Medical

Reflections On An Encounter During My Elective in Vanuatu

Despite being on the top of a hill, the hospital was remarkably unimposing and unimpressive: just one floor high and composed largely of corrugated iron and brick. It consisted of a handful of wards, an A and E “department” and a few small rooms to see outpatients in. It contained several courtyards. Outdoor corridors connected the different wards. The courtyards and corridors were lined by people, patients, families and extended families. Mothers breastfed, children ran around playing games, other adults dished out food or did their washing in a nearby sink in the grounds, whilst some simply sat. By contrast the hospital wards were quite empty—only a few inpatients in each of the four specialities (pediatrics, general medicine, general surgery, and obstetrics and gynaecology). Many of the rooms in the wards were empty. Faded, once-colourful, patterned curtains hang limply. Paint flaked, and biblical quotes peeled off the dirt-washed walls. In the stifling heat even the ceiling fans seemed to be taking a siesta. The hospital was basic to say the least: there were no computers, no observation machines and I had little confidence in when the bed sheets were last changed. Instead a manual blood pressure cuff lay dusty in the corner of the cupboard, adult oxygen saturation probes were clamped onto children’s feet and thermometers were used from patient to patient without cleaning. Inhaler spacers were replaced by plastic bottles with a hole cut in the bottom. Ventilators were replaced by a dedicated doctor bagging the patient throughout the whole operation. Intensive care simply did not exist.
On my first day in the hospital, my first day on pediatrics, my first day in Vanuatu, I met a little boy and his family. He was two years old. He had been admitted several days before with meningitis. In a coma, he lay perfectly still, except for the rhythmic rise and fall of his chest. His eyes were closed, his pupils unequal. Lines and oxygen tubing seemingly dwarfed him. In the side room his parents sat on the bed next to him, while his younger sister scampered over them. His parents smiled and nodded at us. They sat there quietly content, seemingly ignorant of the seriousness of the situation. We conducted the ‘ward round’ led by a Cuban pediatric registrar. As an afterthought a few words were muttered to the parents, words so insignificant in the situation that I cannot remember them. A jarring of languages and cultures had occurred, his limited English and their Bislama had meant that the doctor did not even know how to begin to breach the delicate subject. And so they were left with their blissful but misplaced confidence that everything would be alright.
The next day we went through the same rigmarole: there was no change in the little boy’s condition, and again there was no meaningful discussion with the family. We had just finished the ward round and were sitting in the doctor’s office when one of the nurses gestured for the doctor to come over. There was no urgency or concern in her expression, and so the other medical student and I assumed that it was just a routine question over the translation into Bislama or the drug chart. I waited in the doctors’ office for ten minutes, before wandering out of the office to find out where the doctor had gone. It was then that I saw through the ajar door the doctor and nurse huddled round the little boy. I apprehensively went in. The two year old boy was unresponsive. His eyes were closed. This time his chest was hardly moving. He stopped breathing. Just as I thought that would be the end, his head bobbed up and his throat bulged as he gasped for breath. This cycle of not breathing and then gasping continued. The adult saturation probe was clamped on his doll-sized foot: it read 44%. The doctor started bagging him. The pitch of the beep from the probe increased as the doctor bagged him. He continued until the saturation reached 100%. Then he stopped. The sats immediately started falling and the infrequent breaths and gasps for life resumed. I looked at the parents who were watching from the neighbouring bed. They still had no idea. Nobody had said anything to them. And there they were, watching their only son making agonising gasps as he clung on to life. When the sats dropped to about 50%, the doctor re-started bagging the boy. Again getting the sats up to 100% before stopping: again watching the sats plummet. This cycle continued; only interrupted by the harrowing gurgling noise the boy made as he aspirated and the noise of the suction removing the vomit from his mouth. I again looked up at the parents, this time desperately trying to convey the gravity of the situation with my eyes. They just smiled back. I turned away. The bagging-watching cycle was continuing, but to no avail. To say the situation was bleak doesn’t do it justice; even if the child survived, the chance of him surviving the whole of this illness or of regaining any type of functioning was near impossible. The child urinated and defaecated, filling the nappy and overflowing out onto the sheet. And with that I knew that the situation had gone from near impossible to just plain impossible. I again looked over to the parents, but they were oblivious, if anything they were pleased about the recent development. I had to look away. I swallowed hard.
It was after about half an hour of the repetitive bagging-waiting cycle that the parents began to look slightly concerned. The father stood over the bed with his son on, while the mother sat upright on the neighbouring bed. Somehow in a small room full of people, they were completely alone. I gave her an empathetic smile, which she acknowledged. I so wanted to give her a hug and tell her how sorry I was, but the language barrier and my cultural ignorance held me back. After about 5 minutes I plucked up the courage and put my arm round her—as much for my benefit as hers. I studied her reaction to this physical contact; she didn’t flinch, but she didn’t noticeably warm to it either. After a couple of minutes I resumed my position around the bed.
In the next few minutes, the whole atmosphere changed. The doctor was now also giving the family empathetic looks. The mother curled up on the other bed and began to cry. The father walked out to collect their washing from the washing line. Still the doctor continued the futile bagging-waiting cycle. After an hour he turned to the parents and simply said gesturing to his own head. “Brain dead. Can’t do anything. Sorry. Brain dead.” He shrugged his shoulders and walked out of the room. I pleaded with my face and eyes to show the family the sorrow and sympathy I wished to express, but lacked the linguistic skills to do so. I managed a “sorry” and a heartfelt smile, but wished I could do more. I walked out of the room. I could hear the mother wail. She was joined by members of their extended family, and soon the room was filled with people wailing and writhing around. The wailing, a mix of screaming, sobbing and half singing, filled the ward and echoed down the corridors. In between the wails a deafening silence engulfed the hospital. And so in the next room the doctor and I started the baby checks. With a forced swallow and a few blinks we continued our day, something that small boy and family were unable to do.

E
Emma Cox was born in Hampshire, England. She did the first three years of her Medicine degree at Cambridge University, graduating with a Natural Scien...