"Día de los Muertos" ("Day of the Dead") is celebrated in Guatemala on November 1st each year. It is a day, which, per Wikipedia, is dedicated to "prayer and remembrance of friends and family members who have died."
Early November also coincides with one of the more memorable and haunting cases our center has experienced. Timoteo had just turned two when he made his first and last visit to our clinic. He had, per family, suffered with progressively worsening respiratory symptoms at home in the days prior to presentation. Upon arrival at our center, he was hypoxic, wheezing, and demonstrated marked increase in work of breathing. Oxygen saturation improved with supplemental oxygen. He received parenteral steroids and continuous breathing treatments with nebulized bronchodilators. Initially, he seemed to improve somewhat, but did not demonstrate nearly as much improvement as one would anticipate. His level of consciousness declined. He was intubated. He received epinephrine. He became pulseless and received chest compressions. After prolonged resuscitative attempts, we and his family were forced to confront the futility of our efforts.
Timoteo was dead.
Invariably after such challenging, gut-wrenching, cases, one is left with more questions than answers. One of the many questions I have wrestled with since that particular case is why our patient's parents dealt with his loss in the manner that they did. They were clearly distraught. But, what stood out to me then and continues to give me pause, was their apparent resignation. Undoubtedly, life had not been easy for the family and the loss of a child- while tragic and sad- seemed not unexpected. If anything, I believe they would have been more surprised had there been a positive outcome. They were not accustomed to happy endings. The dearth of hope we perceived then, continues to fuel our work now.
We spiral Upward in an attempt to kindle hope in a land where hope is far too often a limited resource.
To that end, at our most recent monthly clinic meeting one of our didactics focused on AMAX4- an algorithm developed by an emergency physician in Australia, Dr. Ben McKenzie. He developed AMAX4 after the tragic death of his 15 year old son due to hypoxic brain injury secondary to bronchospasm/asthma.
Here is the algorithm:
The key points emphasized in AMAX4 are concisely summarized in a post on the website Life In The Fast Lane.
In retrospect, could our case have been managed differently? Could we have done better? Should we have intubated Timoteo earlier? Given epi earlier, more frequently, started an infusion? Probably. Would the outcome have been different? Impossible to know. Are we as a team seeking to honor the memory of Timoteo by continuously learning and training in an effort to provide our present and future patients with the best possible care? Do we ache for hope to no longer be a limited resource?