London, Great Britain (Fall 2013)
Patient details have been changed to protect patient confidentiality.
Once a month, the heads of service at Lulimba Hospital, in the east of the Democratic Republic of Congo, sit in the meeting room (hard wooden benches in a hut of beaten earth, roofed with plastic sheeting) to go over the statistics. This is the dry accounting of the sick who arrive at the canvas entrances to the hospital’s tented wards: discharged (cured), transferred, died, or self-discharged. The French term for self-discharge, abandon, says more than the English bureaucratese. In our pediatric tent, we had two abandons in one particular month, one while I was on the ward.
Livid flashes of lightning and kettle-drum thunder had burst over the tent earlier in the day, the mothers laughing at me as I jumped at one of the loud cracks. The emerald-green mountains above the hospital were blanketed in silver mist. Some of the mothers had opened their umbrellas inside the tent to shield their children from rainwater dripping through the roof. On my round, I had found a girl of three years who did not look right. Many of the 50 or 60 children admitted to the tent have malaria and suffer the ubiquitous asthenie physique, or malaise, that flatten these children, who, when well, run about and skip with the same energy as the kid goats that frolic on the dusty road that cuts through Lulimba. This child was too still.
I instinctively reached for the child’s foot – a quick way to screen for shock, or severe illness. The foot was icy cold. Pulling away the wet cotton wrap to cool her fever, her little chest see-sawed with severe respiratory distress, her heart batting along at an impossible rate. Lejif, one of the nurses, and I hurriedly took a two-year-old boy off our only oxygen concentrator (he was doing better after a blood transfusion to correct his severe anaemia) to give to the girl and tinkered with her medications. We had been treating her for severe malaria with anaemia and a presumed overwhelming bacterial infection. As we have very few tests, we have to go by clinical signs alone and the knowledge that many children with severe malaria are hit doubly hard by a simultaneous bacterial infection.
The girl’s eyes had rolled far back, the exhaustion in her little body struggling with all its might to drink in oxygen as the malaria and sepsis tried to drown her. The signs of impending death in a child, so rare in my work as pediatrician at home, have become tragically familiar in our tent, where we fight against what at times seem overwhelming odds: poverty, war, multiple preventable pathologies, and a lack of resources to treat some of the sickest children I have ever seen.
But after a couple of hours of treatment, the girl’s vital signs began to improve. Her heart calmed down, the frantic work of her chest eased, her legs had warmed to her ankles. The girl still had a long journey ahead of her but, as the rain on the tent slowed to a patter, I thought her condition had improved.
An hour later, Lejif came to tell me that her father wanted to leave the hospital with his daughter. We talked with the father. He sat on one of the hospital mattresses, wrapped in grubby plastic sheeting, cradling his daughter, grim-faced. He had already taken off her oxygen mask and was beckoning to have the drip removed. Lejif and I explained that his daughter was very sick but that we hoped she might have a chance of recovery after the treatment we had started. He thought for a moment and replied that he wanted to leave to take his daughter to a maison de prière, a house of prayer.
Back at home, this impasse would have triggered a platoon of nurses, doctors and if they could not stop the child from leaving, then social workers in a child protection case. But not in eastern Congo. We suggested finding a priest locally. We pointed to the outside of the tent, where it was starting to get dark and the rain had begun again, hoping in earnest that the journey back to his home town 15km away might hold the family until morning. The father, polite but determined, said he wanted to leave with his daughter. The drip was removed. The father signed a form attesting that he was leaving against medical advice. The father wrapped his daughter’s semi-conscious body in a cotton cloth, held her close to his chest under his coat, and walked out into the dusk.
I do not know how the girl’s journey ended that night. I do not know who was right, the medical team or her father. But the word abandon sounded hopelessly sad as the numbers were read out at our monthly meeting.
CHRIS BIRD, MD, is a pediatric registrar at Hillingdon Hospital in London, and was a medical officer at Lulimba Hospital in South Kivu, Democratic Republic of Congo.