Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (33 page)

I sat back on my haunches and looked down at the patient as he looked up at me. He tried to smile at me, but instead he triggered off a set of spasms. His lips drew back in a rictus of pain. There it was again,
risus sardonicus.

The spasms are extremely painful…

What is the furthest extreme of suffering? I wondered. Where is the endpoint of agony? Is there a place where, if you are in severe enough pain, greater pain doesn't register? Is that point far away? Does anyone return from there? Can they ever tell us what they have felt? Is there a language for it? Would we, under any circumstance, ever want to know? And why the suffering? Why this man? Why this dead end here, a mat on the floor of a tent.
The paroxysms are associated with excruciating pain.
I looked at him, shaking my head. Christ only suffered as all men suffer. There was nothing new on the plains of Calvary.

I searched out Jean-Paul again. Today he was supervising the outpatient clinic. This was part of the old hospital, which had real rooms with real beds. Unfortunately the real beds were really just bed frames and rusty coiled metal springs, the floors were filthy, there were no screens on the windows, and generally the place had such an air of haunted filth that most of my tent patients refused to transfer over once a “bed” became available.

I found Jean-Paul on the back steps of the intake office, examining a measly child.

I told him everything. I told him about the constant spasms, the failure of the penicillin, the excruciating pain that we could assuage for only a little while. Jean-Paul listened and as he did so he passed a large handkerchief over his broad face, nodding his head.

“He's not getting better,” I said. “He's getting worse, I think. I don't know. Are you sure this is tetanus?”

“The source,” he said.

“The source?”

“Does he have a wound anywhere?”

I shook my head. “The brother says he didn't cut himself anywhere as far as they knew. I looked him over and I couldn't find anything.”

“Well, the
Clostridium
is hiding somewhere. Gall bladder, gut. I don't know.”

“What should I do?”

He shook his head, not really listening. “The noise, too. Very bad for him.”

“Then what should I do?”

“Send him to the tetanus hospital.”

“But they had no beds.”

“Maybe they do now. You go with them. They can run tests.”

Tests. I walked back up to the tents shaking my head. Jean-Paul was right. I couldn't even get an x-ray here. We were lucky to have IV catheters. I had no business treating this man under these conditions. Clearly the patient needed to go back to the tetanus hospital.

I found Simon and told him that the brothers needed to take the patient back to the tetanus hospital. Simon went off to find them and then quickly returned.

“They tell me they have no way to get there.”

“What happened to the friend with the truck?”

“He died a few days ago. Malaria.”

Jesus, I thought. That's Nigeria. The rich get rich and the poor get malaria, cholera, leishmaniasis, meningitis.

There was a shadow; Avi, the driver, had been trailing me. “Jean-Paul says to use the car if we can find nothing else.”

“The car” was Jean-Paul's personal vehicle, a motheaten microsized two-door sedan. Doctors without Borders did not go for expensive transportation.

“How the hell are we going to get him into that car?”

Avi shrugged. “Is here a choice?”

I shook my head. If this man went into horrible spasms at the touch of my hand, think what it would be like to cram him into the back of a two-door car. But despite what I thought, I said: “Maybe. Maybe we can, if we take enough Valium…”

The logistics were this. Simon and Umar, who was another nurse, would ride over with Avi and me to the hospital. The brothers would follow by grabbing one of the overcrowded pickup trucks that served as buses in Nigeria. The patient would ride in the backseat with Simon and Umar. We gave him 10 mg of Valium. The brothers carried him to the car and laid him by the door. He wasn't doing well; despite the 10 mg of Valium, he had stiffened just from being moved. I gave him another 5 mg of Valium, then we all grabbed on to whatever we could grip to hoist him up. We had to put him into the backseat by cramming him past the front passenger seat. It was like trying to fold up a spring-loaded manikin. Every time we would try to bend the patient's arms, the legs would extend. Every time we folded the legs, the arms would fly up. It would have been funny if it wasn't so horrible. Every touch made the man shudder; every movement brought another wave of fasciculations and muscle spasms.

Simon stopped and held his hand against my arm.

“This is not working,” he said.

“More Valium,” I told him. “And for God's sake, we can't lose this IV.”

We injected the man with another 5 mg and then 5 mg more. Twenty-five mg of Valium IV. This would knock anyone out.

While Simon and Umar stood talking strategy with the brothers, I watched the fasciculations subside and the clenched muscles relax. After a moment I reached down and flexed and extended the man's right arm. “Let's try this again,” I told them.

Simon got in first and dragged while we pushed the patient into the backseat. The patient was limp for a moment only. The minute Simon tried to set him upright in the seat, the patient's arms and legs sprang to full extension and he rocked to and fro in agony, terror in his eyes. For a moment I turned away. I couldn't stand to look.

Umar clambered into the other side with the patient, hoisting the saline bottle. I got into the front and twisted around, facing them. “Give him another ten milligrams,” I told Simon. We were entering a pharmacologic no-man's-land here, as far as I was concerned. I had never given anyone this much Valium IV. The patient's head arched back and he quivered; each muscle was delineated.

Avi started up the engine and we moved cautiously forward. It was no use. As Avi tried to ease over a pothole, the car bucked a little and that was enough to send the patient into more muscle spasms. It was agony just to watch that frightened, dying man quaking at each bump.

“Give him another ten,” I told Simon.

“That's forty-five,” Simon said doubtfully.

“I know, I know.”

The patient sagged back now against Umar. Umar cradled him with one arm as best he could. Simon gave another 10 mg of Valium.

“How long to the hospital?” I asked Avi.

“Ten miles.”

“Jesus Christ, ten miles. You've got to be kidding.”

We took a right at the sign for Maladrin and sped frantically down the streets, first along the wide row of shops and then, after a right turn, into a part of the city I had never seen before.

The tetanus patient remained wedged between Umar and Simon. Froth had formed on his lips. He looked a little like a rabid dog.

Out of habit I started to go through in my mind what really needed to be done for this patient. He was septic now, I was sure. His infection, once localized, had now run wild, affecting every organ system, the heart, the circulation, the lungs, the kidneys. Septic shock. At home, we would first go for better IV access and control the airway. We would paralyze him, intubate him. Then we would give this guy at least three different antibiotics, none of which had even existed ten years ago. Blood gases, central line, the race upstairs to the ICU to meet “the team.” Interns, residents, nurses, the ICU director. The team would give another set of three entirely new antibiotics. Then the serious technology. They would look for the source and use everything available. Head-to-toe CT scan plus MRI of the spinal cord and the brain. The heart would need an echocardiogram looking for cardiac-wall motion abnormalities to rule out endocarditis. The lungs—chest x-rays, ventilatory support. Also, at home, we would be doing clinical trials—something to help future patients. Maybe we'd enroll this patient in a new ventilator study, one that looked promising enough to raise the dead. (They always start out that way.) Then EEGs, labeled white cell scans. Someone would suggest a Swan-Ganz catheter, someone else would cite recent literature critical of Swan-Ganz catheters. Someone would want an abdominal CT with triple contrast; someone else would argue that, no, an MRI would give more information. The intern would miss the arterial line, the medical student would have trouble with the Foley, and yet, in all this chaos and uncertainty, the right things would somehow get done, and mostly right decisions would be made and the patient's life would somehow be saved.

And the technology, I thought, as I gazed down at my man, now sheened with sweat, his face assuming a permanent horrific smile that twitched more widely with every bump. He had reared back, his spine arched, his legs butting into the front car seat. Umar held his right arm, where the IV still, somehow, hung on. Simon wiped the man's brow with an old rag with one hand and kept the glass liter of saline aloft with the other.

Then the most important thing, I thought. At home we could treat his pain. We could make it tolerable, even transparent. Valium, morphine, Demerol, Fentanyl. If nothing else, this man would never know he was dying. Not like now.

The streets crawled by.

The road was rockier and hot, hot, hot. As always in the afternoon, the air was muddy with pollution, and each passing car brought wave after wave of dust that billowed up from the un-paved streets. The sun echoed from any hint of glass, from the chrome car bumpers, from the bleached white jubbahs. We swam through the dust, past an old gated wall, then climbed a little through winding streets until we reached an open area, a dusty yard flanked by some nondescript once-white stucco buildings.

I turned around in my seat to look back at the patient. He looked as if he would die at any moment. He struggled for each breath, each time like he was climbing a mountain. His jaw muscles were still spasming, despite all that drug. His face was still wrapped in that hideous grin. I didn't dare give him any more Valium.

“This is it,” Avi said, skidding to a halt.

We all looked up and as the dust settled we saw a couple of ramshackle buildings flanking the dirt lot where we had parked. A scrawny, scraggly chicken-like bird was the only sign of life.

Avi pointed up at the most ramshackle of the buildings, a two-story “office building,” its plaster walls a dirty dun color and its big, black windows encased with bars and sided by shutters that hung askew.

“That is the intake office.”

I leaped out of the car and trotted across the potmarked driveway and up the cement stairs into the shadows of an inner courtyard and another stairway. There was no comfort in the shadows. It was as oppressively hot in the courtyard stairway as it was outside in the car. The stairway was black with dirt, and the walls were as crud-encrusted as the stairs. I rounded the corner of the stairway. Here was, it seemed, the intake office, atop another set of stairs. A large room angled off the end of a short hallway. It was empty except for an old wooden desk where two Muslim women, their heads covered with kerchiefs, sat squabbling. Nurses, I assumed.

They looked up at me, half laughing at what they saw—a foreigner, a white woman with her hair uncovered who looked very frightened.

“Yes, yes,” I said. “I'm a doctor from
Médecins sans Frontières.
I'm from the meningitis camp. We have a patient I need you to see.”

One of the women shook her head. “We are closed now. You need to come back in the morning.”

“No,” I said. “This is a patient with tetanus. He can't wait. He needs to be admitted to the tetanus hospital or whatever…”

“Tetanus ward is full,” the other nurse said. “You must come back in the morning.”

“You don't understand. This man is dying of tetanus. We cannot take care of him. Someone needs to see him.”

The nurses stopped smiling up at the white woman standing before them. They were beginning to get irritated with me. Their faces assumed an implacable mask. (This must have driven the colonialists mad.) “Tetanus intake is only in the morning. We only see tetanus in the morning.”

I put my hand to my head. The heat inside the room was suffocating. I felt dizzy, presyncopal. I steadied myself, putting my hand on the table and shaking my head.

“I want to talk to your doctor.”

One of the women lifted a finger and got up, disappearing down a dark corridor, and reemerged in a moment accompanied by a young man. He was pulling on a dirty white lab coat over his jubbah. It was the only lab coat I saw in Africa.

He was a young man. His hair was slicked back; his face had a soulful look to it. He looked the part of the handsome young doctor.

“Yes?” he asked.

“I'm a doctor from the meningitis clinic. I have a patient here with tetanus. We have been taking care of him over the last week, but he is not getting any better at all,
at all.
You need to admit him to your tetanus hospital.”

The doctor nodded sympathetically. “I understand,” he said. “Unfortunately, we only have tetanus intake in the morning.”

“You don't understand. This man is dying of tetanus. It doesn't matter what time intake hours are.”

The doctor nodded his head. “Well, of course, since that's the case, we would try to make an exception but unfortunately there are no beds.”

I looked around. “I don't believe you.”

The man took a step back, offended. He put his hand over his heart. “We are completely, entirely full.”

“Come with me,” I said, grabbing his arm. An infidel woman touching a Muslim man. He recoiled in horror but I kept tugging. “You will come and see this man.”

“I understand your position,” the doctor said, trying to wrest his arm free.

“If you understood my position,” I told him, “you would find this man a bed.”

“But we are full.”

“I want you to
see
him.”

I dragged the doctor down the courtyard steps and back out into the sunlight. Simon was there standing by the car. Umar was still inside with the patient.

“Open the door,” I yelled at Simon. “Open the door.”

The doctor came to a stop a good ten feet from the car. I propelled him toward it as Simon opened the door and pushed the front seat forward, out of the way.