July 30, 2003

Andrew Schechtman is a volunteer doctor working for Doctors Without Borders/Médecins Sans Frontières (MSF) in Monrovia. In this excerpt form his diary, he describes the life and death struggles faced by those caught in the crossfire in the war-torn the Liberian capital.

 

The stress is hard to define. Perhaps it can best be described as the stress of knowing that even giving your best isn't good enough. More is needed. People are still dying, children are still dying despite my best. I take little comfort in going home at night knowing I'd given it my all. All is not enough.
– Andrew Schectman

 

7 July 2003

The work has been exhausting. Seven days a week, sometimes up to 16 hours a day, although thankfully not always.

Yesterday, Sunday, four children died in one day. I ran out of body bags. I think I'm doing the best available for each patient. Still, each time I wonder if there was something I missed, something I just didn't think of that might have saved them. Hearing the mother wailing, knowing exactly what it means, knowing that it will be too late when I get there, not wanting to go but knowing that it was the right thing and going, holding the mother's shoulder as she cried, telling her "I'm sorry, momma," and knowing that I can't lose it in front of her because if I did it would take me too long to pull it all back together and there is too much to be done.

 

Amos

 

There's one baby I've grown attached to in our malnutrition unit. His name is Amos. He's been with us for five days now. He is eight months old and weighs 2.6 kg (that's about 5 pounds nine ounces for us Americans). He is the scrawniest little thing I've ever seen. He looks like a premature infant and a withered old man at the same time.

"Where's baby Amos?" I'd say when I'd arrive on the nutrition unit in the morning. Or "Amos is my favorite." I took some pictures of Amos and had one of the nurses take some of me with him too. When Amos got a little pneumonia on Friday I immediately started him on our strongest, top of the line antibiotic, Ceftriaxone. I knew his frail little body couldn't withstand any additional insult.

I gave him the first injection myself, 1.5 milliliters as an intramuscular injection. I encountered a problem. Amos had no muscle. I squeezed his little thigh to get enough muscle together so I could inject into something and after pushing in only half of my 1.5 ml it had already doubled the diameter of his pencil-thin leg. I gave the second half of the injection into his other thigh. Amos's high-pitched cry sounded a bit like a cat in heat. It was a funny cry.

I didn't enjoy making Amos cry but the sound made me smile. I gave him a little sticker of a flower to put on his hand after the shot. I gave the children in the nutrition unit a lot of stickers. Kids love stickers. Some of them, like Amos, weren't with it enough to realize that they'd been given a nice little sticker but their mom's liked it even if they didn't. The mom's used the stickers like jewelry. Sometimes I'd pass through the ward and find the sticker stuck on the kid's forehead. Not so exciting for the kid but I guess it did make them look a little stylish.

When Amos got a little worse I hit him with the big gun right away. Still, he didn't improve. When I saw him Sunday, his whole pliable chest was sucked in each time he breathed. His ribs weren't rigid enough to maintain the shape of his chest. It was an eerie sight and it wasn't a good sign. I figured Amos might not make it. All the cards were stacked against him. His marasmic body had no reserve. There was nothing left deep inside to call on to fight the new assault on his health.

Still, I had high hopes. I'd started his antibiotics early. I had hope. I knew that if Amos died on Sunday - after I'd already seen four children die that day, after I'd already had to hold it together in front of four wailing mothers…

Two and a half weeks doesn't sound like so long to work hard. In residency, which wasn't all that long ago, I logged my share of hundred hours weeks. But here it doesn't seem to be just the hours or the work. The stress is hard to define. Perhaps it can best be described as the stress of knowing that even giving your best isn't good enough. More is needed. People are still dying, children are still dying despite my best. I take little comfort in going home at night knowing I'd given it my all. All is not enough.

When I went in to work this morning I steeled myself against the possibility that I might hear that Amos had died during the night. Usually I'd go to the cholera tents or the emergency room first in the morning but today I went to the nutrition unit. I needed to see Amos. He hadn't died. Two other children had died during the night. But Amos had lived. Thank God Amos had lived. Amos had lasted the night.

"Is he sucking?" I asked his mother. She shook her head. There was no doubt about it. Amos was worse. His breathing had slowed. His body was exhausted from spending all it's energy trying to suck air into his pneumonia-filled lungs. I knew his days were numbered. No, that's not accurate. I knew his hours were numbered. I wish it wasn't so. Sometimes I wish that I didn't have the experience and the knowledge that told me this morning that Amos would die within a matter of hours. It would have been nice if I could have held out hope longer but I couldn't. Fact was fact. Science was science. An hour and a half later the nurse called me back to the nutrition unit to see Amos. He lay still in his mother's arms. His fight to breathe had ended. "I'm sorry, mama."

"It's not easy" is a common saying in Liberia. It is not easy. I will continue as long as I can. This work is important. I will keep going until I can't go anymore and then I will stop. That is how it has to be. We've received some reinforcements - two new people from the "emergency desk", one doctor and one logistician both with a lot of experience. They came to help support the many new projects we're planning in Monrovia. Cholera is everywhere. Everyday someone is wheeled up to our hospital in a wheelbarrow dead, having arrived too late. We are planning cholera treatment stations in different parts of the city. We are building a 50-bed cholera unit in Samuel K. Doe stadium. There is a lot to do here.

The needs are huge but, with peace, the needs might be met.