Monday, April 2, 2012

A Senseless Death: The reality of default from tuberculosis treatment in Gabon

     Two weeks into my time here, a 15 year old girl checked into the Kopp. She was a very young 15, with a thin frame and the face of a 10 year-old. When my attending saw her chest x-ray, he was so discouraged and angry that he tossed it onto the table before I could see it. I was too distracted by the patient herself to look at the x-ray. She had her hands on her knees, and was leaning forward taking quick and labored breaths. Someone had brought the ancient oxygen machine into her room and put her on a nasal cannula, which she clutched tightly behind her ears. She held that cannula in place, I think because she was too scared to miss one second of the air it delivered.
     When my attending had composed himself, he zeroed in on her mother. Although he already had read  the story in her transfer documents, he asked her anyway.
      Her transfer letter from the hospital in Port-Gentil told an unforgivable tale, one that started with her diagnosis of tuberculosis in 2010 in Libreville. The letter than said that her treatment was “interrupted” by her parents inability to pay for the complete treatment. In 2011, she started to feel ill again, unable to sleep due to coughing fits and a fever that wouldn’t abate. Her parents took her to Port-Gentil, where she restarted anti-tuberculosis treatment. Again her six month treatment was again “interrupted” by her parents inability to pay for the trip to and from Port-Gentil for her appointments.
    Now in February of 2012, almost 2 years after she was first diagnosed, she arrived at the Kopp, with a chest-ray that revealed a fatal mix of atelectasis, fibrosis and several cavitations. Her lungs were a mess, and my attending told her mother as much: “Your daughter has NO lungs. She has no lungs. How are we supposed to help you?”
     In the afternoon, when I returned to enter lab results, she was doing worse. The oxygen settings were maxed out and she still couldn’t seem to catch her breath.  Her mother was frantic at this point, coming into the nurses station every five minutes exclaiming: “She can’t breathe. She can’t breathe.” The nurses were empathetic, but weren’t as affected by her sense of urgency.
       I saw her myself. She was scared and tired. Her eyes frantically scanned the room, looking from face to face, from mine to her mother’s to the nurses’, as if searching for oxygen in our expressions. I called my attending on the phone and told him what I saw: She was tiring and seemed like she wouldn’t be able to keep up this marathon breathing for much longer. He listened to me and said only “OK.” I wanted him to tell me to hang something, to change oxygen settings, to arrange a transfer; I wanted him to tell me to DO something. But he didn’t. It is the most frustrated I have ever been with an attending.
     What I didn’t know was that my attending had been in and out of the service all afternoon and had seen her worsen. The nurses knew, the doctors knew and I think even she knew, but when I saw her at 5 o’clock I had no idea. Everyone knew she was going to die, except for me and her mother.
    She died overnight. Too tired to breathe, she died of a curable disease. A professor of mine once siad that it is stupid to die of tuberculosis today. The combo medication of RHZE works and works well. All that is needed to secure a complete recovery is strict compliance with the regimen for 6 months.
   My last memory of her was seeing the fear in her eyes and kneeling in front of her. Her mother, had grabbed my arm and pulled me into the room. As a medical student, with really no idea what to do in the situation, I did the only thing I knew how to do.  I knelt in front of her, put my hands on her knees and said “Its ok. Its going to be ok.” I smiled at her, in an attempt to reassure her. Because she looked like a child, I remembered that in Pediatrics I learned that children with trouble breathing should be kept calm. Her breathing slowed a bit and my last thought before I left was that if she could keep calm, she wouldn’t tire so quickly and would make it through the night.

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