room for several minutes. Placement of an NG tube revealed frank blood and that made the dried blood around the nares and ETT more notable. After 25minutes I decided to check the pupils which were fixed and dilated. We withdrew support and her daughter died less than a minute later.
Julius and Lisa left the nursery while the three nurses were speaking in Swahili in a hushed tone. I felt the urge to respond to these hushed tones—which I interpreted initially as grief. What followed was an experience I will never forget. Those nurses started at me, at the ground, at each other in silence. In a quiet, polite, respectful manner I asked for their thoughts--wanting to allow a moment to debrief the difficult experience just gone by. Their stare was not one of grief, not one of sadness, not one of surprise or of routine; I did not get it. It was the first time that I was painfully aware of a cultural divide the extent of which I now feel I do not appreciate most of the time.
I spoke with the mother through Lisa’s Swahili interpretation. Through most of my condolences and explanations, she looked at the ground without a tear until I put my hand on her shoulder. Then her weeping leaped from her body like a spirit that was emerging from her.
I had heard that death was common here. I pulled this advanced warning out of my frontal lobe to try to balance the emotions that were welling up in me. There were so many emotions that night as I walked back in the dark toward home with my flashlight and my spirit weakening.
Why was I not called for that admission? Is that protocol here—I don’t even really know my role as an attending for these very self sufficient interns. Maybe they just don’t respect me, maybe something I said or did was inappropriate? Why were those nurses staring at me?
I am a “mazugu”! (The word for white person in Swahili, literally means “strange one”.) Why did this precious daughter have to die? How would I have coped with Liam dying at three days of age and listening to an explanation of his death in Swahili? Why do I have to think about the fact that the mother asked what would happen to her baby if she couldn’t pay for the short hospital stay? Perhaps it was good after all that a chest x-ray and LP were deferred—this would have made it even less likely that she could take her dead child away from the hospital.
Where have I come? What good am I doing here?
There were two more infant deaths that night.
It is really almost too much to bear.