Ilula-Friends-2012: Tragedy and Pragmatism

First the mundane.

It's my birthday. I have gone from Daktari Ken to Daktari Babu in one day. Babu is Swahili for grandfather. I am likely the oldest person on the campus, not a patient. I had a great day with a little surprise party and fireowrks on a delicious banana cake. Enough said!

There is a doctor’s strike in Tanzania. Must be in Dar, since it certainly isn’t in Ilula. However, the doctors here are aware of it. The politicians are meeting with the striking docs. The docs have been warned they must report to work. Apparently not reporting for work is a serious offense. So most are reporting for work, just not working very hard. Or at least not very fast. To add perspective, the politicians get 200,000 Tsh ($115 USD) per diem for being in Dodoma. And they go out of the country for care!

Ilula is getting a “procurement specialist.” This man knows how to work the system (in a good way, as far as I understand). This could significantly help the supply chain.

Today, after lunch, I was chatting with Meg when Serena rushed in and said, “I need your help. I don’t know what to do. A set of twins was born. One is not breathing. They want me to certify death, but he has a heartbeat.”

Before I arrived, Dr. Jen Tessmer-Tuck, Ob-Gyn and Laura Melcher, Jenna and dad Dr. Dan Johnson, the ER doc, participated in a couple of failed resuscitations, which were very similar and both were twin pregnancies as well.

A few moments earlier, as Meg and I were sitting alone at lunch, we heard intermittent screaming. We wondered if it was a woman in labor. Generally, the Tanzanian women do not scream. They tap, mutter, grimace, but they don’t scream. Very stoical. I don’t think we even noticed when the screaming stopped. When Serena arrived, she told of how she had heard the screaming from the labor room and so went there. She quickly related a nice summary of the events.

The first twin was already delivered when she arrived and did make some respiratory effort. The heart rate was 120 – a little slow, but not terrible. Baby hearts almost always and readily recover if they can get oxygen. She tried to assist. No oxygen. Technically, if the baby is breathing, additional oxygen is not absolutely necessary. She tried to use the bag and mask to assist. It was way too big. These twins were probably only 32 to 34 weeks gestation. She could have intubated the infant, but there were no endotracheal tubes. She did her best. She assisted with delivery of the second twin, which did well, initially.

We hustled our way to the L&D area. The firstborn was completely covered with an orange and black kanga. When I pulled back the cloth, I found the tiny tot Serena had been working so hard to resuscitate. Indeed, he was not breathing. His eyes were closed, mouth open. His skin was translucent and pale and blue. As I put my gigantic adult stethoscope to his chest, I could not be sure if I was hearing his or my own heart beating. I used my index and long fingertips. Yes, I could feel the heart beat and Serena could see his thin chest wall move. The heart rate was 40 per minute. For just a moment, I used the two fingertips for chest compressions. The heart rate did not recover.

We expressed our sorrow to Mama who was holding the second twin, a girl, “Pole, pole sana.” We are very, very sorry.

Serena and I left the room to commiserate about this sad situation: no oxygen, no properly-sized mask or E-T tube. Also, no tiny IVs, no incubator type warmer.

The airlines now carry some rudimentary resuscitation equipment, but for many years they did not. Having the equipment carries with it obligation to have knowledge in its use. With that comes extensive training and cost.

As I think of the priorities at Ilula, I am wondering where this level of technology can fit. The equipment I mentioned above is a whole layer of technology over what Ylula has, not simply a few thousands of dollars of equipment and training away. Would this be the best place to start? No, I don’t think so. There are too many people who can benefit from much less costly, simpler interventions – like the Plumpy’Nut for malnutrition and HIV medicines. All the more reason to work hard at these things!

Serena and I went back to see the baby. The heart rate was down to a few beats a minute. We cannot be sure precisely when the baby “died.” This time it was, “Pole pole sana, mtoto na amefuka.” We are sorry, the baby has died. Biologically, he died moments after his agonal breaths truly stopped. We could not let go of the traditional heartbeat as our unfailing sign of death.

The second twin died too.