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A Hand to Hold

Published:September 24, 2018DOI:https://doi.org/10.1016/j.acap.2018.09.009
      “Olyotya,” I said sheepishly, greeting the staff on entering the ward.
      The head nurse giggled and replied “Olyotya, doctor.”
      It was my second day rotating in the pediatrics unit at a large referral hospital in Uganda's capital city Kampala. I had many things to learn, like how to treat falciparum malaria, where to find medical records, and when rounds started. Learning conversational Luganda was lower on my list of priorities. Still, I took pride in my newfound knowledge of the Luganda word for “hello” and said it to everyone I passed.
      The day started at the Mwanamugimu ward, where treatment is provided to children suffering from malnutrition due to a variety of factors, including food insecurity, chronic disease, poor health literacy, and poverty. Mwanamugimu translates to “healthy child” in Luganda and serves as the name of this infant nutritional unit, which was a compelling reminder of the goal for each patient. The patient-to-provider ratio on the ward was nearly twenty-to-one. I was struck by this and impressed that the clinicians found ways to deliver care despite this imbalance.
      The resident team and attending started rounds on 8 of the 60 patients on the ward—those who were deemed by the intern to be either sicker or more complex than the rest. One such patient was a 9-month-old boy named Dembe (all names fictionalized) with chronic malnutrition in the setting of congenital HIV infection. He had recently been started on antiretroviral therapy and had a deep ulceration on his jaw, which increased his risk of life-threatening infection.
      Standing beside the senior resident Harriet, I peered into the shallow crib to find a baby whose body was withered by disease. He wore a cloth diaper that barely hugged his angular hips. His fearful eyes darted around as if assessing the situation or looking for a familiar face. Our eyes met for a moment before he eventually closed his own, presumably to escape from the towering white-coated spectators.
      Dembe's mother showed us a series of printed photos of her child since birth. He had been a beautiful, thriving, well-nourished infant in his first 6 months of life—gaining weight, reaching developmental milestones, and delighting his mother. These photos also served as a visual “History of Present Illness,” as they chronicled Dembe's progressive weight loss over the subsequent 3 months. Seeing the light in this woman's eyes as she recounted her son's better days brought smiles to our faces and reminded me for what we were working.
      We started making our plan for him—a mathematical masterpiece of calorie goals, feeding rates, and electrolyte levels. Suddenly, Harriet scooped up Dembe and whisked him into the adjacent intermediate care unit. I raced to keep up with her even though my mind was already 3 steps ahead. Dembe's head and arms dangled toward the floor as if they did not want to follow his body. Harriet laid his limp body on a stretcher. He was motionless. The attending attempted a sternal rub to no avail. I checked for a pulse but there was none. A nurse quickly found a bag valve mask and we began cardiopulmonary resuscitation, Dembe's ribs visibly buckling under his paper-thin skin.
      We stopped cardiopulmonary resuscitation after a few minutes. There was no supplemental oxygen, no stat labs, no imaging, no electrocardiography, and no emergency medications. I'm not sure any of those would have changed the outcome; he had quietly passed before our eyes.
      My gaze fell on the lifeless body with a blank stare as Dembe's young mother silently wept behind us, collapsed onto her knees in a bare corner of the room. There was no social worker, chaplain, or family member to support this woman physically or emotionally. I desperately wanted to do something or say something, but I felt paralyzed by the language barrier, new surroundings, and, most of all, my own emotional shock. Suddenly absent from my mind were the sophisticated formulas and careful calculations that seemed to matter so much just a few moments ago.
      As the medical team and I continued to stare at the still body, the images of a healthy 2-month-old Dembe still fresh in my mind, my eyes kept drifting toward his grieving mother. And then our attending did something I did not anticipate. He placed his hand on her back for a few seconds. He didn't offer any words, just his steady hand on her heaving shoulders.
      In this moment, I remembered the power of touch. My words would be meaningless to her, so I didn't say anything. But maybe I had something to offer. After everyone had left, I sat next to her on the floor for a few minutes and gripped her hand tightly. She squeezed back.
      Maybe my gesture was little consolation to her. Maybe it helped me process the traumatic event more than it helped her. But maybe this simple, nonverbal act conveyed a shred of humanity (and humility) that often remains hidden behind our white coats in times of tragedy.
      Our patient's mother had arrived at the hospital with her child. She left alone. I don't know her name or where she is from. I don't know if she has family or friends in the village to which she returned. But by giving her a hand to hold, maybe she received some solace and knew she was not mourning alone.

      Acknowledgment

      The author thanks the Yale/Stanford Johnson & Johnson Global Health Scholars Program, which provided funding and support for this global health activity during pediatrics residency.