Difficult choices – Dr Alexander Cary

Posted on Posted in Junior Clinicians

Difficult choices

by Alexander Cary

I shuddered. It didn’t feel right. Zico certainly didn’t look well, and he was breathing hard for a ten-month-old. I met his gaze. His flared nostrils and staring eyes conveyed a state of panic which he could not yet express in words. Zico lay there drawing fleeting, shallow breaths while his whole body strained for air. It felt wrong taking off his oxygen mask. But I carried on. I gently unhooked the worn string from his little ears, and lifted the mask from his face. I yanked the plug from the electrical socket and suddenly an odd silence fell. The familiar whir of the oxygen-condenser ceased and nothing could be heard except Zico’s gasps and the occasional whine of a passing mosquito. The calm didn’t last long as I gathered up the power cord and dragged the oxygen machine down the ward, with its casters clunking along the bumpy floor. The grey machine rumbled with its small wheels racing along the concrete, as I guided it down the ward with a growing sense of urgency. I knew the concerned eyes of Zico’s parents were watching me, as I disappeared down the ward with his oxygen machine pulled along behind me. I almost tripped on an arm that poked out from under one of the other beds and the oxygen machine thudded into it and came to a halt. The man woke startled and rolled back under the hospital bed, taking his wayward limbs with him. His daughter slept on in the hospital bed above him, covered loosely in a thin piece of green fabric and shrouded by a mosquito net. The rumble restarted as I dragged the machine down the ward once more.

 

The hospital staff doubled up as the blood bank when necessary.
Photo credit: Adrian Delport

Moments later, I stopped at the bedside of Marie, a very unwell child with an empyema. She was sat on the edge of her hospital bed with her feet dangling off the end. She propped herself up with her hands on her knees and she too was fighting for each breath. I strapped on the oxygen mask, shoved the plug into the socket and was rewarded with the comforting mechanical sound of the oxygen machine, delivering five litres of oxygen every minute to this five-year-old girl. I pushed thoughts of Zico to the back of my mind as I tended to Marie, talked with the surgeon, and wheeled her across to the operating theatre for a chest drain.

 

The medical ward uncharacteristically devoid of patients. Photo credit: Alexander Cary

Later, when I found a moment, I sat in the ward office, right next to the fan in an attempt to keep the mosquitoes at bay. They still attacked my exposed feet between the straps in my sandals. Whilst I scribbled in the notes, I found myself questioning, “Who am I to take that child’s oxygen machine away?” I start justifying my decisions to myself: “There are only four oxygen machines. Surely they should go to the sickest children?” I glanced through the glass, a transparent barrier between me and my patients on the ward. Zico’s mum and dad looked down at him, his face fully visible for once, without a plastic mask pressing into it. It didn’t matter to them that the other child was ‘sicker’. They were worried about their baby and they knew that I had chosen to take his oxygen away; I had made his breathing worse. I held an x-ray film up to the ward strip-light and asked myself, “Should I have to decide who lives or dies?” Piped oxygen and well-equipped high dependency units seemed a distant memory as I sat in the office of the missionary hospital in Madagascar. The early frustration of my first weeks at the hospital had given way to a melancholy sense of acceptance and I no longer yearned for oxygen cylinders or basic blood tests. Instead, I plodded on with what we had, knowing that a high dependency unit is a distant fantasy in a district without roads, sewers or a reliable water supply.

The office door swung open and my brief contemplation was cut short. The nurse entered looking tired: “Il y a deux malades, qui sont arrivés”. I paused while my tired brain processed the French, and I realised that there were two new inpatients who needed my attention. I pulled on a tatty pair of gloves and hurried over to see the next patient.

[Patient names changed]

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Dr Alexander Cary is an ‘F4’ in Nottingham who recently worked at Hopitaly Vaovao Mahafaly, a well respected hospital in Madagascar which saves many lives with limited resources.

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