Anger

I've experienced a large variety of emotions here in Namibia. Sadness, discouragement, happiness, gratefulness, and sorrow. But today, I experienced anger. In fact, I was furious. I entered rounds today, to find the team discussing a 1 month-old infant who was lying crying in his crib. The first thing that caught my eye was the WBC of 49k with a left shift. The child had been admitted the night before by the on-call intern. The same intern rotating on the ward with me these past two weeks. The infant had been admitted for pneumonia, a diagnosis often used by the interns when they are unsure of the diagnosis but think the child may be sick.

The medical officer was busy saying that we should get a urine culture and lumbar puncture to be complete. I decided to examine the infant at that time, who had continued crying throughout this conversation. Fontanelle soft and flat, lungs clear, heart mildy tachycardic but no murmur, abdomen rigid. No bowel sounds. Distended. Hard. Had anyone examined this child?? I mentioned my exam findings to the medical officer who said, "Yes, we're going to obtain an abdominal series". I pointed out that I think we had our source of infection.

We finally agreed on a plan. Abdominal films as soon as possible. Addition of metronidazole. Follow up. I mentioned that the baby seemed to be in quite a bit of pain. Could we add morphine? I was told morphine is a strong drug. I said this baby needs a strong drug. A one-time dose was written at the lowest starting dose recommended. I asked for Q 1-2 hour dosing. I got QID. Luckily, the decided-on dose was too small to measure, so we gave the higher dose I requested. Unfortunately, we all know the half-life of morphine is a tad bit less than 6 hours.

We continued to round in the room the baby was in. During that entire time, roughly an hour, the baby continued to whimper with periods of intense crying out. No one seemed concerned. No one seemed to be in a hurry to get the morphine. It took 3 reminders and almost 2 hours to get the infant his medicine. I suspect the baby cried out like this the entire night without anyone showing a hint of worry.

The ridiculousness of the situation continued when after about 3 hours the films finally came back and clearly showed stacks of small bowel loops and air-fluid levels as well as questionable free-air. When the medical officer called the surgeon, he said, "we suspect obstruction". Suspect?? It looked pretty clear to me! He continued on, "the baby has bowel sounds and the belly is somewhat firm but soft". Bowel sounds? Soft?? Fortunately, the bile-stained NG outs were enough to convince the surgeon to come by. A pleasant surprise. Unfortunately, he wouldn't be by until after his next surgery.

I'm not sure what will happen to this baby. I'm just so incredibly angry about the entire situation. Starting with, and especially with, the intern who very clearly missed the diagnosis. With the nightly nursing staff who allowed that infant to cry out in pain all night long without questioning or calling a physician. With the medical officer who didn't seem to identify the diagnosis either and who did not grasp the severity of the situation. With the day-shift nursing staff who did not seem to notice or care that the infant was crying out in pain and took hours to get the baby pain medication. With the medical officer, again, for not conveying to the surgeon the critical nature of the infant or even the correct physical exam findings. This infant may die because of everyone's negligence and apparent lack of caring. So much of the death I've seen here is preventible, and that's enough to make anyone angry.