Day 294, Sometimes medicine feels very arbitrary. Things seem to happen that we have no control over, yet an infinite number of decisions lead to it.
Last weekend I was on call again and as with any call I like to avoid disasters. Unfortunately it’s out of my hands whether one strikes. There are factors that can conspire to cause problems and as i’ve alluded to in the past blood for transfusion is a scarce resource, but one that is all too often necessary to function effectively in emergency healthcare. The news at the start of the call that we would have no emergency units came with a sense of foreboding.
Most days we have no real need to transfuse patients but as luck would have it we kept receiving patients that would buck that trend; a woman with a bleed during pregnancy who needed an emergency caesarean, a ward patient who was bleeding after dropping her platelets and a guy with HIV and severe anaemia making him weak and breathless.
Then came a patient I picked up the card for, a man in his twenties who had been started on HIV and TB treatment and was recently in hospital in Johannesburg. He had taken his own discharge from hospital two days previously to come and be closer to his family. They had noted he was anaemic and needed a transfusion. By the time he arrived to us his circulation was being so inefficient that his heart was failing. Johannesburg is a city with millions of people, dozens of hospitals and a vast network of blood banks whilst we struggle to rustle up anything from our whole district.
I was instantaneously frustrated by the decision he had taken to leave the city and recognising the seriousness informed him and his father that we will try to find him blood but that the worst may happen. When a unit of blood was kindly given us by a neighbouring hospital I had to weigh up the plausibility that an obstetric emergency could need it at any point. I tried to manage him conservatively, and held on to the emergency unit. As it happened we used the blood for another patient and though he survived the weekend he eventually died without enough blood getting to us.
His decision to leave the city, our lack of blood supply, my decision to hold back on the emergency unit, these were all decisions that eventually led this twenty year old to die. Each juncture represents an opportunity for a different outcome. Though he had influence on the events he eventually had no control on the result, much as I didn’t. As with so many other patients in Mseleni this made me aware how arbitrary life and death really is and how ultimately powerless medicine can often be.
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