The king is dead. Long live the king! 15 Mar2015

This is an edited journal I wrote days ago. Edited means Im not posting a lot of what I wrote (at the end) because it looked like I was complaining about what "we" don't have. But this story is about someone else:

The king is dead. Long live the king! 15 Mar2015

I killed a 3 yr old boy 2 weeks ago... Except he didn't die until today.
As I finished pediatric rounds this morning I was called to see a few consults. Outside on the dilapidated wooden bench sat a malnourished boy in obvious discomfort. It was Koumla. Koumla means "King" in the local Nangjere language. Right now, this tiny 3yr old boy looked more like a pauper than a king.
Koumla had been here in late February for vomiting and diarrhea and fever (just like 75% of my pediatric patients). He was hospitalized, treated and discharged after several days--presumably because he was doing better. Apparently he wasn't better. After 2 weeks at home, his mother returned with him. His skin was hot to touch and I could see an abdominal mass. Maybe we missed some symptoms 2 weeks ago?
After a quick physical exam I carried him to preop. He needed surgery today and soon! The surgical team assembled and we searched for an IV for a while without luck. He was really dehydrated. I finally put an IV in his jugular vein and started rehydrating Koumla. Tough start.
The first 30 min of surgery under general anesthesia were relatively uneventful but Koumla had a huge intusseception and it was a tough reduction. Then suddenly the pulse oximeter went flat and the blood pressure wasnt registering. After some trouble shooting I started CPR because his pulse was very slow and weak and likely he had very very low blood pressure--that's why his pulse oximeter was no longer working. (We have no ETCO2 monitor or EKG pads). I auscultated his chest again-- he went from a weak pulse to pulseless. Rollin, Danae and I continued CPR and repeated atropine and epinephrine. Danae brought his mother into the OR to witness our resuscitation efforts so she could see him while he was still "alive." After another 30 minutes I decided to exercise good judgement and stop CPR. Koumla was gone.
But he wasnt! Through his skinny little chest wall we could see his heart was fluttering again. It was like some cheesy story in a"B" movie, but this was true. He was "alive" again. More CPR, more meds, and new hope measured with a healthy dose of skepticism. Koumla now had a strong pulse but he wasn't breathing on his own. We quickly finished surgery and closed the abdomen as I continued breathing for Koumla. We have no ventilator. I chose an arbitrary time-- if he's not breathing in 2 more hours, I'm gonna have to extubate him and let him die...Let him die? Who says that?
As the first hour passed I grew more depressed. I'm not a fool and I knew what was going on. Koumla was likely brain dead.
As soon as I started to doubt he could survive, Koumla started to breathe! Just a gasp at first then eventually several times a minute. We may get a miracle after all?!
But then another hour dragged by with no improvement, no responses to stimulation, no cough, no pupil reflexes, nothing.
Another 30min passed and I had to face the realty. We have no ventilator, no rehab center, no nothing. I had been alone in the OR hand ventilating Koumla for hours and he wasnt going home.
I summoned the mother to the OR and explained the what must have been incomprehensible: Koumla is warm and has a pulse and a blood pressure but he is going to die. I invited her to lay with Koumla on the OR table and hold her baby boy one last time.
After I removed Koumla's endotracheal tube, I placed his mother's hand on his chest so she could feel his heart beating, and then slowing and then it stopped.
I'm telling you, friends, that was a gut wrenching moment for me.
This was my first intra-operative death in Chad. Sooner or later we all lose a patient in the OR. But here in the bush in Africa it just feels different. Tonight I am crushed and I am frustrated...