ECU Field Journal: Africa

Marie's Blog from Lambaréné, Gabon<-- back

The edge of a razor...
October 8, 2008

In The Illiad Homer wrote, "Life and death are balanced on the edge of a razor." How true. It is now 5:19 a.m. and I have been lying awake since 3:00 a.m. I woke up thinking about my patient who died at the hospital today. How could this have happened? What were the events in her life that led to that moment? What could we have done differently? I decide the answers to this tragedy have to be somewhere—that there must be a medical explanation somewhere in my books. I know that finding it won’t bring her back, but it may save a future patient like her. In order to drown out my thoughts of her young life lost, her pain, and the role I played at the end of her life, I open my computer to listen to music. As I open iTunes I feel shame for the frivolous technology at my fingertips when we lack even the most basic necessities at the hospital. We don’t even have thermometers right now. I try to rationalize the chaos of emotions I feel. She is the first patient that has passed before my eyes. I will never forget her face. I will never forget how helpless I felt. I grieve for the loss of her life and for our inability to help. She died of severe disseminated intravascular coagulopathy. She was 18.

She first came to Hopital d’Albert Schweitzer in respiratory distress with a right-sided pleural effusion. She was literally drowning from fluid in her lungs. We drained the fluid for about a week, but a diagnosis eluded us. I was reminded of an old adage told to medical students to help them work through a difficult diagnosis…“When you hear hoof beats, think horses, not zebras.” It means rule out common causes of illnesses before chasing after the unusual or rare. However, I have had to rearrange my thinking as there are far more zebras than horses here in Gabon. During the 18 days of her hospitalization, her prognosis fluctuated. Once we learned of the extremely elevated lymphocytosis in her pleural fluid, we finally had some sense of direction on how to treat her. In the United States, tuberculosis in a young person is quite the zebra, but here it’s a whole team of horses. We decided to start treatment with this presumptive diagnosis.

Fast-forward to yesterday, October 7, 2008. I am in the salle d’urgence, or emergency room, helping a nurse give charcoal through the nasogastric tube to a patient who took a sack full of crushed pills. Sadly, suicide is as much an issue here as back home. As I work another patient arrives hunched over in a wheel chair completely out of breath. I could not see the patient’s face, but as I looked closer, I recognized her hairstyle. I bent down to see if I knew her and I felt myself gasp. Her face was so swollen that her eyes could barely open, but I did indeed know this patient. She was the young woman we had diagnosed with tuberculosis.

Realizing the gravity of the situation, we immediately sent her for a chest X-ray. How is it that she was returning to the hospital with an even more severe illness? The chest X-ray came back almost completely opaque. There was but a small area not yet taken in her right upper lobe. She reportedly had only been sick like this for three days. We asked her if she had been taking her tuberculosis medications. She remained silent. After repeated questioning, she stated she had been taking her pills, but we soon realized that she had not been taking them as prescribed. It was very frustrating as she had been doing so while hospitalized and knew the regimen very well.

Because of her grave condition we questioned her about whether she had seen the traditional healer or the n’ganga. With the influences of western culture and western medicine, this part of Gabonese culture has fallen into secrecy. This “bush medicine” has many valid, effective treatments for many ailments, and even illnesses, but for the diseases that we know very well today, such as tuberculosis, it is a detriment to the patient. It is instances of disastrous outcomes that have rendered it taboo to seek treatment chez le n’ganga. As a result, patients hide this information until they cannot deny it any longer.

Sadly, this was the same for her case. As she sat in her chair, we pleaded for any information that might help us treat her. We finally thought we had her stabilized when a nurse came running to us saying that the woman was dying. As I turned the corner, I heard her mother cry out with a chilling lamentation that one often hears at the loss of a loved one. I entered the room, and there she was, just where I last saw her minutes before. She was gone. We were in such disbelief we couldn’t speak. I write this about my patient to share with you her story, as she represents but one of the many tragedies I have seen here in Lambaréné. I wish I could make sense of it all. I wish I knew how life could be so different from place to place. I wish I knew why the continent someone is born on determines their lifespan, their health, and their opportunities. Confronting disparity and death, and realizing your own limitations in medicine brings about suffocating emotions. The only solution that makes any sense is to keep going for the sake of your future patients.