Drumbeats

Drumbeats

I reached down to my right front pants pocket and rubbed my pocket knife back and forth between my thumb and index finger.

‘If I drain this pleural effusion from her chest it will take the pressure off her inferior vena cava and with a few quick chest compressions, I’m positive her heart will start back up.’

Her heart had just stopped. Just now. I saw her last agonal breath and saw her pulse oximetry stop picking up.

‘No. Let her go. She’s gone. Don’t bring her back. Bring her back to what end?’

I knew he was right. He usually is. But something inside me wanted so badly to stab her in the chest. Even now tonight, I know she’d still be alive if I had. But tomorrow she might not be. In a week, probably not. My father-in-law knows. I push. He holds his ground. It goes against everything you train for as a doctor, particularly as an emergency physician, to just give up. To give up on a 17-year-old girl. But what can we really do here? We can’t save her. And he knows it. And I know it. And he does me the favor by making the decision, sternly, for me.

Months go through my mind in an instant.

My church elder and former accountant brings in his daughter with impressive left leg swelling and a bit of pain. I think blood clot, but ultrasound is normal. I think abscess, but there’s none on ultrasound and I can’t find any with a needle. So I go with cellulitis and put her on ciprofloxacin and cloxacillin maximum doses, as well as aspirin and ibuprofen maximum doses. Covering all bases. It keeps getting worse, so I go with elephantiasis, even though it doesn’t really look like it, and put her on doxycycline and ivermectin maximum doses. I treat all parasites. Still getting worse. I get Danae involved and she does a skin biopsy on the wound that finally formed. Danae sees lots of bacteria and lots of Donovan bodies and puts the patient on azithromycin. She even gets ceftriaxone for good measure. Still, the leg grows. The patient gets hospitalized.

One day the staff tell me she’s dead. I start over to the private ward to give my condolences to the family. I see the folks milling about and gawking, not unlike folks at a nascar race. I hear the familiar wailing. But then I see Ndilbe hustling her in a stretcher toward the operating room. Ndilbe quickly tells me he gave atropine and she has a heartbeat. He also tell me she hasn’t peed for the better part of a week. Oh great. She’s uremic.

In the operating room, we place a percutaneous nephrostomy tube and evacuate the urine sitting inside her kidney. We just put in a central line instead of a real nephrostomy tube. I also see that her pelvis is full and her right leg is now also edematous. We figure her infection turned into an aggressive cancer, which Donovanosis can occasionally do. I give her three grams of cyclophosphamide, a really aggressive chemotherapy dose. She’s completely unresponsive, not urinating and already required atropine. You can’t kill a dead patient, and she’s practically there.

The next day, she’s sitting up and laughing. The tumor in her pelvis is smaller. It’s unreal. A few days later, she starts urinating from her bladder, as opposed to from the tube we shoved into her kidney. I decide to repeat the dose of chemotherapy a week later. The pelvic mass disappears. Her right leg is back to completely normal. Even her left leg has returned to normal size and the wound has dried up.

But Danae and Rollin and I know this is not a cancer we can cure with chemotherapy. Sure, we may have bought her a little time, but that’s about it. I let her go home.

She comes back in Saturday night with trouble breathing. Dyspnea, hurts to breathe, tachycardia. Oxygen saturation still good, but she has that sense of impending doom. She just smells like a pulmonary embolism to me. She’s the perfect set up. Cancer patient. Immobile for a long time. Makes perfect sense. I run home to rummage through the medicine on the porch in the dark. I find enoxaparin. I run the Lovenox back over and explain to the nurse to give 1.5mg/kg/day subcutaneously. And I start aspirin and ibuprofen as well, not necessarily for any good reason.

And Sunday morning I stand beside her with my hand by my side, fondling my pocket knife and wrestling with what the right thing to do is. I had just finished rounds when I saw her struggling. Pulse ox in the 70s. No breath sounds on her right. (Why hadn’t I listened to her the night before?!?!?!) Ran for the ultrasound. Complete effusion. Stabbed her with a needle. Aspirated straw-colored fluid. All happened in a couple minutes.

Now her heart has stopped for a full minute. I have the ultrasound probe in my left hand to prove it. My right hand still has a death grip on the knife in my pocket. A quick stab to the chest is all it will take. But Rollin is right. There’s a reason she has a pleural effusion, and that reason is the cancer. A new finding despite my most aggressive chemotherapy. Our chemotherapy and nephrostomy tube bought her an extra three weeks she wouldn’t have had otherwise. What lies ahead of her are either peaceful rest in death or worsening suffering in life.

I know Rollin made the right call. I loosen my grip on the knife. I pull my hand from my pocket. I send the nurse to get her dad. I tell her dad she’s dead.

I drive the family home and sit under a makeshift thatch hangar while watching the women of the family wash and prepare the body for burial. Then I drive the body to the church. I sit by myself, the only foreigner in the church, while the congregation sings in French and Nangere. And I weep. I see the mothers and sisters and friends come in. I see the father stay strong. I see the choir members plucking up their courage and singing for their lost friend, a fellow choir member just a few hours prior, who’s voice will never again be heard on this earth. I hear the elders tell the family not to cry. It’s a sign of lack of faith in Christ’s return and ingratitude if you shed a tear. In the corner at the only Tchadian event I could ever go unnoticed at, a funeral, I weep still more.

J’entends ta douce voix,
Jésus, je viens à toi.
Je viens, ô Sauveur, lave-moi
Dans le sang de ta Croix!

Jésus, Roi des rois,
Qui mourus pour moi,
Je veux mourir avec toi,
Avec toi sur la croix.

J’entends ta douce voix,
Qui me dit : ‘Crois en moi!’
Je crois, Seigneur, soutiens ma foi,
Tiens-moi près de ta croix.

Jésus, Roi des rois,
Qui mourus pour moi,
Je veux mourir avec toi,
Avec toi sur la croix.

J’entends ta douce voix,
Elle pénètre en moi
Et me dit d’aimer comme toi
De l’amour de la Croix!

Jésus, Roi des rois,
Qui mourus pour moi,
Je veux mourir avec toi,
Avec toi sur la croix.

J’entends ta douce voix,
Toi qui mourus pour moi.
Seigneur, que je m’unisse à toi
Dans ta mort, par la foi!

Jésus, Roi des rois,
Qui mourus pour moi,
Je veux mourir avec toi,
Avec toi sur la croix.

I hear Your soft voice,
Jesus, I’m coming to You.
I’m coming, oh Savior, wash me
In the blood of the cross.

Jesus, King of kings,
Who died for me,
I want to die with You,
With You on the cross.

I hear Your soft voice,
Which tells me: ‘Believe in me!’
I believe, Lord, sustain my faith,
Hold me near to You.

Jesus, King of kings,
Who died for me,
I want to die with You,
With You on the cross.

I hear Your soft voice,
It penetrates me
And tells me to love as You
From the love of the Cross!

Jesus, King of kings,
Who died for me,
I want to die with You,
With You on the cross.

I hear Your soft voice,
You who died for me.
Lord, that I be united with You
In Your death, by faith!

Jesus, King of kings,
Who died for me,
I want to die with You,
With You on the cross.

Mon Dieu, plus près de toi,
Plus près de toi!
C’est le mot de ma foi :
Plus près de toi!
Dans le jour où l’épreuve
Déborde comme un fleuve,
Garde-moi près de toi,
Plus près de toi.

Plus près de toi, Seigneur
Plus près de toi!
Tiens-moi dans ma douleur
Tout près de toi!
Alors que la souffrance
Fait son oeuvre en silence
Toujours plus près de toi,
Seigneur, tiens-moi.

Plus près de toi, toujours
Plus près de toi!
Donne-moi ton secours
Soutiens me foi!
Que Satan se déchaîne
Ton amour me ramène
Toujours plus près de toi,
Plus près de toi.

Mon Dieu, plus près de toi,
Dans le désert!
J’ai vu, plus près de toi
Ton ciel ouvert!
Pèlerin, bon courage!
Ton chant brave l’orage.
Mon Dieu, plus près de toi,
Plus près de toi.

My God, nearer to Thee,
Nearer to Thee!
It’s the word of my faith:
Nearer to Thee!
In the day or in the trial
Overflowing as a river,
Keep me near to Thee
Nearer to Thee.

Nearer to Thee, Lord
Nearer to Thee
Hold me in my pain
Right next to Thee!
Even when suffering
Labors in silence
Always nearer to Thee,
Lord, hold me.

Nearer to Thee, always
Nearer to Thee!
Give me Your relief
Sustain my faith!
When Satan unleashes himself
Your love brings me back
Always nearer to Thee,
Nearer to Thee.

My God, nearer to Thee,
In the desert!
I have seen, nearer to Thee
Your heavens opened!
Pilgrim, take courage!
Your song braves the tempest.
My God, nearer to Thee,
Nearer to Thee.

From the church, it’s another drive out to where she will be buried. Men have been hard at work chiseling at the dry earth six feet down. It’s much easier in rainy season. After being warned of the chastisement to follow, should there be excessive weeping, the pathfinders sing. Her nearest friend starts, solo and a cappella, brave voice quivering. Gradually her friends follow suit, joining her, a cacophony of teenage sorrow, genuine and profound, but doing the memory of their friend a grave justice and they hold it together, tears streaming from their faces. Grown men all around me, we tremble and shake and shame our cheeks with tears of our own, feeling the pain for our loss, but feeling so much more the palpable and heavy pain of the youth having to sing for, and then bury, one of their own.

She is lowered into the ground. The first handful of dirt tarnishes the white drape. There are a few more handfuls. And then the shovels come out. Shovel after shovel, the men work at a torrid pace, slinging the dry earth and heaving a thick cloud of dust into the hot January air. The dust dries the tears to the face. The frenetic shoveling has filled in six feet of hole in a matter of a couple minutes. The dirt is now piled high and the men walk around the hole counterclockwise, smashing the dirt down with the blades of the shovels. She is buried. I drive the family home.

Tonight I will hear the heartbeat of Africa continue on in the mourning of the drums. They beat regularly here. They typically don’t bother me. I may wake up and hear them, and then go right back to sleep.

But tonight it is different. It is my 17-year-old patient, daughter of my elder and friend. I will hear them. They will keep me up. My right hand reaches instinctively back into my front pants pocket. The knife hasn’t left the pocket all day. I reluctantly pull it out and toss it into its drawer. While my head knows her earthly life had nothing but suffering ahead of her, and that we made the right decision to let her go, and that my father-in-law did me a favor making a very wise decision so I wouldn’t have to, my heart will always wonder… And tonight I will hear the drums.