It was early morning in northern Rwanda, and the sun was just beginning to burn away the mist blanketing the yellow-green patchwork hills outside the hospital windows. I was scheduled to give a brief training on resuscitation to the nurses working in the neonatal unit of a rural, government hospital where I volunteer part of my time through the international organization Partners In Health. Five or six nurses gathered around the table where I had a low-tech, plastic simulation baby for them to practice their CPR technique. Less than 10 words into my presentation, though, another nurse rushed in to interrupt the training.
“Doctor, there is a baby… I think she is not breathing. Can we do reanimation?” he asked, using the French term for resuscitation, or CPR.
Training abandoned, the other nurses and I followed him to the patient, a five-day old girl who had been transferred to the hospital from a nearby health center. Apparently the child had been well after birth, but had developed fever and difficulty breathing the night before. I grabbed a stethoscope and listened for lung sounds and heart sounds—there were none. The baby lay still on the neonatal resuscitation table, bathed in the weak sunlight streaking in through the windows. Her limbs were cool and limp, and blood dripped from her nose and mouth. My heart sunk. Who knew how long it had been since the baby stopped breathing? It could have been any point in the hour-long trip along the bumpy dirt road that snaked around the hills between the health center and hospital.
Clinical instinct told me that this baby was already dead, and wasn’t coming back. But the nurses were all looking at me expectantly, and I decided that we had to try. I felt my heart start to beat a little faster, as it does at the start of every resuscitation I have ever participated in since medical school, but my voice was steady as I handed the nurse closest to the baby’s head the mask and bag we had been about to use for the training and instructed him to place it over the child’s nose and mouth and begin delivering breaths. I sent a second nurse to grab the oxygen concentrator machine and attach it to the bag the first nurse was holding. I had a third nurse place her two fingers in the center of the child’s small sternum and start delivering chest compressions as I counted out the time in French. Yet a fourth nurse went to grab a small device to check the child’s sugar while a fifth placed an intravenous catheter. On the surface I was calmly running through the resuscitation algorithm, making sure the nurses stayed on track, but deep down I was already mourning the small baby I had just met, and wondering how the young mother standing just a few feet away would react when we finally gave up the effort.
About ten or fifteen minutes later, while everyone else was caught up in the rhythm of the resuscitation, one of the nurses spoke up. “Doctor, I think we should stop now.” I nodded my head, thinking to myself that we had dragged this on for long enough. I was about to open my mouth to say so when the nurse added: “I think the child has a pulse now.”
At first I thought I had misunderstood him, or that he was mistaken. I felt for the small divot where the baby’s thigh met her pelvis, and sure enough there was a strong pulse. We stopped CPR and I listened to the chest with my stethoscope… a heart beat, regular and fast! A moment later I could hear breath sounds that were crackly wet but at least audible on both sides. The baby had a fever, and her stomach was distended, and there was bloody goo coming from the anus – all signs of a severe infection called necrotizing enterocolitis, or NEC – but she was alive! There were large smiles on the nurses’ faces as we gave the baby oxygen, started antibiotics, put down a tube to decompress the stomach, and, once she was stabilized, finally got back to my lecture.
It would certainly feel good to take credit for saving this child’s life, but I can’t. First, the child is quite ill, and may not survive to leave the hospital. But even if she does, it will have been chance that saved her life. Random chance that she had stopped breathing just as she reached the hospital instead of minutes or hours before; chance that I happened to be in the neonatal unit at that moment and happened to have years of experience in resuscitation as an emergency physician; chance that the entire neonatal unit staff had been there for the training, providing plenty of able hands; chance that all the many pieces of equipment we needed were available and functioning that morning, as is certainly not always the case in this setting. Had all of these random events not lined up this morning like ducks in a row, the child would surely have died.
I can’t take credit for saving the girl’s life today without taking responsibility for the man’s death last week, so I choose to do neither. Instead, I prefer to simply keep working to improve the system as a whole.
I know this, because I’ve also seen the other side of this life-or-death coin toss many times before. Just last week, while rounding with a Rwandan doctor on the inpatient ward at another hospital, one of the patients passed away while we were chatting with another man just a few beds down from him. The man who died had serious heart disease, but had been doing well when we saw him the prior day. We had begun seeing patients that morning on the far side of the large ward, three long rows of evenly lined beds away, and by the time we got to his row around noon he was already dead. Without the loud, shrill beeps and flashing of colored numbers that punctuate hospital life back home, we hadn’t noticed as his lungs filled with fluid, his breathing got faster, and the oxygen level in his blood began to fall. Nor had the patients and family members in the beds surrounding him wanted to interrupt us to let us know. We were two beds away when we finally noticed him, but by that time it was too late. Had we started our rounds on his side of the room that morning, he would have been one of the first patients seen, and we probably would have been able to intervene with some simple medications to stave off death. But by random chance, we hadn’t.
I can’t take credit for saving the girl’s life today without taking responsibility for the man’s death last week, so I choose to do neither. Instead, I prefer to simply keep working to improve the system as a whole: training more nurses and doctors, increasing the efficiency and effectiveness of care through improved triage and other basic structures, pushing for steady supplies of basic drugs and equipment, and conducting research into new methods to improve the delivery of emergency care in poor settings such as this. In the United States, we talk of a “Swiss cheese” model in healthcare. There are so many redundancies in our own system, that for a patient to suffer a bad and unexpected outcome, all of the holes must be lined up just perfectly. In most low-income countries, though, the healthcare system is like a single slice of Swiss cheese, with plenty of holes for patients to fall through. The greatest challenge in global health development remains adding enough layers of cheese—enough people, enough supplies, and enough organization—so that when a baby’s life is saved it becomes the expected outcome, and chance no longer gets to take any of the credit.
Adam Levine is an Assistant Professor of Emergency Medicine and Co-Director of the Global Emergency Medicine Fellowship at Brown University. He currently serves as the Clinical Advisor for Emergency and Trauma Care for Partners In Health/Inshuti Mu Buzima and as a member of the Emergency Response Team for International Medical Corps. His research focuses on improving the delivery of acute care in low-income countries and during humanitarian emergencies. The views expressed in this blog are his alone and do not necessarily represent the views of any of the organizations mentioned above.