The Curse of Introspection on Friday the 13th

My ER shift started in chaos.

“Does it have something to do with today being Friday the 13^th?” I wondered, although not really being all that superstitious, I knew it was just a momentary thought.

On bed 13 lay Aleya, a 13-year-old previously normal and healthy girl, youngest of 13 siblings. To add insult to injury she got ‘tubed’ (intubated), unsurprisingly, at 1300 hours. But I get ahead of myself, so let’s start at the beginning.

     

For the past 13 days Aleya had been running ‘very high’ fever, not confirmed by a thermometer.

“Jism bahut garam tha” [body felt really hot] said her 18-year-old brother, repeating the fever-detection-by-hand story that I must have heard over a thousand times already since starting work in the pediatric ER, just a few years ago. 

I didn’t say anything to Aleya’s brother then as I was tired of getting on the soap box about inaccuracy of that approach for fever detection.

“Get a thermometer next time, or use one, if already available at home”, I said to myself instead.   

More concerning than what we doctor type call ‘subjective fever’, was the fact that Aleya had become progressively drowsy. The family started taking it more seriously, when over the past 2 days Aleya became unable to walk without stumbling. After visiting a community clinic and a small hospital in the low-income neighborhood of Korangi in the sprawling megapolis of Karachi, Aleya ended up in my ER at midnight.

By the time I saw her the next morning she was in a critical state. Was she suffering from dengue? Or cerebral malaria? Or typhoid? Or perhaps Congo Crimean fever, given close proximity to sacrificial animals in the compound where she would often play. Did she have meningitis or encephalitis? We never did find out to our satisfaction, in spite of the battery of tests we ran.

Her Glasgow Coma Scale (GCS) was 5: she was not opening her eyes and only moving her arms purposelessly when given a painful stimulus. For the discerning reader who might erroneously jump to conclusions: the ‘painful stimulus’ phrase above is used to gauge consciousness by us medics - it’s not some god awful experimental intervention on human subjects (aka patients). A GCS of 5 essentially meant that she was at risk of losing her airway (being unable to breathe on her own) if she clinically deteriorated further.

Given her precarious state, I had reached difficult cross-roads: to tube or not to tube?

“We need to tube her to protect her airway”, said one team member; “What if there isn’t a bed and ventilator in the pediatric ICU…what then?” asked another; “What if they don’t have enough money to afford care here?” enquired a third. 

As is the norm in such circumstances, I approached the next of kin at the bedside as part of the ‘patient-family centered care’ model we promote in the ER. Unfortunately, the child’s father, the primary decision maker was out on the streets trying to arrange finances for hospital admission.  

So the decision to tube the patient fell squarely on the shoulders of the male family member present there: her 18-year-old brother. He told me to go ahead, but his dazed look indicated lack of understanding of the intensity of the situation. Perhaps that was the reason he got upset at me once we had tubed Aleya at 1300 hours.

“Doctor you said she would be better once she’s got the tube inside. Before the tube going in she was at least able to breathe on her own. In fact, she was better before we brought her to this ER”. 

By that time I was frustrated with their inability for consistent decision-making and their distrust in the ER team. Once Aleya’s father was back, I realized that he didn't seem too eager about keeping Aleya there: lack of finances was most likely the culprit. 

“Perhaps because there’s a daughter involved. Had it been a son then the family would’ve paid up instantly”, one of the senior residents speculated. “The father needed assurance that paying the advance would guarantee improvement of the child”, the resident continued.

I witnessed remarkable drama and dynamics, with family members arguing and shouting amongst themselves, at Aleya’s bedside. It seemed like they were split right in the middle regarding the course of action to take. There were 2 camps: one represented by a few of her siblings wanted us to ‘save and cure’ her there and then, whereas her father and 3 of her 13 siblings representing the other camp were skeptical about the return on investment vis-a-vis paying for her care there. Both sides were unrealistic in their expectations, I felt, but there was no point in counseling them further.

Once all that real life drama had played itself out, the final decision taken by the father was to transfer Aleya to another hospital where she could be on the ventilator and the cost of medical care there would be more affordable for the family.

Later that day once the ER became less chaotic, several hours after Aleya had been transferred out, I got a moment to reflect on the above event and I realized that:

(i) I had been conflicted about ‘tubing’ Aleya and then sending her elsewhere – to a hospital of which I had little, if any, evidence regarding quality of medical care doled out.

(ii) I had been unable to tell the family with any degree of confidence what Aleya’s ultimate clinical outcome would be.

(iii) Although it was serious decision making about directing outcome of a sick child, the said outcome was not really in my control.

I haven't related this narrative to anyone as yet, but since that eventful Friday the 13th it's like a film reel playing in my head, that loops back repeatedly. It’s again got me thinking about similar episodes over the past three years, since I’ve been working in Karachi, after practicing in Houston.

“Am I really impacting health outcome with any medical intervention that I perform on the sickest kids that I see in Karachi?” is what I’m really trying to address through this narrative writing, I suppose.  

At times it feels like a cross that I would rather not bear, given the huge responsibility of implementing care in the acute phase and then simply passing the patient, like a baton, to someone else, either in the same hospital or another. At other times the same events are grounding because they are unique teaching and learning moments for myself primarily – moments that I consider part of my inner journeying. These events highlight life's transience and preciousness - a constant reminder not to sweat the small stuff.

Perhaps this is my lot: trying to resolve my various conflicts - a curse of introspection?

Not all narratives can neatly achieve closure. This is one of them.

[from Narrative Medicine]

CREDITS:

Editorial Note: This is from a 'phase II' continuation of Narrative Medicine at AKU - what started as a Workshop-based initiative on January 20^th, 2016. The editorial work was performed by the Writers’ Guild, an interest group at AKU, with the purpose to promote love of reflective reading and writing, within and outside of  AKU. 

Acknowledgment: First published by the Express Tribune.        

DISCLAIMER: Copyright belongs to the author. This blog cannot be held responsible for events bearing overt resemblance to any actual occurrences.