A time to mourn...

For everything there is a season, and a time for every matter under heaven:

²a time to be born, and a time to die;
a time to plant, and a time to pluck up what is planted;
³a time to kill, and a time to heal;
a time to break down, and a time to build up;
⁴a time to weep, and a time to laugh;
a time to mourn, and a time to dance;
⁵a time to throw away stones, and a time to gather stones together;
a time to embrace, and a time to refrain from embracing;
⁶a time to seek, and a time to lose;
a time to keep, and a time to throw away;
⁷a time to tear, and a time to sew;
a time to keep silence, and a time to speak;
⁸a time to love, and a time to hate;
a time for war, and a time for peace.

Ecclesiastes 3:1-8

Steve found me this morning. "I scoped your patient." The sweet little old 60-something lady, black stools, last patient yesterday. I could hear something Bad in his voice. How'd it go? "Gastric adenoCA, inoperable." He exhaled. "Soft diet, liquids, comfort measures." They'll probably go home from C ward, then. No reason to die in the hospital here: the PMV won't take a dead body and it's 125 kina to rent a vehicle to transport one home. As if dying weren't injury enough.

In the three hours I was seeing patients while my OB labored, writing scripts for plenty of PPI's (coffee seems to be a staple everywhere I go, with its attendant friend gastritis), tentatively ruling out pyloric stenosis (nobody knows if they'd recognize it on ultrasound or not) and seeing five-year-old boys who might have hepatitis, the power went out twice. Today, that was our curse - the pouring rain and gusting wind brought instability at the other end of the power train, and since the hydroelectric power for the station hasn't worked since (a) something broke in the plant and (b) the river went elsewhere during a flood, we're on city power from a long way off.

Most of those times were brief - not more than a minute or two - but this hospital doesn't have battery-backup failsafe power outlets and generators to keep the mechanisms working. When the power is out, we have nothing. No X-ray, no lab, and no oxygen concentrators in the wards. I'm not entirely certain what happens in surgery; I know I keep a flashlight in my bag any more, just in case. (An addition to my Medical Missions list: A Mini Maglite (the AA battery kind) with the LED adapter kit). And suddenly there was a knock on my door and there's a man standing there in a nursing uniform, and behind him are two girls in nursing student uniforms, and they say "We need you on A ward. Emergency."
And they ran, so I ran, and left my patients waiting. And I said "What is it?" And they told me "Baby having trouble breathing," and all of the permanent missionaries had jumped ship from clinic to go meet the American ambassador over at the new hospital, so there were only three of us volunteers running clinic, and one of them was already in the A ward pale-faced and managing the code on a baby boy.

His name is Michael. Admitted for rule-out meningitis with a tap that looked clean, chest X-ray suggestive of heart failure, on oxygen and the things that we can do here, and then the power went out and the oxygen went off, and then he just stopped. And it wasn't just trouble breathing; it was trouble living he was having.
We don't have an ICU. Or ventilators. We could maybe have found some epinephrine, it's on the code cart, and it might even be less than two years out of date, but there's only so much you can do here, and we did what we could. I pushed the nurse out of the way, I'm sorry to say, and got some actual chest compressions that actually gave the child a brachial pulse going, and they bagged and we compressed, 15:2 like the sign said, because continuous two-rescuer CPR isn't on the teaching sheet, and all the time I knew it was hopeless.
Maybe six months old, this little one, limp and lifeless, not breathing, chest silent. No pulse. Not even the sound of a heartbeat - and Jessica gave me her stethoscope, which is better than the good-enough one we found for me to use, to listen. And we tried, but there wasn't anything else we could do for him, not here. So we stopped, and we took the tape off his face, and Jessica prayed - I don't think I could have kept my voice steady; it was a good prayer. And then I helped his father wrap him in a blanket while his mother wailed and beat on the bed, and then we walked them outside.
It's been a rainy day; no different. A soft grey drizzle and we stood underneath the eaves with a bundle of dead baby covered in blankets to keep him from the cold, and his mother wailed and sobbed and I cried and Susan-the-pediatrician came and helped us with the administrative stuff, but it still amounts to having to buy a ride back home for him. And it's not fair. Not fair that babies have to die and that we can't save them.

We stayed outside for a while, away from the family, under the eaves still, Jessica and I - probably mirrors of each other, red-nosed and spike-lashed and sniffling - and we did what we do in these cases. There wasn't anything else to do. I was trying to think of drugs to give him. Maybe epi. But what are you going to do then? And I talked about the little baby with recurrent GBS meningitis and a brain like Swiss cheese in the PICU back home, and we wondered out loud whether maybe it was better like this. It's so rarely the heart in kids, anyway. If you oxygenate them and they don't come back... I know. Unless it's WPW or something. Maybe he had something like that. I'll, um...just get the peds cardiologist on that now. Put in a pacer. We laughed. It's the guilty sort of laughter that comes with knowing that you are alive and someone else is not, but all the same it's what keeps us going sometimes. A time to weep, and a time to laugh.

They told me it would happen, that babies die here, people die who wouldn't in our world of technology. And now it's real. And it's a jagged little gouge in my heart with a sweet baby face that I never saw smile. And you always wonder - why?

Requiescat in pace, Michael.