Dead On Arrival

He was not dead on arrival. He was gasping for breath, like a child does with severe respiratory distress. It was not more labored than any other child who comes in with severe pneumonia or respiratory distress. And I've seen some really bad cases in the past year here - much worse than he was. He was a transfer from Kirehe, our other district hospital and my first step was to send for oxygen. Oxygen is not readily available in this hospital, it is not available on every ward, so one of the staff went to go find some in another ward. As I am accustomed now to the fact that nurses run to other wards to fetch oxygen, I went quickly to buy the father some basics and start getting him settled: a basin, some soap, a towel to wash up the child - things nurses do not provide here, nor does our hospital. I have tried to instill this practice here, but as it is nothing that any public hospital does in Rwanda, and probably East Africa for that matter, going to buy a patient a basin and soap down the hospital driveway is above and beyond a hospital staff’s call of duty. Some supposed international health experts call the organization I work for gold-plated for things like this: like walking on your own to a store and pulling out your own 2 dollars to buy a needed commodity for a patient. They tell us we cannot expect international aid organizations to hold this standard of care for patients and be scaleable and replicable. Creating dignity is, so I’m told, not scaleable.

So after my running back to the ward about 3-5 minutes later, the child is still upset, nurses are still pulling oxygen equipment together (this part of oxygen administration drives me crazy here, that it takes 20 minutes to get oxygen gauges attached to tanks, attached to tubing, wrench found, then used, to be able to turn the tank on - I still do not understand why there is no sense of gravity of getting equipment prepped in advance - before the patients start decompensating - no one takes ownership for this - even those who are told it's their job), I take off his pants to clean him. I would say he smells horribly of soiled underclothes, but three year olds do not wear underclothes here. Underclothes are a luxury too amongst the rural poor of Rwanda. My little friend is about 3; he is thin but not marasmic. I pull off his pants to clean him myself because cleaning a child are basics to U.S. nurses, but here, nurses do not bathe or wash patients, the family does, so again I hope to set a different example, I wash the child myself. Then I hear from the 4th year Harvard medical student who is with me, “He’s not breathing.” I am incredulous, it’s been maybe 30 seconds since he was sitting up, visibly agitated in his dad's arms and eyes open. I put my fingers in front of his nostrils, his mouth, to feel his breath, he is laying back, I don’t feel anything. Then his eyes roll back. I listen to his chest with my stethoscope. Not a heart beat to be heard. “We gotta’ run a code,” I say. I grab the ambu bag and place it on his mouth and start squeezing, the medical student starts doing chest compressions, but the kid is dead. I am unfortunately all too familiar with the look now. Air is not going down by my squeezing the ambu bag. His cheeks are filling up with air like a chipmunk – air is not reaching into his chest or belly. Something is lodged in his throat or deep in his lungs. Mucus plug? We have no suction. We have no way to intubate. And within a matter of maybe 20 minutes of coming to us from the ambulance, he was dead. Not quite dead on arrival, but almost.

I don’t know what to do in cases like this. I have no idea what he had. He had intense crackles throughout both lung fields. Pneumonia? A bacterial bronchitis? The father said symptoms of cough started Tuesday. It’s Saturday. What kills a kid between Tuesday and Saturday? I think about our oxygen again. When are we ever going to get it operating better here? When is there going to be oxygen for all beds, all kids, all patients, whether they need it or not. Oxygen for all. Is that a civil right? It should be. All over the world. That should be free, like clean running water should be free. But not to this child. Today was another day in the day in the life of working as a nurse practitioner here.

There are days I wouldn’t rather be anywhere else because the joy of these children is like no other, when they are well. And there are days when I cannot believe 3 year olds die partly because of no oxygen, partly because of a lack of basic emergency medical equipment and know-how, that would have been provided in, literally, a matter of heart beats at MGH. According to WHO, Rwandan child mortality for the lowest wealth quintile is 246 per 1,000 live births. Belgium is 4 per 1000 live births. ~50% of children in Rwanda rural areas are stunted in terms of growth for their age. And only about 20% of births in rural areas are attended by any skilled health personnel including traditional birth attendants. What are we going to do here? To me there is hope. There is definitely hope. Children get better with trained staff and medicine. So do moms and dads. But we have to start investing in these communities. To me, I feel like this is the war we should be fighting. Why aren’t we investing in the war and defense of these front lines?