Simple, complex, unjust.

It’s been a while, but I’ve had a long day, so here it is.  Warning: this is not a happy post.  A child dies.  Skip it if you don’t want to read about that.  I’ll try to make a happier post soon.

 

Today I lost a toddler to malnutrition. He had been seen at three other health centers, including one where we are running a pilot to improve pediatric care, prior to showing up in our emergency room today.  He was correctly tagged as gravely ill and sent my way.  Too quiet to attract much attention, I could see how he might have slipped through the cracks.  Kwashiorkor is funny that way – the kids get swollen instead of skinny, so it’s harder to identify them as malnourished.  

A closer look, though, told me an all too familiar story.  Cold, low glucose, barely conscious, anemic with a hematocrit too low to be a healthy hemoglobin (Hematocrit 7.8), grunting and breathing as quickly as his starved body would allow him.  We did everything right, or as right as we could.   We got him on oxygen as quickly as I could pull it off a less-sick kid, (we were out of oxygen tanks, but had a concentrator that worked,) got a glucose bolus into him, fluids started.  Couldn’t warm him because we couldn’t find an extension cord for the bare lightbulb that serves as my warming lamp – a proper way of warming bigger kids is on my wish list.  His mother sat across the room, unwilling or unable to engage.  Labs sent, appropriate antibiotics started, and he was in our most visible bed.  

But all that wasn’t enough, and a few hours later my nurse called me over to begin resuscitation.  She was the one to initiate chest compressions, while I got a bag and we began a code that I tried to get as close to the PALS protocols that I once taught as possible.  15:2. Something firm (my other hand) under the patient. Compressions deep enough.  Breaths that moved the chest, not too deep.  NG placed to decompress the stomach.  Verified hypoglycemia was no longer a problem.  Discussed using drugs.  (I was told epinephrine wasn’t available.  Turns out it was, but it wasn’t immediately apparent in our catastrophe of a drug cabinet.)  Reviewed whether there was anything else we could do, given the circumstances.  Concluded that in absence of labs, monitor, diagnostics, warmer, or any sign of response to our resuscitation efforts, there was not.  

And so all of our efforts were not enough, and I lost a little boy, someone’s little boy, to a problem no more complex than this: he didn’t have enough to eat.  It makes me angry and sad that in the marvelous world that we live in, there are still so many kids who suffer this criminally simple problem – not enough food.  They get sick.  They die.  It happens all the time.  All.  The.  Time.  

And the rational part of my brain can process that it’s not simple at all, it’s complex – the factors that go into my kids in Boston shortening their lives from obesity while my kids here in Haiti are literally dying for lack of food.  That foreign food aid has created the obscene problem of locally grown food being more expensive than the cheap imports we fly in, robbing Haitian farmers of incentive (or means) to produce enough food to feed their people.  That custom or superstition or convenience or marketing has convinced a whole generation of Haitians that formula – way too expensive and prepared with unsafe water – is a better option than the breast milk that is superior in quality, availability, and safety.  That centuries – centuries – of injustice have rendered this country So Damn Poor.  These are hard problems and complex ones, but they boil down to the same thing again and again – too little food, and a child dies.  Just barely more and they’re sick.  Stunted.  They lose a few IQ points, a few inches of height.  Their parents lose work because they’re in and out of the hospital.  It’s a vicious cycle.

I’m angry and I’m sad that that little boy died today and that it was shocking to nobody – not to the mother, not the nurses, and not to me.  I hate that it was not shocking to me.  When I started here I swore I never wanted to be not shocked by malnutrition.  It is shocking.  But there are only so many times you can face it, so many times you can hear the same story, before it stops being such a shock.  It’s life here.  Not enough.  Never enough.  We can improve the care in our unit, and we have.  We provided good care today.  We could make it even better, but until we figure out how to address the galling inequality that got that child and so many others into that situation, it will never be enough.

Because I can run the best code in the world, in the best hospital, but if patients are really badly malnourished, it’s just not enough.  The body can only take so much.

I can only take so much.  My heart hurts tonight, and the solution is so much bigger it makes me wonder if it’s even possible.  There is just so much to do.  I remind myself of the ones that do well – the majority of our malnutrition patients – and vow to spend a little extra time in the malnutrition room tomorrow.  To work with our assistants to clean up the medication closet so we can find the epi next time.  To put together a proper code box.  To find that damn extension cord.  To look into other options for warming bigger kids.  To find a spare lightbulb for that stupid lamp.  To try to do some preventative maintenance on the oxygen concentrator that keeps quitting on us.  Oh yeah, and to provide care to about twenty of our sickest patients while juggling whatever other crises might arise.  

I love my job here, but I’m starting to really look forward to the quiet hospitalist position that awaits me in MA when I return to the US this summer.  As unjust as the US system might be, we have it so much better.