Monday, January 15, 2007

A matter of conscience - Rounding with Dr. Akingbe

Dr. Akingbe can come across as stern. His black leather shoes are often covered with plastic booties, for in a pediatric ward many things are spilled, spat, dribbled, and so on, and these substances end up either on shoes or, if you wear them, plastic booties.

Dr. Akingbe always wears his white coat, which is no longer entirely white, for not all spills fall uninterrupted to the floor. His pockets contain tongue blades, a few blank green discharge forms, and a black coiled stethoscope. On the left breast of his off-white coat, there is a small beaded ornament affixed with a tarnished safety pin. The beads are tied together in rows with thread so that they create a mosaic of a red AIDS ribbon. The thread is also soiled, worn. The beads and thread curl up at the bottom.

Dr Akingbe has a mustache and expressive, worried eyes. When you look into them, you feel as if you are being asked a question, and not just any question, but a very difficult one.

Dr. Akingbe speaks with a determined voice, and speaks loudly, louder than he needs to in order to be heard. His mild Nigerian accent adds additional emphasis to his words.

His accent has echoed through Ward 8 for nearly ten years. Ward 8 is Mbabane Government Hospital’s (MGH) pediatric ward, where Dr. Akingbe cares for some of Swaziland’s sickest children. (See previous entry-"You have the wrong hospital"-for more on Ward 8).

Ward 8 is permeated by the sweet, mentholated scent of kerosene (used for scrubbing the floors) and the sweet, smoky smell of a still, warm room where dozens live and sleep. The strong smells compete with each other, and both dissolve into a thin film that coats the back of your throat if you spend more than four consecutive hours there.

Ward 8 has limited nurses, limited medicines, limited equipment, limited everything, with two exceptions—sweet, pungent odors and sick-sick-sick kids. Dr. Akingbe knows the ward's smells, diseases, and limitations as well as anybody, and he has not yet tired of talking about them.

“We are using the mother’s as nurses, but they are not!” he recently professed as we waded among the children during bedside rounds. He went on to say, “It is possible to say that a thing should be done.”

Dr. Akingbe says things like this, and when he does, everyone in the room hears him, for he speaks such words forcefully, perhaps in the hopes of being not only heard but also understood. In this case, he was advocating for the hospital kitchen to provide enough food to feed the mothers who are boarding with hospitalized children and providing round-the-clock nursing care. (At MGH, even food is limited, and current policy allocates meals to breastfeeding mothers only.)

In a loosely-organized monologue spanning the remainder of the morning consultations, Dr. Akingbe went on to say,

“If someone is incapacitated and we are here to help and we don’t help, we are saying we don’t care.”

After pausing to examine a patient and jot down a treatment plan, he continued, “It is not going to add anything to my salary; it is a matter of conscience.”

He reached into the crib of an emaciated child. After laying hands on the young, diminished body, he picked up the order sheet and asked if the child has received the required volume of high-calorie formula. Receiving unknowing glances from each of us, his eyes again became question marks, and for several seconds he peered around the room to ensure that everybody understood the obvious question. One nurse broke the silence, and in a quiet voice, said, “We will do it.”

“There is a difference between saying ‘we will do it’ and yourself doing it.”

Dr. Akimbe can come across as stern.

As if to lessen the blow, he suddenly began to describe nutrition programs in other hospitals where he has worked, describing how enjoyable it is to see children get stronger, fatter. He spoke of well-organized, well-funded malnutrition programs in Uganda and Nigeria. He spoke of effective protocols, dedicated staff, death-defying results.

“Why can’t we do the same?”

As if answering his own question, he muttered, “They didn’t get the enthusiasm in one day.” His voice was now softer, his eyes more distant.

In pediatric training, young doctors learn all about the effects of chronic severe malnutrition on a young body. Arms and legs the shape of underlying bones, inelastic skin, swollen tissues, mucous membranes fading from crimson to pink and eventually blush-white, as blood cells themselves starve to death.

We also learn about how long-term calorie deprivation can create more subtle findings, such as diminishing a child’s level of alertness. Even the strength and quality of a young voice can fade. A scream becomes a squeak, then a whisper, then, eventually, quiet ensues. Such is the famished body's last-ditch strategy to economize.

I never appreciated this fully until I began rounding at MGH. In Ward 8, wispy voices and distant eyes abound.

There are too too many hungry, frugal bodies in that place. Too many voiceless, subdued children.

After completing rounds, my colleague Nanda and I offered to help Dr Akimbe with the day’s procedures (blood draws, IV placements, etc.). He sent us to place a nasogastric tube in a three year-old. The child’s arms and legs were like bamboo. At the bedside there was a container of brown formula, similar in color to a coffee with two creams, but cooler and much more nutritious. The hospital kitchen mixes this formula, called F75, every morning.

The volume of F75 that this severely malnourished child needed to take to gain weight was large. They might as well have delivered a lumberjack breakfast, or perhaps fitted the child with a snorkel. It was a mismatch, so much so that I initially thought that the wrong container had been delivered to the bedside.

This dilapidated 3 year-old would never be able to drink enough F75 to grow. Hence, our being sent to place a feeding tube.

He coughed as the NG tube passed through his right nostril and down his esophagus. In his left nostril, another tube hissed softly with moisturized oxygen, for his lungs were also sick. How sick it is hard to say, for there is no pulse oximeter to measure blood oxygen levels in the MGH pediatric ward, and chest x-rays require the mother-turned-nurse to take the child across the hospital campus, a difficult task when portable oxygen is unavailable.

HIV in Africa is a thing without mercy.

As I tore off strips of paper tape and secured the feeding tube to the patient’s face, the child’s mother asked me how much F75 she should push through the syringe every hour. I told her, and asked the patient’s nurse to ensure that the mother understood the basic technique.

“I will do it," she told me.

After bidding a temporary farewell to Dr. Akingbe, I walked with Nanda toward the parking lot.

I looked forward to lunch, for I had not eaten breakfast, and the mild taste of petroleum and honeyed body odor lingered around my tonsils.


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