Today was a busy day.
We have twenty new third year medical students, ten new interns, seven new Masters level postgraduates, as well as all our continuing postgraduates from last year. But the main circumstance that made my day busy was not teaching. It was trying to care of a 23 year old girl with sudden severe illness.
She had been admitted two weeks ago and I had seen her then. A thin slip of a girl, still smiling through her laboured breathing, in florid heart failure from severe anaemia. We had treated her heart failure, arranged several gradual blood transfusions, and she looked to be on the road to recovery.
Over the weekend that all changed.
By Monday she was sicker than she’d ever looked, neck veins bulging with extra fluid, half conscious as she puffed and panted away. We did what we could; the hospital had no ampoules of diuretic medicine to remove the excess fluid so we improvised, borrowing some from other patients and those left by discharged patients. I was hopeful but worried; why had she deteriorated so far so fast? Her mother, a weary middle aged woman with eyes that had seen too much death and misery, rearranged the pillows with resignation.
At nine that night her blood results came and with it a diagnosis; kidney failure, cause uncertain. Her kidneys had worked when she reached the hospital but that was changing fast for some reason. By next morning she had made no urine at all. In the midst of teaching and wading through scores of students, I tried to make a plan. I did a quick ultrasound to ensure no blockages in her waterworks, gave calcium and insulin to reduce the danger from her high blood potassium, and prescribed urgent dialysis to remove the fluid and excess minerals that were poisoning her.
In theory, we are a major dialysis centre taking referrals from across the country. In practice, supplies and equipment are difficult to obtain and bureaucratic processes too slow for many of our patients’ needs. Today, it was more complicated than ever. We had only 2 of the single use lines for the dialysis machines left, and another patient with severe renal failure after a difficult Caesarean section was already assigned these. I negotiated, I cajoled, I rang senior administrators. Finally an agreement: one for each patient then an urgent request to our sister hospital in Kigali to lend us some more.
I revisited the patient: still alive, just. Then home for a Kinyarwanda class and lunchtime and back to the hospital for an afternoon’s teaching to fifteen undergraduates. In the midst of this, I was asked to sign her dialysis approval letter, surely a good sign?
As soon as teaching was finished I made a beeline through the rain to the ward. She must have had dialysis by now. All had approved, everyone had been convinced or coerced, at the very least I could pray for her and her family that she might live the long night before a morning transfer to Kigali….
A roll of sticking plaster. Balls of cotton wool. New clothes. The accessories of death.
Her mouth taped shut, her eyes and nose blocked against the world that could no longer disappoint her, her tatty T shirt removed and replaced with a fine new one. The rituals of death, performed by a resigned by kindly mother with all-knowing eyes.
It had been water in the end, I discovered as I trudged home through deepening mud and rain. No water from the mains this afternoon. A minor inconvenience at home necessitating the use of jerry cans. Such a simple thing, but no water means no dialysis, and for her time had run out. I prayed for her anyway, and for her mother, and debriefed the fresh intern who had done his best for her all day. Rain hid any chance of detectable tears.
