5 Lives

Rounds on the ward last week:
Wednesday. First patient- routine patient with fibroids and heavy bleeding: plan for hysterectomy. Second patient, gasping for breath. So many people here die gasping for breath. KCMC hospital is the referral hospital for 11 million people, so the hardest, most desperate patient cases end up here. Gasping for breath leads to miserable deaths. Air hunger, dyspnea, shortness of breath, respiratory fatigue.....little relief for them when there is only one ventilator available in the hospital for non-surgical patients, no morphine. She had been admitted that morning at 26 weeks pregnant with shortness of breath. Known HIV positive patient on antiretrovirals, still a very young woman. Oxygen saturation low (56%) pulse high (160). Suspected PCP pneumonia, but no prior xray and no blood work. Lungs sounded horrible. Declined admission in the ICU as there were no beds, at least no beds for an HIV positive person at that time. Quick bedside ultrasound: Twins at 26 weeks, looked normal- surprising that they were moving with such a low maternal oxygen saturation. Perhaps in the last agonizing throws themselves. The patient received oxygen, antibiotics, lasix just in case, steroids. She looked a bit more comfortable with slightly rising oxygen levels. On to the rest of the patients and plan to check on her in 10 min. The next room, second patient collapses and is not breathing. Pulse 50's . Pupils fixed. Oxygen level 65%. Blood pressure normal. Her neighbor tells us she had a severe headache that morning with a stiff neck and fever. We start A,B,C's (airway, breathing, circulation)......IV.....O2....Bag mask ventilation and a call for anesthesia. Reviewing the record, she had been treated for malaria for the last 10 days at an outside facility. 25 weeks pregnant, single fetus. Live. After a few minutes of bag mask, she breathed a little on her own , but not normally. Anesthesia intubated her and took her to the ICU and she was able to get the one ventilator overnight. As the second patient was being intubated, the first stopped breathing as well and rapidly progressed to pulselessness. A,B,C's, Bag Mask ventilation, CPR, No defibrillator.....15 minutes of CPR, Epinephrine and Atropine, no response, pronounced dead at 11:15.
Back to the ICU: The second patient had normal oxygenation on the ventilator but showed signs of brain death so was extubated and died in the morning. The neurologist said it was likely a subarachnoid hemorrhage.

Justice is the ethical principle that ethical theories should prescribe actions that are fair to those involved. Most commonly in medicine we speak about justice when it comes to allocation of resources. For instance, it is unfair for the rich to have access to life saving drugs or technology in the USA when the poor do not. Or, questioning whether it is ethical to spend 2 million dollars saving one person when 100 die for lack of immunizations that could have been saved with that 2 million dollars. The two cases above are not about our commonly applied notions of justice because justice is most commonly applied and described within the boundaries of a country or a state, sometimes ethnicity or religion or another possibly arbitrary boundary or group identity depending on where you live and what your leaders believe. That is: it is ok to withhold the treatment for X condition for the person in Juarez Mexico, but in El Paso, Texas it would be unthinkable if not illegal even though I could have a conversation with my Mexican neighbor from my back porch in El Paso.
I called out to the residents and nurses for many things when we were handling the above two patients. The one thing I did not call for when these women were dying was a scalpel. I like calling for the scalpel. It usually means some solution to the problem is coming. Typical surgeon. In the US, with these patients, it would have been near the top of the list. Airway, breathing, circulation, scalpel........ Get the babies out fast. For each passing second of cardiac arrest, the baby has a smaller chance of survival. In fact, you even help the woman by removing the baby quickly to facilitate CPR. I didn't call for the scalpel because I knew these babies would not, could not survive here in Moshi and the chances for the mother were dismal either way. There are no ventilators for babies, no NICU, no surfactant, no neonatologist. So, 5 lives, 5 deaths. 2 mothers 3 fetuses- minutes from being babies. Fetuses in Tanzania. Babies in the USA. No overlapping circles of justice.