The majority of our patients live. But sometimes they do not. Their stories, their memory and the lessons we can learn from their lives are just as important those we learn from the many lives MSF saves. As I have been rounding quite a bit in our Amtiman Hospital intensive care unit (ICU), I have cared for some of the most critically ill children lately. The patients in the ICU have problems such as extreme prematurity weighing just 900 grams, severe malaria and anemia, and severe malnutrition complicated by dehydration, pneumonia or sepsis.
I have seen many children make dramatic recoveries. I have seen a few die. A child dying is something I mostly only have experience with in Africa, back home in Canada I have rarely had this tragic experience. Here, sadly a child dying is not unexpected for most families. Chad has among the highest child mortality rates in the world.
I started intensive care rounds with our Chadian staff by first attending to Mahamat. Mahamat is an orphan who was found in the street abandoned. The ICU is not the best place for a baby, but the nurses can keep a close eye on him there. Mahamat likes to be held and sometimes when he is crying, a kind grandmother, nurse, or our expatriate logisticians like Ben and Oliver from Germany, and Diana from Canada, will hold him. Eve, our Canadian hospital nurse, will sometimes do her medical stock counts on her computer with Mahamat on her lap. Mahamat thanked Diana yesterday for carrying him by peeing on him -- to the laughter of the Chadian women watching. It turns out being peed on by Mahamat is a benediction to having many children oneself.
As we sat on Mahamat's bed to examine him the nurses noticed Oumere, the child in the next bed, had stopped breathing. They quickly grabbed the oxygen bag and started artificial respiration along with stimulating the child. We quickly checked the blood glucose level. Normal. We still gave a small dose of intravenous glucose anyway. His heart was beating very weakly. I slipped my hands around the small baby's chest and began chest compressions. Although a few minutes before the electrical generator had failed, cutting off all oxygen to the ICU -- including to Oumere -- I'm not certain that is why he suddenly fell ill.
Oumere's parents stayed in the ICU while we resuscitated him. They did not ask questions but watched silently -- as did all the families -- in the one cramped room with no curtains between the beds. This tight physical space incidentally is being replaced in the next 5 days by a beautiful, airy, bright and new ICU building that MSF has built from scratch on the hospital grounds -- which we will donate to the local authorities.
Moments before Oumere went into cardiorespiratory arrest, Dr. Guy from Congo had seen the child and suspected the reason he was not breastfeeding anymore was because he was infected by tetanus. Neonatal tetanus is a disease that is entirely preventable by vaccination of pregnant mothers. Oumere's mother we learned had only gone to one prenatal consultation visit. She and Oumere were likely not vaccinated against tetanus. MSF provides prenatal consultation and tetanus vaccination just a few steps away from the hospital, in one of the nearby primary health care centers.
Dr. Guy prescribed the necessary antibiotics and had requested Oumere be put in a quiet, dark room in order to prevent the painful spasms that accompany tetanus. In addition, I urgently called our Canadian hospital nurse, Eve, to find the immunoglobulin needed to give Oumere quicker immunity against tetanus. Eve delivered the immunuoglobulin from our stock in a few minutes.
Meanwhile, artificial respirations and cardiac compressions were still ongoing. At some point, Oumere started to breathe on his own and stabilized. We kept him on oxygen and continued ward rounds on the rest of the children, but kept a close key on him.
At the end of rounds, Oumere went into cardiac arrest a second time. We gave him artificial respirations and cardiac massage again. I could see the hands of the nurses grow tired as they provided chest compressions and artificial ventilation, so we called more nurses over to help. A training nurse under my direct supervision learned how to use the oxygen bag to ventilate for Oumere. We also gave him intravenous fluid, intravenous glucose, and intravenous epinephrine [adrenaline]. I rushed to the operating room and took a car to the MSF base to get equipment to invasively ventilate Oumere with a technique called endotracheal intubation. The procedure was a success, but Oumere's body was shutting down.
After about two hours later it was clear Oumere was not going to make it. We had hoped to stabilize him until his own body could take over and his own lungs could work again. We had followed our protocols and balanced the local reality with the best resuscitation medicine possible in a sub-Saharan context. Despite the medications, cardiopulmonary resuscitation and efforts we had made Oumere was not responding. A gentle stroke of his abdomen resulted in his body going into spasms. He had stopped breathing for a long time now and although we could stabilize his vital signs with our efforts -- it was clear three hours later that he would not survive.
I spoke to Oumere's parents several times during the critical event. His father spoke French and I explained the efforts we were making and the lack of a response. He was calm and understood. Oumere's mother was in tears and came and went from the ICU at different times.
I asked the rest of the medical team if they had any ideas what we could further do to aid Oumere -- we all felt we had exhausted our efforts. There was agreement in the team we had given our best to save Oumere's life. We stopped our resuscitation and Oumere passed away.
I gave my condolences to Oumere's parents. His father thanked us. I thanked our own team as well since the prolonged resuscitation had left everyone physically and psychologically worn down.
Oumere died today, but not without a fight. His parents always stayed by his side in those last moments. He received the best medical care we could provide under the circumstances.
Child survival in Chad is a day-to-day struggle. Many survive thanks to low-cost interventions like vaccination, proper nutrition, antibiotics, rehydration, blood transfusion and oxygen. Sadly, these interventions are available to too few.
On this Earth, some children have access to life-saving medications, and others do not. This unfair imbalance means lives of equal value are treated unequally. Our MSF action seeks to make a dent in this injustice. It is unfair and tragic that children like Oumere die so early in their lives.
Farewell for now from the house-call....to Chad.
Raghu
Please note all names have been changed to protect identity.