Broken Hearts

Thursday, October 10

I headed out the door today with a little excitement about it being the last work day before a long weekend on a Safari.  However, Thursdays have been some of the tougher days here and I think that is largely because several on staff are gone and it seems busy and with fewer people.

Morning report was interesting only in that Pediatrics did not have any overnight admissions to report.  Therefore, they report on one of the more serious patients on the ward. Stella was the one reported. That brought up discussion about palliative care, her oxygen dependence, the family’s reluctance to go home, medical costs, and how to handle this delima.  It was just a little frustrating to hear all the questions and comments. They have all been fully explored. We have been thorough, the end is clear, but how do you push for a type of care the family can not embrace. In the medical wards, they also have had a 17 year die with no good understanding of why.  The assumption is another organophosphate poisoning. It is all just so heavy and serious here.

I headed to the wards.  I rounded again with the new Malawian intern.  His name is Pempo and he will be at Nkhoma for a year and rotate in all the wards.  We rounded on one admitted with malaria and possible meningitis. Many patients were new to me since I was in the clinic yesterday.  

Then we came to Stella.  She was much worse. Her lungs don’t sound more fluid filled but her breathing was gasping and she was weak and not alert.  Her swelling was more intense as well. Her sweet daddy sat at his post on the hard wooden bench next to her bed. He reports that she has not been drinking.  I can tell that the end is near. I make eye contact with Dad and see his pain and can only offer a sympathetic look. I discuss with the nursing students again that if she should stop breathing or her heart stops that we will not resuscitate as that is not best for her and will only cause pain and a possible delay of the inevitable.  Even as I explain this, my eyes are damp and red. These instructions fly in the face of everything we have been trained to do. What our hearts want to do.

I take a breath to gain composure and we move to the next patient. Pneumonia, then gastroenteritis, then nephrotic syndrome, then seizure, then……

Then the sound.  The wail. The sound of a heart breaking.  The sound of the evil of death and the depth of love crashing into each other.  The cry of Stella’s mom.

Stella’s death was confirmed.  The papers were completed. The dreaded divider was pulled around the bed.  The grandmother and mom were led away. The little swollen body was cleaned and wrapped.  All the while the wails continued. Sometimes shrill and piercing, sometimes deep and guttural. Sometimes a lone voice and sometimes 2 or 3 twirling together.  

The other patients watch and crowd around, a sign of cultural respect, but it drips with awkwardness of grief on display.  We stand helpless and wanting. I did leave to go to the financial office to ensure that I would get the bill and that the family would not suffer that blow as well.  In the solitude of the hall, Christina offered a hug and I shook and sobbed. In her office, she gave me the space to cry a moment and voice my frustrations. If a dose of penicillin had been given in Stella’s past, this all could have been avoided.  One little shot! Also, my inability with language and culture to offer any comfort to the family or grieve with them. We talked about this and my heart’s desire to embrace or touch the mom-my sympathy.

I left quickly and did go to the chaplain.  I just asked him if it would be appropriate for me to approach the mother and offer my sympathies.  He said he thought it would be good and actually went with me and translated. I told the mother that I was thankful that I had been able to know Stella and her precious family, honored to have gotten to care for her, and I was so sorry for her loss and would be praying for her.  I touched her arm and squeezed her shoulders. She remained stoic in my presence and cried after I had passed. I hope my heart communicated despite all the differences. Sam reported later the father‘s appreciation for all that had been done.  I wish we could do more.

The body was wheeled out on the dull metal cart that I have learned to despise.  The crowd of women followed behind the mom and the grandmother was physically assisted. The wails became more and more quiet as they left.  The chaplain used his vehicle to drive the family and body back to their village. The echos of the wails continue to bounce around in my mind.

We went back to rounding on the children still needing our care.   Several more with seizures, malaria, CP, bronchiolitis, and malnutrition. The surgeons had seen the orthopedic cases.  Then new admissions started coming in. While the IV’s were started I went down to the NICU. They had just done a rescusitation attempt on a newborn that was not successful.  It was a hard morning for everyone. There are a few that very sick but most are improving and growing. One was on CPAP and seems to have some facial anomalies. 

I went back to the ward and we had four to admit.  One with a prolonged respiratory illness and HIV, one with severe hip pain, one with malaria and anemia requiring a transfusion, and one with bronchiolitis.  We got the charts written up and medicines started. Xrays were written for the kids with hip pain and HIV. Then it was time for lunch.

I made myself busy straight away at lunch.  I am having dinner with Marleen’s family and had agreed to bring dessert.  Melissa had found a packaged brownie mix at the store so I made that and put it in the oven.  I made a cheese sandwich and found Melissa to download my morning. After the brownies came out, we decided to take the girls for a walk to return library books.  I think I mentioned this crazy amazing little library that some Koreans established here. It was a long and hot walk. I has been so hot here! We also went in the little store and got phone minutes and juice boxes.  On the way back, we picked up some carrots at the roadside market. It was good for me to move and think of something else for a minute.  

Then I headed back to the hospital.  We had another admission of a very small infant with pneumonia.  We then looked at the xrays. The child with HIV has a little pneumonia but the bigger issue is that his heart is very enlarged.  We will eventually need to send him for an echo to see what is going on. Sam was concerned about HIV cardiomyopathy. I have never even heard of that-more research and reading.  The boy with the hip pain has a dislocation and the ortho guys are going to talk to the central hospital tomorrow to arrange for an open repair. We are giving him a transfusion tonight secondary to anemia.  Then we had a last admission. Another child from Nicole’s home with gastroenteritis and pneumonia.

I started texting with Nicole about the admission, Immanuel, and about Telesa.  Today was her echo appointment. I had worried that her murmur sounded like a VSD and unfortunately that was correct.  Only, she has three separate defects and will need surgery to close one. That means getting her to gain weight so she qualifies for the repair that is done in India or in the Netherlands if Nicole adopts her.  So we worked out a feeding regimen. I had increased the calories of her feeds yest and she did gain weight overnight.

Now I am getting ready to go to Marleen’s.  I will enjoy dinner with them and then packing up for my adventure tomorrow.

I am fine and I have hope and I know I belong to the God of love.  These kids with the broken hearts are just breaking mine.

Thank you all for being in this with me.  Your love, comments, and prayers are sustaining me in every step.