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What one can bear

Posted Feb 23 2009 7:49am
For the past week I have been assigned to the Pediatric Emergency Unit. This is the ward where children with critical conditions are admitted and stabilized before they are sent to the regular pediatric wards. Most children spend only one or two nights in this ward. There are two rooms and a total of 16 beds. Three nurses cover each shift and a team of physicians round every eight hours, assessing the patients’ conditions and adjusting their treatment plans. There are three monitors for vital signs available and about five oxygen tanks. The number of eyes and amount of attention received by each patient is significantly higher than that in a regular ward. The most common cases included: severe malaria (cerebral malaria), sickle cell patients in aplastic crises, and diarrhea and vomiting resulting in severe dehydration. Thursday when I entered the ward my eyes were drawn immediately to a boy of about 10 years old. He dug his heels into the mattress and his body arched unnaturally. His hands gripped at his chest and his eyes were wide and fearful. His mother and father moved around his bed anxiously, one sitting then the other, then standing, both directing pleading gazes at the team of doctors then at their son.

Five days previously Samuel was playing on a merry-go-round and fell off onto something which cut deeply into the meat of his heal. His parents took him to their local hospital where someone stitched the deep wound with two layers of sutures, carefully bringing severed flesh together, stopping the bleeding, then calmed the boy and his family and sent the family on their way. They returned home satisfied but after a few days his muscles began to spasm. His parents rushed them to KATH in Kumasi when he cried from the pain of the spasms and his jaw froze shut.

Samuel had developed tetanus. Spores of the tetanus bacteria are ubiquitous in the soil and were introduced into his wound by whatever object cut his foot. The anaerobic environment of the sutured wound was the perfect environment for them to grow, so they multiplied in his foot and produced a potent neurotoxin. The toxin causes severe muscle spasms which are at times are strong enough to crush vertebrae and collapse the airway. The prevention, is simply a tetanus vaccination either as part of the routine immunization schedule and/or a booster immediately after injury. Once the muscle spasms begin recovery depends on the severity of the case, the age of the patient (in general children fare better than adults), access to tetanus immune globulin, and access to a ventilator which improves survival by ensuring that the airway remains open. Muscles spasms are precipitated by minimal stimuli – noise, light, even gentle touch – so patients should ideally convalesce in a dark quiet room. Mortality can be as high as 40 percent.

When the physician cut the sutures, Samuel’s wound gaped willingly as though his flesh was making an effort to physically push the toxins out of his body. Again and again Samuel would pull his mother’s hand to his chest and she would try to soothe him by gently tapping his arm, then his back would arch and he would cry through clenched teeth. The team of doctors passionately discussing his case feet from his bed at times were sensitive to the noise level they produced and at other times talked over each other and his cries.

Two small careless moments resulted in Samuel’s agony and a fierce battle for his life. Perhaps it was a broken bottle discarded carelessly. Perhaps it was metal from the merry-go-round unattended for years and left to decay. Certainly it was just a common item without power over life. The moment of power was most likely so casual and forgettable; a simple toss of the hand. If written in front of us as part of a screen play it would only take the tip of an eraser to cancel that moment from the possibility of existence. Then later another careless moment, perhaps the doctor who sutured Samuel had a long stressful day. Perhaps there were other urgent cases waiting. Samuel says he was not given an immunization. His parents did not know to ask for one. The doctor gave them his attention, addressed the messy problem in front of him, but a fraction of attention was missing - no vaccine, no instructions to seek the vaccine elsewhere (if it was unavailable at his facility).

At the end of my shift Samuel was calm, asleep. He had been given anti-tetanus toxoid and sedatives. All the other patients had been discharged from his room. It was a rare moment of quiet and peace in the PEU. His father’s face was calm, grateful, full of love for his son. In my limited Twi I told him I would see him ochena (tomorrow). He smiled and replied in Twi that they would be there with their son tomorrow.

Friday morning the nurses in PEU told me Samuel had been transferred to one of the pediatric wards as he was no longer considered an emergent case and they wanted to find him a quiet corner to recover. I walked up to the ward where Samuel had been sent. As I walked through the ward all the parents who had met me in the PEU came forward with smiles pulling me over to see their children. I walked through two rooms and saw many smiling faces but did not see Samuel. I asked the nurse sitting in the second room and she directed me to another ward. I walked through two other wards before I returned to the first room and asked the nurses. Hoping that he was recovering in one of the small quiet side rooms behind a closed door I asked the nurse about him. But, instead of leading me to a quiet room she told me he had died during the night.

I thought of his mother and father sitting by his side, taking turns holding his hands, placing their hands on his chest where he directed them to ease the pain. I thought of the nurse who, when I asked whether she had counseled the parents about the condition said “Yes, I told them everything will be all right.” I thought of the mother standing helpless over her son while he cried and his muscles spasmed looking pleadingly at the doctors talking nearby, not realizing that they were discussing his case and his treatment and were waiting for the medication to arrive from the pharmacy. Samuel was surrounded by love. He was raised in poverty but in the midst of deep love. His death at 10 was completely preventable. His death was completely devastating for his family and all but unnoticed by the rest of us.

After witnessing such unnecessary suffering and cheap death I often think about the platitude I have heard so many times but have grown to abhor, “You are only given in this life as much as you can bear.” What does this mean? Does this mean the poor are inherently stronger? That they can bear senseless death and early death easier than the rest of us? What measure of strength is used? Does this mean that tragedy will be heaped on your shoulders until just before you can no longer pull yourself to your feet in the morning or find the energy to eat? If this is the case then let me scream to the universe that I AM WEAK. And, WHO is it that gives us our burden? the “Universe” or God presumably. But to believe in such a way is to believe in a cruel God and to arm ourselves with religion to rationalize suffering is to reduce it to a talisman against our worst fears and a basis for maintenance of the status quo.

I believe in God but not a cruel God. I believe in a God who has united us all with life and the ability to love and who leaves it mostly to us to honor, respect, and cherish the life in us and around us. The poor are not stronger, or more saintly, or more sinful. The poor are less powerful. If there is anyone portioning our burdens it is us. And, if there is any burden to be born it can only be born as a community, as a global society, not as individuals. Perhaps together we can bear and transform these burdens but they will never be transformed as long as we turn away with gratitude and relief that it was not our child who died.

How many significant moments of our lives have their roots in the smallest action or gesture? Likewise, positive or negative, we will never know what ripples the majority of our words and actions effect. The doctor who sutured Samuels wound will never know that his carelessness resulted in Samuel’s death. And, I can never have my perfect self-contained life. So let us be conscious. Let us understand that all segments and divisions are of our own making. We are woven together by life itself.

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