Friday, January 30, 2009

Infant Emergency

Up until this moment, I thought I had seen malnourished children. I thought that I could handle sick babies, and undernourished laboring mommies. I thought that I had had all the heartbreak I could take when one of my namesakes (a twin, five months old, I think she was a Down’s syndrome baby) died last fall. My first baby death.

I was wrong.

While I was in Thies, working with Operation Smile, providing translation and logistical support to the post-op nursing staff, I had the most devastating experience to date. I almost can’t write about it to this day because it affected me so profoundly.

It was the last day that I was working with Operation Smile, during the last hour of a 13-hour shift. I was exhausted, but too excited about the work that week to notice. I had been on my feet, non-stop, barely eaten and hardly hydrated, but I was running on excitement and a love of feeling useful.

All of a sudden, one of the young Op Smile volunteers came in to get one of the nurses I was working with.

“Sandy, we need you out here quickly, a woman brought in a really sick baby.”

We rushed over. There was a Pulaar woman, sitting in a chair holding a tiny bundle. When we unfolded the layers of material, I gasped and felt dizzy and sick to my stomach.

There he was, a cleft palate, underweight (possibly even premature) 6-day-old baby boy. Not even old enough to be named yet. He was so tiny he wasn’t even the length of my forearm. All the skin on his body was peeling off in handfuls. He was lying in his own feces, with huge red, throbbing soars on his inner thighs and groin. He was so dehydrated and malnourished that he couldn’t even cry to express his distress. He was simply too weak and periodically would just make little breathy whines.

The nurses immediately took action.

Suddenly there was a flurry of activity while the three of them tried to find something to make into an infant IV. All I remember is seeing the panic stricken look on their faces and one of the nurses pleading with the surgeon in charge “If we don’t do something right now, this baby is going to die!”

Then I was sent to the storage room (the operation brought all of their own supplies) to look for an infant oxygen mask. I was thrilled to have a task, as standing there staring was totally useless.

I ran back from the storage room, mask in hand, and discovered that the surgeon had made the call to send the little guy to the local infant care wing of the hospital to be treated by Senegalese nurses. He was right, in that the operation was leaving the following day, and would have to no way to monitor him, and that ultimately, they needed to treat him locally. This of course devastated me, knowing the conditions of these hospitals. I sighed a little bit with relief though thinking that I would be able to tell myself that he’d be fine, and I wouldn’t have to get attached to this one.

Wrong again.

“Caitlin! You need to go over there. The woman who brought him in only speaks Pulaar. You need to translate.”

“Shit…I’m on it.”

I ran over there, clutching the infant oxygen mask, naively thinking it would do some good.

I arrived on the heels of the surgeon and his wife who had brought the baby to the baby ward.

It was like night and day, coming from the “little America” that Operation Smile had created in the wing the hospital relinquished to them, and going into the baby ward of the Senegalese regional hospital.

There were probably 50 women and their babies crammed into a dimly lit cement room the size of my parent’s living room. Beds were everywhere, and there were multiple mommies and babies to each bed. Women sat on the floor, leaned up against the beds, and crammed onto the few available chairs, waiting by their sick kids, looking tired, unsure, anxious, and bored.

We brought him in with a flurry of activity. Three of our local Senegalese counterparts (two doctors and one nurse) who were working with Op Smile came in to assist and help transition him over to the nurse in charge of the ward. She of course was in the break room, watching television and not attending to any of the patients. The Op Smile surgeon asked me

“How old is he?”

“Six days” I said. “He was born on Saturday.” I took a breath and asked hesitantly, “do you think he’ll be okay?”

“He won’t make it,” he said matter-of-factly.

My heart sunk. My mouth went dry. This was what it felt like.

This was what all those doctors from Drs. Without Borders and the International Red Cross went through constantly. I felt discouraged, knowing that I was letting myself get too attached, get too invested in this one life. But I was absolutely powerless to stop myself. As the nurses and doctors prepared, I leaned over him, pet his tiny head, tears streaming down my cheeks and whispered,

“Come on little baby, don’t die. You can make it. Fight for me okay? You’ve got to fight baby. Fight.”

It sounds like some cheesy line from a Hollywood film starring some gorgeous Hollywood starlette who goes to the 3rd world for the first time to “help people.” But that’s exactly what it felt like. Except that this wasn’t a movie. I couldn’t save him. In fact, I could do absolutely nothing for him. I was helpless and terrified and alone in a room full of onlookers.

Now came the horrible part.

I was already, overwhelmed, exhausted, and panicked by the state of this little guy. We shoved over another toddler to make room for him on part of one of the 1950s style hospital beds. The doctors hooked up the oxygen mask to an available tank (I was amazed that it even existed) and we tried to position it on his little face so that some of the oxygen would actually get to him. He was so tiny the plastic practically covered his entire head and face leaving huge gaps for the oxygen to diffuse into the room. Wheezing all the while in an attempt to cry, the doctors began searching for a vein on his tiny little arm.

They searched and searched.

They tied rubber strips around his arms to bring the blood to the surface. They found nothing. They pricked him repeatedly. Nothing. They tied rubber strips around his legs, hoping that his feet would be more promising. They failed. After ten minutes, they agreed to shave his head and start looking for a vein there instead. He was simply too dehydrated to administer an IV normally.

This is when I really started to lose it.

Here he was, cleft palate, malnourished, near death, lying in his own feces, premature/underweight, 6 days old, being poked and prodded repeatedly just at the off chance we might be able to save him, or at least stall death for a few precious hours. They jabbed him over and over, still nothing. He gasped in soundless protest.

A cockroach the size of his foot ran over his naked exposed sores and legs. I nearly gagged.

The nurses and doctors moved him to a countertop with “better light.” Another ten minutes went by. They shaved his head, pinched his skin, poked him with a needle, and waited for blood to show. But the second they pulled out the needle to try a new spot the blood would come rushing out. Great. He was so freaking dehydrated they wouldn’t even be able to save him from dehydration. It was sick. I was losing it.

By now tears are streaming down my face and neck. Stifling my sobs and wiping my tears and nose on my t-shirt, all eyes are on these doctors and I. The other women in the room are all mumbling sounds of sympathy and blessings, realizing how grave the situation really is, and probably feeling thankful that their babies don’t look as bad as ours. The light is so dim they can barely see. Realizing that I have my cell phone, I feel a moment of pride at my momentary usefulness and turn on its flashlight.

Finally, after about 20 minutes, success! They found a vein and they got the IV going. The two nurses moved him back to the filthy, dusty, cockroach infested bed.

The moment they put him down, the IV came out.

“NO!” I shouted.

I knew that I was being unreasonable, that they wouldn’t give up, that in this culture I shouldn’t show this much emotion, but I was too tired, and too devastated to care. I gave in to my sobs. I ran out of the room, pushing past people, blinded by my tears. I collapsed against the wall outside the entrance, trying to hide myself as much as possible behind a bench. I wanted to indulge in the wretchedness of it all. I was despondent.

I sat there and sobbed. I sobbed and sobbed. I sobbed for this little baby, for all the babies like him, for the unfairness of it all, for myself and my helplessness. I sobbed because I just needed to let it all out.

I must have sat there for a good ten minutes. With no end in sight, a Pulaar woman heard that I spoke Pulaar and she came up to me and put her arm around me. She spoke softly and slowly, but firmly to me in Pulaar. She shushed me gently. She told me that I was good, that I had a good heart, because I cared so much for this little baby, but that I was scaring everyone. She said that I was scaring the woman who had brought him (not his mother…or she lied out of embarrassment), and I was scaring everyone around me. She shushed me kindly and firmly and helped me to my feet. I don’t know why, but somehow she was able to shut me up almost immediately. I just needed a figurative slap on the face. She was right. Crying wasn’t helping anybody. I dried my now red swollen eyes, and marched back inside. I hadn’t even asked her for her name.

There he was, lying in that same spot, still in his shit covered cloths, but attached to an IV!
I was ecstatic.
The nurse came up to me, “See? We got him hooked up, it’s okay.”

I spent a few moments talking to the woman (supposedly a neighbor) who had brought him in, explaining what had happened, and why he was so sick. Now that he was “stable” I could take a few more moments to ask her some questions and chastise her/the mother a bit for waiting so long to seek medical care. They know better, and they know when their children are sick and this behavior was entirely unacceptable and that now it was too late and he would probably die. I told her that if not immediately, then in a few weeks, or months, because he would be too weak to fight off any infections or other illnesses. I was not mean, or rude, just firm and clear. I know I made her feel ashamed though. That was not my goal, but I needed her to share in my sense of urgency.

Apparently what had happened was because he was a cleft palate and lip, mom had no idea how to nurse him. Cleft palate babies can’t suckle properly and the milk just dribbles right out of their mouths if they can even manage to “latch on” well enough to express milk. Moms have to learn to squeeze their breasts and aim the milk towards the back of the baby’s throat so that it stays down.

Because the health post workers have little training and there are minimal resources, they kept shifting the mom of the baby around to different health posts. One told her to go to Dakar. She said she didn’t have the money, so she waited, went back a few days later when she still couldn’t feed him and they told her there was an American medical mission doing operations on cleft palate babies in Thies (closer to her house and much cheaper). So she came to us thinking we could “fix” him. Obviously major surgery on an infant that tiny and malnourished was impossible. She had waited until he was practically on death’s doorstep. Although I can’t imagine a feeling so awful, a large part of me thinks she was just going to let him die. She had no idea how to care for him, and had let him dehydrate for six days. In six days this little baby had probably not even had a spoonful worth of fluids each day.

When I finished speaking to her I spent a few more minutes cooing over him, pleading with him to make it, to survive. Then I found the nurse and told her to change his dressings, and warned her that I would come back to check on him in an hour.

I returned to the post-op room and cried some more to the sympathetic nurses. They hugged and consoled me, but I could tell that they were far better at not getting attached than I was. It wasn’t that they didn’t care (quite the contrary), it was just experience. They’ve been there, dealt with so much fear, anxiety, and emotion, that they were just better able to handle it.

I finished up my shift amidst more sympathetic cooing from other PCVs, patients, and nurses, and I gathered my strength for a final visit to Baby Boy.

I went into the room and the woman who brought him was nowhere to be found. There he was, his IV almost empty, still lying in his own feces. Not making breathy whine, just awake and lethargic. The nurse of course was in the break room, snacking and watching television.

I put on the best fake smile I could muster,
“Hi again. The baby’s IV is almost empty, would you come change it please? And he really needs to be changed, he’s filthy and his whole body is infected.”

She indulged me, was perfectly cheerful and got up quickly. She put up a new bottle of IV fluid and reassured me that she was going to change his cloths right away.

It was time for me to leave.

There was nothing left for me to do. I had half a mind to stay there all night, willing him to live, to fight, and to pester the nurse to care for him. I had a fight with myself. I told myself to be reasonable, that I couldn’t behave this way every time I encountered a sick baby. I told myself that it’s okay to go the distance, and I had, and that I needed leave for the sake of my mental health. The next day I had to hold a film screening in Dakar and I would have to trust that I had done everything in my power to help Baby Boy.

I kissed him on the forehead and left him a miniature stuffed koala bear (I had had attached to my jeans belt loop for ‘flare’ during the mission). I shook the hand of the woman who had brought him, and accepted her blessings. I clasped my hands together, held them up in the air (a sign of thanks when you can’t shake everyone’s hand) and said goodbye to the room. I walked out…never to see the little guy again.

I was sure he was going to die.
“Tonight, tomorrow, or next week even” I thought to myself.

I called another PCV as I walked out, sobbing again, and explained the whole story.

We were all meeting up for a fellow PCV’s birthday dinner. I knew I was going to be a downer, but that I couldn’t be alone at the training center. So I went. I was glad I did because it was the distraction, and comfort that I needed.

I also called a friend from home, wanting to hear a sympathetic unjaded voice. Even though he felt powerless to do anything to console me, I realized that sometimes you just need someone to say,
“Oh my god. That’s awful. I’m so sorry. That shouldn’t happen. I’m sorry.”
As I spoke with him, the angry phase kicked in.

“Fucking CARE damnit! Why didn’t she care? Where is her sense of urgency? What’s WRONG with people? Why wasn’t she panic-stricken and trying harder to keep her child alive? What’s wrong with her? Just…just GIVE a shit!” I swore into the phone.

I of course knew the answer to all of those questions, but sometimes you just have to let it out. I knew the lack of urgency and powerlessness stemmed from the fact that women here expect to lose children during their lifetime. They know that they have a very high chance (1 in 21 in Senegal) of dying in childbirth. (It’s about 1 in 8,000 in the USA, just to give you some basis of comparison).

Everyone else loses babies, why should this mommy be any different? It was all in God’s hands anyway right? They have to tell themselves that if God wants their baby, then he is going to take him or her. If they let themselves be inconsolable every time, people would just die of heartbreak. It’s their coping mechanism. They’re trying to survive too.

I also think that part of the apparent “lack of urgency” is that women have no reproductive rights. They have no choice in the timing, or frequency of their pregnancies. It’s taboo to use family planning and half the time they don’t get much say in who they’re married off to. They are literally baby-making receptacles.

Can you imagine? Birthing your 6th child with a man you never liked, knowing that maybe this time you will have a complicated delivery and bleed to death? I know that every mother loves her baby, but there’s got to be some kind of animosity towards the babies, and relief at not having another infant to carry on your back when your last one has just been weaned.

And that’s just healthy babies!

Imagine having a handicapped/deformed child in this society? It’s such a burden on the whole family. There are no institutions in place to help a busy, uneducated mother with 5 other children raise a special needs child like that. They certainly would never be able to afford an expensive surgery for him if it weren’t for missions like Operation Smile.

After we hung up the phone I felt a lot better.

I went back into the restaurant. We all threw back a few GnTs, shared a delicious meal and fell into bed at 10pm. As I drifted off to sleep, I reflected on the absurdity of it all. I thought about the dichotomy of being raised and ultimately going home to a world of privilege, while working in a world of destitution.

I fell into a dreamless sleep, exhausted.

The next morning I went to Dakar, and held a film screening at one of the fanciest private schools in the country, the International School of Dakar, for high school kids of the wealthy expat community. Talk about polar opposites.

When I got to Dakar I called another PCV and discovered that in fact, by some kind of miracle, Baby Boy had not died that night!

He was alive and fighting and still hooked up to an IV. I was amazed. Relieved and amazed. But I was still disappointed. I knew that the next day the mission would pull out entirely and I would never hear about Baby Boy again. I can only hope that he’ll make it. But not just survive, I hope that he survives, becomes fat, and well nourished, and doesn’t die from malaria, or an intestinal parasite, or some horrible infection. That he goes to school and lives a long and prosperous life.

The reality is that that won’t happen. Baby Boy, like millions of babies before him and after him, don’t stand a fighting chance at life and will more than likely perish before their fifth birthday.

I apologize for my frankness. I’m just being realistic.

I need to go to nursing school…


Matt said...

Cousin, we don't get to talk very often, but I wanted to say that this story makes me quite happy thinking about all the wonderful work you are doing. You truly are a light in a dark world and I am humbled by how much you care for others.

Just remember... rejoice in suffering, because suffering produces perseverance; perseverance, character; and character, hope. And hope does not disappoint.

Keep up the amazing work.

phyllis said...

Kate, I just cried when I read this post, just cried, and thought, how peaceful for that baby that you were there to share your love for him. I don't doubt that the mom loved that child with her whole being, but, my immediate thought was, she also doesn't want to see him have a lifetime of suffering and ridicule..doesn't make it right of course, to not seek treatment.. And it sounds like the dehydration and wound infections were beyond quikc treatment... scalp IV's are very common for babies, veins are very superficial, and less likely to be pulled out...
You never cease to amaze me, what a wonderful mark you are leaving on this world...
I love you so much!

Liza Sánchez said...

What an amazing story. I check back on your blog from time to time to see what you are up to. I am always amazed at the depth of the experiences you are having and the fact that you never give up but also write about them in such a clear and beautiful way. Much love, Liza