Wednesday, April 18, 2007

Another dead child – A patient encounter

“The child is not breathing.”

The nurse began giving mechanical breaths by squeezing a bag attached to an airtight mask that she held firmly around the child’s mouth and nose.

“What is the blood pressure?” I asked.

“The machine is not reading it.”

“Is there a pulse?”

“We can’t feel it.”

CPR was initiated.

I probed with the IV needle on the fleshy part of the arm opposite the elbow, hoping to see a flash of blood on the other end of the needle.

The arm was cool to the touch. It was an arm of more bone than flesh, the kind of arm that you see on documentaries about famine. The diameter of the elbow was far more than that of the biceps, which sagged over the humerus like an oversized nylon tubesock.

In short, it was the arm of a dying (if not dead) child.

IV fluids, dextrose, and antibiotics were placed beside me, even though all present knew that they would do little good.

“Please get Dr. Mahuma in case I cannot get this,” I said, knowing full well that an IV was useless in the absence of a beating heart.

Still no pulse.

I finally saw a drop of blood appear and advanced the plastic portion of the IV catheter into the child’s vein. The IV dripped very slowly, suggesting that it was in the wrong place or that there was little blood flow to pull the fluid along.

I feared the latter.

Dr Mahuma, an experienced South African colleague, walked in and surveyed the child.

“This child is not with us,” she stated.

Indeed, though we were giving breaths, several attempts to find a pulse were in vain, and a series of physicians listened intently to the chest and heard nothing.

I placed my right index and middle fingers over the child’s carotid artery and felt a periodic surge of blood in my fingertips. I placed my left hand on my own neck and confirmed that I was simply feeling the beating of my own heart.

It pumped vigorously, doing its part to help resuscitate the child.

Dr. Mahuma, Dr. Eileen, and Dr. Jo were also there, doing all they could and trying to decide what to do next.

The stuporous, vital-sign-less patient had never been to our clinic. By the time she arrived, unresponsive and stale, there was nothing we could do.

As I listened carefully over her chest for sounds of life, my eyes settled on the child belly.

The skin over her stomach looked like dried fruit. Her still chest protruded violently from the sunken abdomen, and her ribcage appeared old, almost mummified. There was little tissue.

My gaze wandered up to her face. Her eyes were rolled back, the whites still shiny and bright, like two crescent moons. Her mouth was slightly agape. A ivory-colored film coated her tongue and soft palate.

The child’s final facial expression told the story of a girl that had needed help for a long long time.

Now, the lifeless eyes and mouth seemed to ask, “Why not sooner?”

After some more artificial breaths and somber discussion, we declared the child dead.

She was ten years old.


Ventilators and intensive care unit beds are rare here. End-stage AIDS is not.

It is an abyss that few escape.

This is why we strive to test and treat HIV positive children as early as we can, so that they do not show up to our clinic stagnant, cold, pulseless, breathless, skin and bones.

When a child dies from a treatable disease, leaving wrinkled, empty skin, eyes half closed and lips unnaturally parted, the question “why not sooner?” is ours to answer.

The abyss that is unnecessarily claiming so many is our problem to solve.



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