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Teaching and Learning Moments

On Lessons Learned in The Gambia

Tan, Aidan C. MD

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doi: 10.1097/ACM.0000000000003874
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Eight years ago, I was sitting at a narrow wooden bench at the back of a small lecture theater at the University of Sydney when the lecturer on normative ethics mentioned a quote often misattributed to Joseph Stalin: “A single death is a tragedy. A million deaths are a statistic.”

I think of those words often. I thought of them a year ago, as I sat on a broken plastic chair beside a bare metal bed in a hospital without doctors, deep in the West African bush, while I manually ventilated a 3-month-old infant with pneumonia. Only minutes earlier, his mother, a young Fula woman with indigo ink facial markings and red-gold hoop earrings, had called out in a language I did not understand but with an urgency I did. Her 3-month-old infant was still, too still to be sleeping.

We commenced cardiopulmonary resuscitation (CPR); I manually ventilated the infant and the nurse performed cardiac compressions. A minute later, we taught an untrained staff member to take over cardiac compressions while the nurse prepared adrenaline. Ten minutes later, when the 6-year-old boy in the adjacent bed began convulsing from cerebral malaria, the same staff member was able to take over cardiac compressions while the nurse prepared diazepam.

Our history was limited by language, examination was limited by urgency, and investigations were limited to pulse oximetry. Yet I was able to fall back on the management principle of providing positive pressure ventilation, procedural skill of sealing the mask to the infant’s face, and clinical reasoning of reducing the volume of air pumped to decrease gastric inflation. While health care teams and patient assessments are contextual, effective teamwork, management principles, procedural skills, and clinical reasoning are universal.

After receiving 2 doses of adrenaline, the infant resumed breathing. I watched his chest rise and fall. Four minutes later, he stopped breathing again and I recommenced manual ventilation. Whenever I paused, he would breathe until he stopped, and I would continue manual ventilation. I feared it was futile, but, worse, I feared it wasn’t, and I would have to decide when to stop. Six hours later, his heart stopped beating, and despite CPR, it did not start again.

When he died, I swore I could hear the faintest heartbeat and feel the weakest pulse because I wanted it to be true more than I wanted to be right. The reality is that the objectivity of basic and clinical sciences, mechanisms of health and disease, diagnostic investigations, approaches to management, and even ethical and legal responsibilities are vulnerable to the subjectivity of being human.

When we stopped CPR, we said nothing. I believe in words, but there is nothing we could have said to the infant’s mother that was not said as we dipped gauze in saline and gently wiped the mucus and saliva from her infant’s face. While the mother sobbed into her hijab and the father and Imam wrapped the infant in cloth, we moved on to the 6-year-old boy with cerebral malaria in the next bed. When the nurse asked me to go to the mosque for prayer that afternoon, I hesitated, but went nonetheless, because my responsibility to the infant in life was a responsibility to the community in death. These social approaches to health and cultural aspects of disease extend clinical care beyond the patient to the community. I learned that sometimes, the most effective communication with patients, families, and communities is not with words.

That infant was not the only one to die. A child died every other day in that hospital. Some died suddenly and some died slowly, but no matter how they died, I held myself responsible—for the medical knowledge I lacked and could not apply and for the financial resources I possessed and did not provide. It is only with time that I have come to recognize and accept where the role of disease in death begins and where the responsibility of a doctor in death ends.

Since that infant’s death, I study, because when I return to that hospital without doctors, deep in the West African bush, I want to be better. I teach, because I am but one, and it is the many which make the most difference. And I research, because while I know that someday I will join that infant, knowledge never will.


The author wishes to acknowledge Dr. David Champion, Dr. Jill Griffith, and Ms. Ria Mehrotra for their valuable feedback on this manuscript.

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