A death at Mulago

I ran around all day drawing blood from the patients that needed labs. The hospital only had Large gloves available, which could fit hands twice the size of mine. It was quite unnerving drawing blood from ISS (code for HIV positive) patients when I couldn’t grab onto anything tightly because of my oversized gloves, but I got over it by about the eighth patient of the day. I once almost dropped a needle (once again secondary to the oversized gloves) and I caught it on my outstretched hand. I freaked out for about a second, thinking that I had pricked myself with an HIV positive blood-stained needle. I tore off my glove, and squeezed the surface of my hand – there was no blood oozing out. “I don’t feel any pain,” I remarked, “but maybe that’s my fear-fuelled adrenaline talking.” “No, you’re fine,” Dr. Wilson reassured me. I poured a ton of hand gel onto my hands and rubbed them together furiously anyways, just in case. You can never be too careful when trying to avoid contracting HIV, or worse – Hepatitis C!!! At least there’s post-exposure prophylaxis for HIV; there’s nothing of the sort for Hep C. I vowed to be much more careful when dealing with sharp objects around here.

With my new careful attention to safety details, I drew blood from a patient with suspected disseminated Kaposi sarcoma to get baseline labs (RFTs, LFTs, CBC, CD4 count, and serum CRAG; and if there are signs of liver disease and enough red tops, Hep B and Hep C titers). Dr. Wilson then proceeded to do a bedside biopsy of one of the lesions in order to get a histological diagnosis, so that we could send the patient for chemotherapy. Just as he had donned the sterile gloves, a nurse strolled up to us to tell us that she had found one of our patients with no pulse and no respirations. No pulse and no respirations!! You mean she’s dead?!! “I’ll check on her after the biopsy,” Dr. Wilson said. There weren’t enough pairs of sterile gloves for him to waste the pair he had just put on. I gave him a look of pure shock and horror. “Would you like to go check on her?” he asked me. Of course! That would be the only right thing to do! I ran to her bedside – everyone stared at me; nobody ever ran on the ward, not for any reason, so I was quite a sight, running down the corridors with my hands pressed tight against my pockets to prevent their contents from spilling out onto the floor stained with all sorts of bodily fluids infected with all sorts of pathogens.

I went straight for her carotids - no pulse. I put my fingers next to her nostrils – no respirations. I shone my penlight into her eyes – pupils were fixed and dilated. She was gone. Her eyes were wide open, staring blankly into the far-off. I wonder what her last moments on this earth were like. Did she wonder why there was nobody around her trying to resuscitate her, or had she been expecting to slip away unnoticed, with no fuss or commotion? Did she wonder where her attendants had disappeared to, abandoning her during this critical moment in her life? There was no one around to even mourn her death. This shouldn’t be. It felt unnatural. Somebody should be howling with anguish by her bedside. Death should not be an unremarkable incident. “I’m sorry we couldn’t do more,” I whispered into her ear. “Godspeed.”

This particular patient we had rounded on less than an hour ago. She had been severely tachypneic (RR 40) and we had moved her over to the “critical area” close to the nurse’s station. This was the only area on the ward where the patients could be closely monitored, due to its proximity to the nurse’s station. This means that if a patient’s condition goes south, it might get noticed sometime before the patient dies. Unfortunately for this patient, that hadn’t been the case. The other reason we had moved this patient here was because this was where the only oxygen tank on the floor resided. All patients who needed to be hooked up to oxygen had to be moved here; they all shared the same tank of oxygen, flowing at the same rate – it could not be individually adjusted. The flow rate was set at 1L/min, shared amongst 6 patients; that was barely anything at all, but they had to conserve the limited oxygen they had available.

Dr. Wilson arrived and he unhooked our patient from the oxygen. Then we pushed the patient’s bed into a side room to await transport to the morgue. As soon as we started to move the patient, another arrived to take over her “oxygen bed”. After we had transported the patient to the side room, I asked Dr. Wilson if we should pronounce the patient’s death. “No, a nurse will come by to do that,” he replied. “So we leave the patient unattended before her death has been verified and pronounced?” “Well, she’s definitely dead.” And we continued on with rounds.