I'm looking at a child with a swollen, rigid tummy. He can't bear anyone to touch it, and he's semi-conscious. He's in the resuscitation room, having been brought in by one of the Land Rover "ambulances" that drive around the more remote districts once or twice a day picking up people who need to come to hospital. There's no triage or priority system associated with this: it makes a number of stops and then comes to the hospital. People may walk for miles, carrying their child, to get to the ambulance stop and then endure the journey to hospital, deteriorating all the way.
The land rovers then drop everyone at the door to the emergency department. This may result in multiple patients arriving all at once (the intended passenger numbers of the vehicle are irrelevant). At home this would likely be classed as a major incident. Here the team just get on with it.
One of the doctors makes an assessment. It's clear that the child will need an operation. Right now, he needs stabilisation. IV fluid, probably a blood transfusion, oxygen. The nasal cannulae are applied to deliver oxygen from the free standing concentrators on the floor. There is no piped oxygen like at home. These run off electricity and concentrate oxygen from room air. At this moment the power goes off. No electricity and therefore no oxygen. This added to the fact that we've had no running water for three days now.
I'm looking around for oxygen cylinders. There would be one on every trolley at home. I can't see any. It's urgent: apart from this boy, there are three other patients in the room requiring oxygen. Babies with breathing problems. Someone produces an oxygen cylinder (singular) and we are just in the process of working out which patient has the greatest need, as the power returns. Relief.
We take him to the radiology department for an X-ray of his abdomen. This is a feat in itself. A baby also needs an X-ray and he goes on the other end of the trolley. The oxygen cylinder is shared between the two patients by means of a Y-shaped connector. It's not high-flow, but it's something. There are around 150 people in the queue for X-ray, lining the corridors. Some look like they may not survive to get to the front and yet no one complains.
He's moved to the high dependency area of one of the wards. As he's a bit bigger than many of the other patients, he has a bed to himself. The team have made a working diagnosis of typhoid perforation, for which the child will need bowel surgery. He's deteriorating fast. Barely conscious with faint pulses. There is one monitor between 15 patients. Continuous monitoring as at home is not possible. The clinicians here rely much more on clinical examination and judgement than on numbers and I reflect that we could learn from this. Gut feeling plays a part too.
IV fluids are being given as fast as possible to treat shock. Blood is ordered. The surgeons are called. Oxygen is being given but he's sharing a concentrator with the baby in the opposite bed. Turning the oxygen up for this patient will result in less being given to the baby. There's a finite supply. This is not some abstract conversation about resource planning; this is about choosing which patient to give the treatment to when both are in front of us. We may be feeling the pinch at home, but not like this.
So how will the story end for this boy? We wait for the surgeons to assess him and decide whether he will tolerate an anaesthetic and surgery. If he does, he will have a long recovery ahead of him. Despite best efforts in acute care, there is no infrastructure in Malawi for longer term follow up and rehabilitation.
I talked about gut feeling. My own is that this will not end well. I hope I'm wrong.
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