Turning Point

Caring for the very sick, especially in Africa, one learns to recognize when the tide of illness turns forcefully against the patient and begins to drag him beneath the waters.  In the States, it is at this point that the severely ill are transferred to the ICU, or placed on a breathing machine.  But there are rarely such options here.

Kamwendo served a high government official as driver.  The long trips up and down the narrow country of Malawi probably precipitated his condition.  He showed up near closing time on a Friday following several weeks of worsening shortness of breath and swelling of the legs.  The oxygen level was a little low, but not dangerously so.

What was curious was the finding that the "right side" of his heart had ballooned and was not functioning well.  The "right side" is the chamber which pumps blood returning from the rest of the body to the lung, where it receives oxygen.

And sitting inside the main right pumping chamber was a very large blood clot.

So what had likely been happening is that gradually, piece by piece, small components of that blood clot had been breaking off and travelling to various areas of the lung's blood vessels.  Frequent fliers or patients who have undergone major surgery are aware of the risks of a blood clot moving from an immobile leg up to the lungs--a pulmonary embolism, which characteristically manifests as the sudden onset of chest pain and difficulty breathing.

In Kamwendo's case, the process had been less abrupt, with each wayward loose particle incrementally increasing the pressure within the blood vessels, like a slowly clogging drain.  The right heart distended.  Blood and fluid further backed up into the legs and liver, producing swelling.

We placed Kamwendo on shots of a "blood thinner" called heparin.  His vital signs remained stable, and over the next 24 hours he appeared to improve.

The following day, a Sunday, the symptoms were more alarming.  Kamwendo had experienced an episode of chest pain overnight, and his dyspnea (or, shortness of breath) became more troublesome.  I surmised that another segment of the blood clot had landed somewhere in the lung.  In other words, the heparin wasn't working.  "Blood thinners" don't break up clots per se, but instead prevent the "thrombus" from growing.  The body then tries to digest the organized proteins.

Now came a serious decision.  Do I continue the same therapy, and hope these events cease?  Or do I look for an expensive and potentially dangerous injection which might actually "lyse," or dissolve, the blood clot?  Once, a decade ago in Kenya, we had used the drug streptokinase to save the life of someone with an acute pulmonary embolism.  We have employed the same agent at Partners in Hope to reverse a blood clot in the arm, and to assist a patient with a heart attack.

After reviewing the literature and balancing the risks and benefits, I began searching for the medicine.  An expatriate doctor had a donated vial, so I drove across town to pick it up, a process which took nearly two hours amidst the unmarked, byzantine roads of Lilongwe.  Working with the nurse, I prepared the infusion of streptokinase and followed the standard protocol, having informed the patient about the major risk of bleeding.  Then we waited.

About thirty minutes later Kamwendo's condition declined further.  This time he wasn't simply uncomfortable but had become frankly panicked from air hunger.

Then came the point, the turning point, which has occurred too often during my career in Africa:  the juncture at which the patient has drifted beyond the reach of our modest resources.  A glazed, faraway look entered Kamwendo's eyes.  I urgently called for the nurse.

We almost never resuscitate cardiopulmonary arrest cases at Partners in Hope.  Even if the rescue is successful, we still have no way to support such a sick person.  I recalled my Kenyan client from ten years prior, and how his critical situation had resolved with the clot-busting drug, how we had pulled him back up from beneath the swirling waters.  So we instilled normal saline, injected adrenaline, gave oxygen, and continued the streptokinase.  The situation became desperate.  I began CPR, and ventilated by mask. 

To no avail.  Kamwendo died.

Had the streptokinase itself loosened the clot enough and sent a fatally large section hurtling toward the lung?  Or had this latest episode been just another step-wise deterioration?  Would the end have been the same no matter what we did? 

Any doctor who treats the gravely ill, who takes on the responsibility and does not shy from it, faces such haunting questions, and is kept awake by them.  The burden is especially heavy when it rests on just one set of shoulders.  No one except me was there to make the call.  Given the stark clinical facts, and the literature at my disposal, I made the best decision I could.

What about the resources?  In much of Malawi, patients lack access to basic antibiotics; health workers don't have gauze or gloves.  Even at Partners in Hope we struggle at times to access and afford an adequate supply of these fundamental items.  The trend in philanthropy today is to gauge every intervention by quantifiable cost-benefit, every program by "dollars per life saved."  Certainly, we too are careful to utilize resources wisely and have established a panel of acceptable tests and medicines in the free HIV clinic.  It's not possible or effective to do everything for everyone.

Yet how can one weigh these calculations against the distressed individual lying in the bed right before you?  Maybe the charitable "intervention" should be the creation of a holistic institution of excellence, which is radically committed to each individual who finds his or her way to the hospital.  I couldn't just watch Kamwendo die at age 45, without a struggle.  Some have termed an approach which neglects the most acutely ill a "failure to rescue"--which can lead to the community's lack of trust in a facility.

This past week we faced the same issues again, when a young HIV-infected woman finally surrendered in her fight against severe Pneumocystis pneumonia, despite aggressive efforts and two weeks on a special mask like a ventilator.  Also with her, I witnessed one morning the turning point, when I knew we would lose, when fatigue overwhelmed her.  We could do nothing else, and watched her go later that day.

Last year I shared the story of Enelesi and her battle against a severe lung infection.  She did not give up, and we did not give up.  Now she is entering university.

Our patients demonstrate tremendous courage, a kind of nobility.  The medical team is frequently left physically drained and psychologically demoralized.  All would choose health over heroism.  There is a reason our hospital is called Partners in Hope:  it is one of the few places in the country where people find real hope and professionals willing to fight for each of them, with whatever is available.

Grace,