Drumbeats

I reach into my pocket and rub my thumb and index finger back and forth along my knife.

“If I drain this pleural effusion and give her a few quick chest compressions, I can bring her back.”

“No. Let her go. Bring her back to what end? To die tomorrow, next week?”

I know Rollin, my father-in-law, is right. He usually is. But something inside me wants so badly to slip my knife between Anne’s ribs to save her life. I push. He holds his ground.

It goes against everything I trained for as an emergency physician to just give up, especially on a 17-year-old patient. But we can’t save her. He knows it. I know it. And he does me a favor by making the decision, sternly, for me.

The Past Few Months

Months go through my mind in an instant. Pierre, my church elder and former accountant, brought his daughter Anne to the hospital with a swollen left leg and a bit of pain. I thought, blood clot, but the ultrasound was normal. I thought abscess, but none showed on the ultrasound, and I couldn’t find one with a needle. So I went with cellulitis and put her on maximum doses of ciprofloxacin, cloxacillin, aspirin, and ibuprofen to cover all the bases.

It got worse, so I went with elephantiasis, even though it didn’t really look like it, and put her on maximum doses of doxycycline and ivermectin. I treated all parasites.

It still got worse, so I asked my wife, Danae, to get involved. She did a skin biopsy on the wound that finally formed and determined that Anne had a rare bacterial disease called donovanosis. She put her on azithromycin, but the leg remained swollen. Finally, we hospitalized her.

A few days later, I was told that Anne was dead. I started over to the private ward to give my condolences to her family. There I saw Ndilbe, my hard-working nurse, hustling her in a stretcher toward the operating room. He told me that he had administered atropine and that she had a heartbeat. He also told me she hadn’t been urinating.

In the operating room, we threaded a tube into Anne’s kidney and evacuated the urine that had built up there. I saw that her pelvis was full of a huge, cancerous tumor and that now her right leg was swollen. We figured her infection had turned into an aggressive cancer, which donovanosis can occasionally do. I administered an aggressive dose of chemotherapy, but she was completely unresponsive, still not urinating, and requiring injections just to keep her heart beating.

The next day, Anne was sitting up and laughing. The tumor in her pelvis was smaller. It was unreal. A few days later, she started urinating from her bladder. I decided to repeat the aggressive dose of chemotherapy a week later. The pelvic mass completely disappeared as well as the swelling in her legs.

But Danae and Rollin and I knew this was not a cancer we could cure with chemotherapy. We had bought Anne a little time, but that’s about it. I let her go home.

She came back in Saturday night with trouble breathing; her heart beating wildly. My gut told me it was a pulmonary embolism. My gut is right two-thirds of the time, and I had no labs or imaging to go against my gut. A cancer patient who has been immobile for a long time; it made decent sense. I ran home to get enoxaparin and asked the nurse to administer it subcutaneously.

I had just finished my rounds Sunday morning when I saw Anne struggling. Her oxygen monitor read 70 percent. Not good. There were no breath sounds on her right. I ran for the ultrasound. Her right chest was full of fluid. I poked her with a needle to confirm and aspirated straw-colored fluid.

The Right Call

Now her heart has stopped for a full minute. My right hand has a death grip on the knife in my pocket. Slip it between the ribs and give a little twist—that’s all it would take to bring Anne back. But Rollin’s right. There’s a reason she has a chest full of fluid, and that reason is cancer.

I know Rollin has 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 that she’s dead.

I drive the family home and sit under a makeshift thatch hangar, watching the women prepare the body for burial. Then I drive the body to the church. I sit by myself, the only foreigner, while the congregation sings. And I weep. I see the mothers and sisters and friends come in. I see the father stay strong. I see the choir singing for their lost friend, a fellow member whose voice will never again be heard on this earth.

From the church, it’s another drive to the burial site. Men have been hard at work chiseling the dry earth six feet down. The Pathfinders stand to sing. Anne’s best friend starts, a cappella, her brave voice quivering. Gradually, the others join in, tears streaming down their faces, the palpable and heavy pain of youth having to bury one of their own.

Anne 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. Scoop after scoop, the men work at a frenetic pace, filling the hole in a matter of minutes. Then they smash down the dirt with the blades of the shovels. She’s buried. I drive the family home.

Tonight I’ll hear the heartbeat of Africa continue on in the mourning of the drums. They beat each night that someone dies. They beat regularly here. They typically don’t keep me awake.

But tonight will be different. They will beat for my 17-year-old patient, daughter of my elder and friend. I reluctantly pull the knife from my pocket and toss it in the drawer. While my head knows Anne had nothing but suffering ahead if I intervened and that we made the right decision to let her go, my heart wonders.

And tonight, I’ll hear the drums.