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Well by Sarah Thebarge

Healing Our Beautiful, Broken World from a Hospital in West Africa

Intro:

At 10 a.m. at a hospital in rural Togo, West Africa, I stood at the bedside of a forty-year-old man who had come in the night before with altered mental status — he was confused, he couldn’t walk in a straight line, and his family said the man’s level of alertness had waxed and waned over the past few days.

The hospital didn’t have a CT scanner or an MRI, so the doctor had to make her diagnosis based on a few blood tests and a physical exam.

Soon a diagnosis emerged. His HIV test was positive. He was running a fever. His neurological exam showed he had increased pressure inside his head, which indicated he likely had a brain infection because of his weakened immune system.

Within an hour of arriving at the hospital, his condition worsened. He needed a hole drilled in his skull to release the pressure or else, in a matter of minutes, his brain stem would herniate through the hole in the back of his skull, where the brain meets the spine, and he would die.

The doctor paged the surgeon, who ran to the hospital and rushed the man to the OR. As soon as the surgeon drilled a hole in the man’s skull, copious amounts of clumped white fluid started pouring out. Like cottage cheese, the surgeon said later. In my ten years of working as a physician assistant, I had never heard of anything like that. Clumped white fluid that looked like cottage cheese pouring out of someone’s brain.

The hospital didn’t have a microbiology lab to identify the pathogen that was causing the brain infection, but the doctors concluded that the man likely not only was HIV-positive, but also had end-stage AIDS and, because his immune system was almost nonexistent, had contracted a rare fungal infection called cryptococcus.

The patient came out of surgery with white gauze wrapped around his head, like a soldier from the Revolutionary War. His bed was propped up at a forty-five-degree angle to keep the pressure off his brain. The doctor ordered every antibiotic she could think of, as well as two medications to decrease the pressure in his brain. But the hospital pharmacy didn’t have the anti-fungal medications needed to treat cryptococcus.

The following morning, I reported to the hospital to work my twenty-eight- hour shift. I arrived at 7 a.m. and wouldn’t be off until 11 a.m. the next day.

I stood at the man’s bedside during rounds, where the doctor who’d worked the night before, as well as the surgeon who had performed the operation, summarized the patient’s clinical course to me and the doctor I was working with that day.

The anesthesia had had plenty of time to wear off, but the man still hadn’t woken up.

When we finished rounding on the other patients, I came back to the man’s bedside and studied the monitor above his head. His blood pressure was high and his pulse was low, indicating there was still too much pressure on his brain. But there was nothing else we could do.

The doctor I was working with took the man’s two brothers to a quiet room around the corner and explained in French that the man was HIV- positive — which no one had known until then — and had a dangerous infection. She told the brothers that we’d tried everything we could, but the man hadn’t woken up from surgery, and his condition was worsening.

“We’re probably going to lose him,” she said.

The older brother, six inches taller than the younger, brushed a tear away from his eye and nodded. When they returned, the brothers stood at the foot of the bed and silently looked at the patient, whose head was still wrapped in white gauze, his bed still propped up at a forty-five-degree angle.

The hospital only had three patient rooms with doors, which were reserved for patients with contagious infections, like tuberculosis or meningitis.

Because the man’s infection wasn’t airborne, he had been placed in a large alcove with two other beds. There was just a curtain across the entrance, and no partitions between the beds. On the patient’s left was a ten- year- old boy with malaria. On the patient’s right was a fifty-eight-year-old man with pneumonia.

I watched as the patient’s oxygen level dropped to 70 percent, then 54 percent, then 35 percent. I watched the heart rate as it went from a regular 100 beats per minute to erratically swinging from bradycardia, 30 to 40 beats per minute, to tachycardia, in the 170s.

The ten-year-old boy looked on with fear in his eyes.

I retrieved a privacy screen — a large piece of cloth hung on a wheeled metal frame — from the hallway and placed it between the ten-year-old and the man who was dying.

I brought two chairs to the bedside so the brothers could at least sit down while they watched their sibling die. We had done everything we could do for him, but he was dying, rapidly decompensating before my eyes.

I had other patients to see, medications to order, and lab results to review, and yet I continued to stand at his bedside. If I can’t prevent his death, I thought, the least I can do is witness it.

Maybe I was standing there for them — providing physical presence and visible support for the man and his brothers. Or maybe I was doing it for me — because it made me feel like I wasn’t completely powerless. I felt like I was doing something, even if it was just watching the monitor as his vital signs became more and more unstable. After a few minutes of an erratic heart rate and an oxygen level so low the monitor couldn’t register it anymore, the tracing of his heartbeat turned into a flat line on the monitor, and it started blinking, the monitor blinked, and alarmed loudly.

I reached up and turned the monitor off. The last word Jesus said on the cross before he died echoed in my head in the profound silence that followed my patient’s death.

Tetelestai.

It is finished.

The monitor’s screen went black.

It was over.

Just like that, as I stood there watching, the man’s soul left his body. He was still sitting up in bed, his eyes closed, his head wrapped in gauze. He looked like he was sleeping, and his body was still warm. But he was dead. He was gone.

I wanted to journey with his soul to God. I wanted to hold his hand as he passed beyond the veil of the physical world and into the other side of eternity. I wanted to accompany him because I wanted to ask God why. Why did some people in the world have so much, while others had so little? Why were some people in the world so comfortable, while others suffered so much?

Why did we have lifesaving treatment for some patients but not for others?

The injustice and unfairness were maddening.

I felt helpless as I stood silently at the bedside, resting my hand on the younger brother’s shoulder while he buried his face in his hands and wept.

Later that afternoon, the ten-year-old boy with malaria lapsed into a coma and died. His father collapsed into the chair I’d drawn up to the boy’s bedside when it became clear that his son was leaving this earth, and there wasn’t anything else we could do to keep him here.

After his son took his final breath, the father frantically searched the pockets of his shirt, pants, and jacket, looking for money to pay his son’s medical bill so he could take his son’s body home and bury him.

The fifty-eight-year-old with pneumonia was a wealthy man from Nigeria.

He motioned to me, and I walked over to his bedside. He asked me to hand him his wallet, which I retrieved from the pair of pants that were hanging on a hook near his bed. He opened his wallet and pulled out enough money to cover the ten-year-old’s medical bill.

“Take your son home,” the Nigerian man said to the grieving father, who nodded his head in gratitude.

And then the father picked up the limp body of the son we couldn’t save, and carried him out of the hospital.

I worked through the morning, then into the afternoon, then late into the night.

Patients kept coming.

And for the next three months, patients kept dying.

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