September 25, 2018
It was the end of a long Tuesday.
Tuesdays are long in general, because we run three clinics simultaneously: the usual sick line, the baby shot line, and the bel mama (expectant mother) line. On this Tuesday, Marie and I had been working together, independent of an experienced nurse for the first time. Emma was working the baby shot line, and Manandi was taking care of the bel mama clinic.
Sick line was down in numbers, which was fortunate for us. New nurses take longer with each patient, probably due to inexperience and paranoia about missing something (coupled with learning Pidgin in the process). A little after three o’clock, Marie and I were finishing cleaning up on the porch. Manandi was still checking several bel mamas in the exam room. I don’t remember what Emma was doing – probably cleaning after finishing the day’s vaccinations. Down the road, we could hear and see a crowd gathering (never a good sign). Then Anjuda, Pastor Ben’s wife, ran up the clinic steps, breathless and teary-eyed.
“They’re — they’re bringing a man in a stretcher…there was a fight…he was cut,” and she motioned a slash across her neck.
Dear God, I thought. Help. I don’t know a lot, but I know that a cut across the neck as she indicated would probably mean a severed carotid artery. If this man had sustained THAT kind of injury, he was either already dead or about to die on our porch. How far had he already been carried? When was he cut? How much blood had he lost already?
MaryBeth appeared behind Anjuda to offer help. She had heard from someone what was coming our way, and started gathering supplies with us. IV kit, suture basket, extra saline and iodine bottles, absorbent pads, pulse oximeter…
The poor unsuspecting bel mama waiting for her checkup was cleared out of the exam room, joining the audience on the porch to open space for whatever was coming up the clinic steps. The crowd surrounded the men bearing the pole on their shoulders, supporting a body wrapped in a pink sheet. As they lowered him onto the porch, my stomach churned in apprehension of what we would unwrap.
He was moaning softly. That’s good – at least he’s conscious. His neck was not bloody. So where’s the big cut? There wasn’t much blood on him or the sheet. So why is he about to die? Is there internal bleeding? Is this drama? What in the world is going on?
Marie the ER nurse slid seamlessly into incident commander mode. “You count respirations. I’ve got blood pressure. Pulse ox is 94. Somebody write this down…”
“Hemoglobin’s 11. That’s good.”
“Blood pressure – one hundred over forty.”
I tried unsuccessfully to get people to back away on the porch, then gave up and went inside to find a pillow and make sure the exam table was cleared. As soon as Marie and Emma completed the initial assessment, Manandi got the stretcher-bearers to bring the patient inside.
Pieces of the story drifted together over the next hour (and week, actually). His name was Simon. On Monday, he and another clan had disputed ownership of some ground. On Tuesday, Simon went to his garden. Nine guys from the rival clan came for him and beat him up with sticks. There was a knife involved, but fortunately he wasn’t cut severely, though he was unquestionably in pain.
3:27 P.M. – pain med administered
We started with him on the exam table, but he began to lose consciousness and then wanted to be on the floor. Okay. Whatever you want, bro. He’s shaking so badly…he must be in shock. But where’s the blood he’s lost? Transitioning to the floor, we got him wrapped up with blankets better, and that eased the shivering.
3:37 P.M. – BP 100/64, RR – 24, HR – 59
Simon’s vitals remained stable, but I expected an imminent crash anyway. I was just certain that he had lost a lot of blood, and he was about to go down. He had been beaten with sticks, and his torso was bruised on the upper left quadrant. Spleen rupture?
There were two cuts to be addressed – one on the back of his left arm, and one on his head. It was impossible to tell how bad the cut on his head was, under such thick, curly hair, matted with blood. Manandi shaved it away, with remarkable speed and dexterity, revealing a less-than-remarkable laceration that had already stopped bleeding. His head was swollen where he’d been hit. Intracranial bleeding? There HAS to be something critical here…
3:50 P.M. – BP 100/70, HR – 73, O2 – 95%
Marie started an IV. “Can you grab the 20-gauge? Thanks…Hm, he has nice veins.” (I’m sure he was proud to hear that.)
“Hey, inap yu holim dispela?” I recruited an observer (friend or family – not sure…probably some kind of family…we were down from the audience of fifty-two on the porch to only seven in the exam room) to hold the saline up for his drip, and took vitals again, adding the stats to my little 3×5 card.
Simon started shaking again, as the IV fluid entered his bloodstream. We got a pillow underneath his torso to get it off the floor, and the shaking stopped.
Once everyone was certain he was stable, the next task was determining what to do with him from there. The head trauma seemed to indicate that he should be observed overnight, which we are not able to do here at Kunai. We had given him pain relief that could have been masking the severity of his injuries, so even though he seemed alright, we couldn’t really be sure about his neurological status.
4:25 P.M. – Manandi cleans and sutures the laceration on his arm
My recollection of the conversation is unclear, but the decision was to send him to Kanabea Hospital for the night. Unsure of their supply, we packaged the meds he would need and gave them to his sister.
4:30 P.M. – Transfer to Kanabea General Hospital
Simon walked out of the clinic, which felt like a win since he had been carried in. Regrettably, he was not the least bit interested in going to Kanabea. “You fixed me. I’m a strong man. I’m going to my house.” The end.
His family said he was talking crazy. Was that from his head injury or the pain meds? No way to be sure…but he was walking down the road, arguing with his company (and the other random people who just came to watch the show. I guess there was nothing interesting on the evening news or sports channels in their huts).
I felt sick again. What if he really was critical, but we gave him too much pain medicine? What if his confidence in his ability to walk two hours home was based on the meds? What if he went home feeling fine and died in his hut from internal bleeding or swelling around his brain?
The drama after Simon left the clinic was just about as intense as the drama that preceded his arrival. He’s walking towards Kanabea, entourage in tow. He’s turned around and sauntering towards home, entourage still in tow. Everyone’s yelling. He’s going to the hospital. Now he’s going home. Now he’s going to the hospital. What is going on?!?
Should we go get the medicine back? We hadn’t given detailed instruction for the oral antibiotics, because we thought we were just sending the stuff to Kanabea. Did anybody in Simon’s crew know the amount and timing of the required dosage? Also, we had sent something for an IV or an injection (I didn’t know what…and I still don’t). That was a total waste if it went off to the bush instead of the hospital.
I walked toward the company with Linda (she works in the clinic) to at least explain to Simon’s sister, the holder of the medicine, how to take the antibiotics IF Simon ended up going home. Manandi came right behind me – good. Far better. Linda could translate my Pidgin into Kamea, but Manandi understands everything that’s happening and can just talk to whoever. She’s awesome.
After plenty of dialogue incomprehensible to me, we walked back to the clinic together, Manandi shaking her head. “These people…” You said it, not me…and they are your people, so that’s okay for you to say, I guess… “I don’t know if he’ll go to the hospital or not. He wants to go home. He says he is fine. He’ll go home and then get people and go fight back tomorrow.”
Well, that should work out beautifully…
And we cleaned up the clinic and went back to the house. The end.
Sort of.
Over dinner with MaryBeth and the kids, we reviewed the afternoon’s scenario – what we thought was happening, what actually happened, what we would do differently, what we’d do again. Did he actually need an IV? Did he actually need the pain medicine?
I realized that my initial response was an adrenaline spike and the expectation of a very critical patient. What we uncovered was less than what we expected, but my mind never came down from the expectation of imminent death. I convinced myself that since what I saw was not critical, there must be critical internal damage.
Or not. Drama happens. Maybe the patient really has a severed artery and is bleeding out. But maybe he has two small cuts and some bruises. We don’t know what we’re getting until the sheet is unwrapped.
We determined that we need to communicate better, both what we want to do for treatment and why we want to do it. We need to learn to balance a sense of urgency for patient care with an ability to pause and assess what we see. AND, we need to assess what we SEE, not what we expect to see – without losing the ability to still look for what we can’t see at the moment.
And at the end of the day, patients are autonomous. We can do everything we know to help them, but they can only get the care they decide they want. Once again, I am not God. I cannot determine the ultimate outcome for any patient. I can and will do everything in my power for their care, but I have to trust and pray where my power ends.
That has to be enough.
(PS – Simon did end up going to Kanabea overnight. He walked home on Wednesday, and was feeling well enough to gather his clansmen and go fight another round on Thursday. But that’s another story…literally.)