A Candid Account of Death

It’s 7:15am on Wednesday, March 14th. I just arrived at MTRH (the hospital) with my pharmacy team. Moments after sitting down to begin going through patient files and forming our game-plan for the day, a visitor calmly approaches me.

“Can you check the oxygen on my dad?” he quietly asks, motioning towards a bed about 30 feet away. Caught off guard initially, I reply “of course”, grabbing the pulse oximeter from my pocket and heading towards the patient (*a pulse oximeter is the thing you put on a patient’s finger to read oxygen saturation and heart rate). I quickly slip the tiny device on his finger and wait.

Fifteen or twenty seconds tick past – no reading. Hmm, I’m thinking, this is odd. Let me warm up his hands, you can’t get a good reading on cold fingers. I try again.

Nothing. For the first time, it occurs to me to actually look up at the patient’s face (why hadn’t I thought of this yet, silly me).

Shit. He doesn’t good look. Mouth open, eyes closed, and no noticeable air going in or out of his body. Adrenaline and fear rush through me as I quickly find Megan and Lindsey, borrowing a different pulse-ox and praying mine was faulty. I slip it upon his finger and to my relief, numbers popped up.

SpO2 – 30%; HR – 32 bpm

[For context, SpO2 (the body’s peripheral oxygen saturation) is 94%+ in healthy adults. Heart rate (HR) may be anywhere from 60-100 beats per minute in most adults; there is leeway depending on fitness level, comorbid diseases, etc.]

It doesn’t look good, but he’s alive. Thank God, he’s alive.

What happened next was what I believed to be the right thing to do. I am not ACLS (advanced cardiac life support) trained, yet. I have never responded to a patient crashing. I was scared.

I ran to the nearest nursing station (none were at ours) and explained what was happening, begging for help. They looked at me perplexed. After a minute, a nurse slowly got up and went with me to the patient. Within minutes, she began chest compressions.

Over the next 10 minutes, I tracked down one of the IU medical students, David, to help in whatever capacity he could. There was not a single physician in the wards this early in the morning. Megan helped bag the patient to get air into his lungs while Lindsey ran to various pharmacies in an adjacent building in search of medications, only to find the windows shut, doors locked, and no response to a fist rapping on the door (mind you, one of these was inpatient pharmacy supposedly open 24/7). Trying to get an extra set of hands, I approached a nearby nursing station with three nurses sitting on their phones. My request for urgent help was met with apathetic eyes and complete disinterest. So while we, a group of underexperienced students, tried to stabilize him, a crowd had gathered despite my efforts to pull curtains around his bedside for privacy.

After many more rounds of CPR and one brief stint of ROSC (return of spontaneous circulation – aka his heart was still beating and his lungs were moving air in & out), our patient’s body was far too overworked to keep fighting. He had passed away. With two of his sons at the bedside and a slowly dissipating crowd, we gently pulled the blanket over his head.

This wasn’t my first experience with death. During my critical care rotation at Eskenazi in Indy, I witnessed some pretty morbid things. But this… this was entirely different. I had my hands on this man, I felt the life in his body. And I watched as it slipped away. To be candid, too much was happening for me to process all at once, it’s still overwhelming. I try not to speculate often, but I feel pretty comfortable saying that this man would have survived had he been at a hospital in the States. Would his quality of life have been great? I do not know. To me, the point is to highlight multiple sharp contrasts in the healthcare system here. And to be fair, this story paints everything in the worst possible picture. It was a horrid morning. It is not the norm. Nonetheless, it happened.

At this point, I owe you all some background. I assumed a lot of you are curious about what life is like at the hospital. There is a reason I have kind of skated around the main reason for my being in Kenya. Before I published something about my experiences at the hospital, I wanted to gain familiarity with its systems, resources, and workflow; I needed time.

The last two weeks, I have been rounding with a medical team on the male side (the general inpatient side of the hospital, known as the ‘Nyayo wards’, are segregated by gender). Our team’s daily census, the number of people we care for, is normally somewhere between 15-25, which apparently is a significant workload reduction from the past, where teams commonly reached 30+ patients.

There are a lot of competent and dedicated healthcare workers here; nurses, pharmacists, physicians, dietitians, students… the list goes on. Currently, and unfortunately, we are experiencing a nationwide ‘physician lecturer strike’ in hospitals – meaning all physicians employed by a medical college/university that help educate students and work in public hospitals are refusing to work. The reason for this is incredibly complex and multifactorial, but essentially it boils down to the government refusing to keep their promises and improve their pay, working conditions, etc. Physicians here are not nearly as well compensated as their counterparts in the US. Like, it’s grossly different; so before jumping to conclusions, please understand this strike is not out of pure greed.

So what does this mean for me, and more importantly, what does this mean for our patients? For me, it means I have to take a bigger role on the medical team. Our team is bare, consisting of only medical officer intern (equivalent to a just-graduated , PGY-1 medical student), a clinical officer intern (equivalent to a physician’s assistant student), and us pharmacy students. Of the 5 of us, only 1 is graduated and has a degree. About twice per week (if we are lucky) a consultant (aka physician) is on rounds with us, which makes things exceedingly better. And we are the ones managing the care of the 15-25 patients I mentioned above, roughly half of whom are quite ill and would likely be in an intensive care unit if a bed were available. For our patients, it means they are often receiving sub-standard care. Aware of the this (the strike), many are waiting to come to the hospital until they are intolerably ill. But many specialists are unavailable to provide important services. It is a vicious, vicious cycle.

Here is a list of things we (pharmacy students) do each day, many of which we would not be doing as pharmacy students back home:

  • Help diagnose the patient’s problems
  • Assess the patients each morning, take vital signs, etc.
  • Recommend specific labs and other diagnostic tests
  • Determine the treatment plan for each problem (medications, dose, duration of therapy, etc)
  • Physically obtain the medications from the pharmacy and deliver to the nurses (or patients)
  • Give medications to the patient
  • Track down lab results from the various labs scattered across the hospital campus
  • Consult different specialists around the hospital
  • Talk with patients and family members about what we are doing for them
  • Bring patients food when they refuse eating what is provided by the hospital

There is a lot on everybody’s plate. Our medical officer intern has had a total of 10 days off work since May 2017. Yes, TEN. You read the correctly. That includes weekends. That includes holidays. We are pretty she is actually paying (out of her pocket) to have people help her during the week so that she is not entirely consumed by the workload. Furthermore, the resources at our disposal are astonishingly limited. The medications we have in-stock change on a daily basis. Temperatures and blood pressures are often unable to be taken due to broken thermometers and missing blood pressure cuffs. One of the students on my team didn’t even have a working pen one day.

All of this is to say that things here on the wards are difficult and often frustrating; however, at the same time, the work we are doing as student pharmacists has never been more rewarding. Without our efforts, less people would be going home. We work with a striking amount of autonomy and I am becoming more and more confident with each passing day. Two weeks in and I feel more prepared than ever to handle the workload demanded by residency programs.

The next few weeks will continue challenging me, but I am excited for it. I pray each morning as I walk to the hospital that I will never have to go through a similar experience as the story above, but the realist in me feels that might not be the case. Even as I finish typing this on Monday, another of my patients passed away over the weekend. It doesn’t get easier. Nonetheless, we will continue doing our darndest to provide care at the best of our ability, learning from our successes and mistakes along the way.

I know this wasn’t a happy-go-lucky post, but those stories don’t create the conversations that need to be had here. To those of you still reading this, thank you. Thank you for being curious about my time in Kenya. Thank you for keeping an open mind. And above all, thank you for sparing judgement. We are making the most of a difficult situation.

Onwards and upwards.