Malawi Day 7: Life, and death

There are five patients in resus this morning. Two of them came in half an hour or so ago and were barely conscious. They're all receiving treatment and undergoing investigations. Four of them are sharing trolleys and oxygen concentrators.

I step outside the room for a few moments to talk to the lead Paediatric ED consultant. She's an inspirational lady who has an enormous amount of experience in this setting and in the UK. She's talking about raising funds to expand the department, in particular to provide more space in the resuscitation room. She is acutely aware of the lack of space and privacy and the fact that children and families witness things they should not see. Overcrowding is the big issue.

As if to underline this point, a car arrives outside and the driver rushes in asking for a trolley. We go out to the car to see a child of about 12 years slumped on the back seat. His mother is crying inconsolably as she cradles his head in her lap.  He is unresponsive as he's lifted onto the trolley. I tilt his head to open his airway and I look for signs of breathing. For any sign of life. I put my fingers where his brachial pulse should be. It's not there. The consultant checks his pupils. They're fixed and dilated.

A few sentences exchanged with the family as we run inside tell us that this child was taken to a health centre in one of the districts this morning after repeated vomiting and several fits as they thought he had cerebral malaria. He was sent here for further treatment and stopped breathing on the way.

As we enter the resuscitation room, a trolley space is made available by moving one baby to share a trolley, one to another area of the department and one onto his mother's lap as she sits on a stool.

Resuscitation begins. The resuscitation algorithm is followed as it would be at home, but something is missing. There is no cardiac monitor. The child's pulse is checked every two minutes. 

As the team are focusing on this child, another mother appears in the doorway with a child in her arms. It's obvious at first glance that this child is dead. He is malnourished and looks like he was ill for sometime.  There is nowhere else to lie him, but on the end of the trolley with a baby on the other end.

Both mothers wait outside the tiny room. There are other mothers and a few family members in the vicinity and they sit close, providing support in physical presence. And they wait.

One of the doctors is assigned to assess the second child, while a medical student takes some information from his family. From his healthcare passport we can see that he's 'non-reactive' (HIV negative). It sounds like the history suggests cerebral malaria. Although it is clear that any resuscitation attempt would be futile, a finger prick blood test is taken for malaria RDT (rapid diagnostic test). This may help to provide answers to the family about why their child is dead.

The dead child is covered with a length of fabric the mother had him wrapped in. The baby is still on the other end of the trolley. Her mother looks on quietly. I feel a sense of shock and unreality at the sight of these two children together; one alive and one dead.  But what else could the team have done in that moment?

Meanwhile, the team have continued to work on the other child. Following two doses of adrenaline, he regains a pulse but  he can't sustain it. It may be the case that if he went to intensive care, he would survive another few days on a ventilator but his brain has been without oxygen for too long. He won't be able to breathe on his own. The decision is taken to stop resuscitation. I can see that some of the medical students feels uncomfortable about this and it comes out later in the debrief. I'm at peace with that decision though. This child is going to die. It doesn't feel right to prolong the agony.

In the space of twenty minutes, I've seen two children die from a condition that could have been prevented or treated. Malaria nets are widely provided but not necessarily widely used. There are reports that they are used as fishing nets or for other practical purposes, rather than sleeping under. I reflect that if you and your family live in one or two rooms, have to walk some distance to get water, and every day is a challenge to feed yourselves, maybe preventing an abstract disease is a lower priority. So much progress has been made in providing education and support in the remote districts (villages) but there is still a way to go.

Resus 1: a rare moment of quiet

Healthcare is often accessed late here, even though it is free at the point of delivery thanks to government funding and massive international aid. It's understandable when you might have to walk miles to get to a health centre and then many more miles to get to hospital, or spend a month's wages on the taxi to take you there.

In the Malawi culture, death is seen as part of life. Having been here even for a short time, I can see that it is common in childhood and that must play a part in this view. One of the key cultural differences is that the healthcare team must not talk of impending death. It is seen as a sign of giving up on someone. Instead, the team make it clear in other ways by talking about not being able to make the child better.

Emotion is not displayed publicly here, until after death. Then there is open sobbing and wailing. Before this, there is quiet acceptance and tolerance. I think about the first mother who arrived with the child in the car. She was sobbing openly. So she knew. She knew he was dead or at least dying. Still she came. Was she not ready to let go, hoping for a miracle? If so, despite the cultural differences, she would not be so different from any mother I might meet at home.