Undesirable Outcomes

Fuck. Our patient died in the night. And rather than keep referring to her as our patient, her name was Amilouise, pronounced like Emmy Lou. The plan was to take her to the hospital 4 hours away at 6 AM when the first truck would leave Ranquitte in the direction of the hospital. The journey would not have been easy. Especially for someone who was in too much pain to roll over on her own. But it turned out to be something she would never have to endure.

This is the last photo taken of her alive. Only now can I see how it foreshadowed what was to come. The look of concern on Pam’s face and the posture of resignation in Amilouise hint at what we now know to be true but tried to prevent. I can’t decide if it’s in poor taste to make this photo public. I’m not trying to sensationalize her death. I’m only trying to humanize her, make her something more than words on a computer screen. She was a normal teenager with hopes and dreams. And then something unfortunate befell her. And no one was able to help her, try as they might or wish as they did. And so she had to face the transition of death earlier than any of us would hope for anyone. Even though her appearance and circumstances are probably about as far from yours as can be, there is something of her in you and you in her. Think about it for a moment and you’ll find it.

The money that was put together to send her to the hospital for treatment was instead used for her funeral. This is in line with one of the primary objectives of this mission, to instill dignity in the community. The manner in which death is treated is an important part of finding closure. And even though we ultimately failed in saving the life of Amilouise, we tried until the end. This also helps with closure for the family that remains, knowing that everything that could have been tried, was. At least I hope so. Or maybe I’m just rationalizing my disappointment.

There was more to this whole thing than I was able to convey in my quick blog posts. But here, I will try to give a more complete picture of the challenges we faced.

15 year old Amilouise came into the clinic 3 days before her death. She was breathing more than twice as fast as a normal with crackling lung sounds in 60% of her left lung. And her left knee was 22 inches around and hot as hell. Regardless of any other underlying pathologies, she was headed toward sepsis, a systemic infection which eventually shuts down all the organ systems one by one. The first report we received was that this had started about a year ago and grew to its current state rapidly. Later, we were told that it may have been progressing for more than 2 years. This is common in Haiti. Time seems to be mutable. Patients often report numbers at random. That seems crazy to schedule obsessed Americans, difficult to comprehend. But times of onset, a very important diagnostic fact, are reported at random. Ask someone three times and get three different answers. Sometime in the past few months, they had gone to the state hospital. It is still unclear why they didn’t receive treatment. But hearsay reports anything from “they didn’t get treatment because they were poor” to “her knee didn’t look as bad as it does now.” This only served to further convolute diagnostic accuracy. We don’t have imaging equipment and no one had any definitive information. So it could have been a lot of things. Septic arthritis with pneumonia. Osteosarcoma that had metastasized to the lungs. Or any combination thereof. But the infection was clear and obvious. And it was the thing that would kill her. And it was the thing that could be treated. So a plan was made and we hoped for the best.

The best is not what we got. She seemed to get better in spirit. But maybe that was due to the effect of having the group of us join her in her fight. Her physical condition was the same on the second day. As advanced as it was by the time we initiated treatment, this was to be expected. She made her way to the clinic for us to check on her. And we all invested a little more emotionally in her survival, as she was so pleasant despite her state. That’s how everyone is here, though. They are stoic. The thing causing them the most pain will be the fourth complaint in their list. And they’ll undergo injections and minor procedures without flinching. I scrubbed, fucking scrubbed the burns of a 5 year old and all she offered was a concerned look. Not a single tear. She smiled hugely as she climbed on to her mom’s back with fresh dressings. It is this quality that gave us hope for Amilouise. People here suffer silently and they fight intensely, somehow also without making much noise. After her second day checkup, she went on her way.

On the third day, she didn’t come to clinic. So we asked around. It’s a small community. Only 10,000 people. And someone always knows someone. It was less than 15 minutes before we found out where she lived. And it was close. One of the PAs and I put together a treatment bag and headed out. A few minutes later we were at her dirt mound doorstep. We walked into a 160 sq. ft. house and were greeted by her 3 year old brother and mother. We saw Amilouise laying on her bed, still breathing way too fast. She was on a raised bed, where the rest in the house were on the floor and she had a bowl which she used for her waste and the vomit she had began to produce the night prior. We asked through a translator why she didn’t come to clinic today and she told us that the pain was getting worse. Too bad for her to walk. So we treated her and headed back to the clinic to figure out what was next.

There was no debate, given her decline, that we needed to get her to a place where she could be monitored. In the US she would have been in ICU long ago. This disease (and most of the diseases in Haiti) would have never been allowed to progress to this point. We put the money together, arranged for a translator to accompany her and her mother to the hospital so that they got there safely and we had a point of contact for updates on her condition. It was evening already and as I mentioned, the next truck was in the morning.

It was a trip she would never make. She died in the night. Probably of respiratory failure. We will never know for sure. Her suffering is over. And her family’s suffering can begin to head in the direction of being over. Her mom said a voodoo priest had cursed her through this child. So the mother never expected her to make it. I remember when we first saw her one of the PAs was telling her mother how important it was to treat this aggressively, as she could lose her leg or her life. As the translator was relaying this message to the mother I was watching Amilouise’s face. It didn’t change.

I’m wrestling with the same questions everybody is. I’m confident that we did everything we could given the resources available to us. Our team is composed of talented, dedicated people. The real question weighing on my mind is this…

Was there anything that could have been done to save this girl?

They don’t do autopsies around these parts. And Amilouise is in the ground. So I’m going to have to find a way to come to terms with this one question remaining unanswered until I’m in the ground as well.

But I (and probably everyone else on this medical team) always approach these situations as if the answer to that question is yes (although reversing voodoo is something I have no idea how to do). But I’m purposely naive. It’s that naiveté that probably drives many of us here. Fighting battles that seem impossible. And it’s that same naiveté that every once in awhile, wins an impossible battle. I’m in it for those once-in-a-whiles. Knowing this doesn’t make the losses any easier to deal with. Regardless, they have to be dealt with efficiently. Because tomorrow is another day, and another battle may present itself. Like a 2 year old with severe malnutrition and pneumonia. And 2 severe burn patients. And a giant abscess. And cellulitis. And 270 other patients. And a torrential downpour. That all happened today.

St. Naiveté, carry us through. Good medicine and good luck, do your part as well.