Benedict was on the veranda of the inpatient department, cradled in her mother’s arms when I first met her.
Source: Emma Pedley/MSF
The ten-day old 1.5kg bundle I lifted was more blanket than baby. She had been experiencing episodes of diarrhoea for the past two days, her mother reported, and she hadn’t wanted to breastfeed that morning.
I remember unwrapping her and laying her featherweight form across my lap to squeaking protests and examining for signs of dehydration; she thanked me by weeing on my trousers. Not too dehydrated then. Alex, the interim expat doctor started the admission procedures.
I helped the mum express a little breast milk into a sterile cup and showed her how to coax Benedict to feed using a syringe. It doesn’t take much for a premature baby - as she seemed to be - to lose the will to suck properly, but she took the first few millilitres avidly enough. As I watched three generations of women squeezed onto one bed, I recall being cautiously optimistic that we could knock this infection on the head.
In the next couple of days baby Benedict took syringe feeding well, urinated regularly and even started breastfeeding normally again. Benedict’s mother spoke slightly better French than most of the women and in an enticing, throaty alto. I spent a little more time with them than I did some other patients, drawn in by the small family’s warm smiles and our mutual focus on the little baby on the bed of the crowded room.
Then, Benedict’s temperature and oxygen levels began to lower and she lacked the energy to breastfeed. We taped an oxygen cannula to her tiny, wide-eyed face and reverted back to syringe feeding. Her mother and grandmother took it in turns to nurse her kangaroo-style on their bare chests.
The results of the mother’s lab tests were normal, Alex concluded, and she had been in good health throughout her pregnancy and delivery. We cross our fingers and hope that the antibiotics start working soon.
An hour or so later I arrived back to the room to see Alex crouched by the side of Benedict’s bed fumbling with an ambu bag; he was still trying to get an IV cannula in, which meant we had no way to give her the drugs she needed.
Benedict’s stick thin legs were splayed on the bed and I gripped one tightly to stabilise it as I pushed an intraosseous needle - a wide bore specialist needle that enables delivery directly into the bone marrow - into her tibia, which felt as thin as that of a bird.
I closed my hands around her chest and began CPR. It only took the slightest pressure from my thumbs to depress her ribcage. The mask of the infant ambu bag that Alex was pressing to her face was hopelessly too big and air hissed out of the gaping space around her chin. He fruitlessly adjusted it several times. We don’t have a premature baby mask in IPD; in fact, I’m not even sure that we have one over at maternity.
I leaned in to do something I had only previously practised on a rubber mannequin, as the slightest puff of air from my mouth into Benedict’s saw her chest rise. The effort on my part was minuscule - I was able to give all five breaths for her with less than one of my own. I resumed compressions, her elastic ribcage flexing beneath my hand. Two breaths. 15 more compressions. Two more breaths. 15 compressions.
Benedict shuddered and finally took a in-breath of her own before she let out a faint cry. Her heartbeat fluttered under my encircling hands with increasing speed, but for how long? We resuscitated her three times that afternoon, after which I placed an erratically breathing Benedict skin-to-skin onto the chest of her mother again, the only way we had of preserving her body heat, and, kneeling on the floor I leaned onto the bed, fatigued. The grandmother lightly placed one hand on mine and with her other she reached up, touched my head and spoke in Sango: ‘Qu’est ce que elle dit?’
‘She is wishing that God go with you’ the mother replied in French as her warm eyes met mine. I suddenly felt hopelessly divided from these women - by race, material wealth, language and now, by grace. I clumsily exited the room, my eyes smarted with unshed tears of frustration and a sense of impotence. Alex put a sympathetic arm around me and I buried my head in his shoulder, just for a few seconds.
We had used every resource available to us. She needed an incubator to stabilise her temperature, a central line to deliver drugs and fluids, a ventilator, and sophisticated monitoring equipment to help her breathe. There is no doubt in my mind that at home with western-level resources, Benedict’s survival would have been assured, but here all she had was the warmth of her mother’s body, a dribble of IV glucose and my breath - and the odds were that wouldn’t be enough.
I jumped at every crackle emitted by from my radio handset that night in bed, hoping not to hear the call from IPD that seemed inevitable, but just after midnight it came.
I tumbled out of the vehicle and into the paediatrics room where we were faced with an empty corner bed. After Benedict had stopped breathing a fourth time her family had expressed a wish to take her home.
The weight of Benedict’s death, as well as not being able to say goodbye to her and the rest of her family lay heavy on me for the rest of that week. I remember the overwhelming, crushing feeling of inadequacy as I repeatedly chewed on the inside of my cheek to prevent myself from crying. Alex finished her interim role and it was tough to say goodbye; working in such intensity forges a depth and quality of friendship that you don’t often find.
And then, some days later as I was standing outside the lab, two women stepped hesitantly towards me. It was Benedict’s mother and grandmother. They had come back to look for Alex and me.
Words failed me. I wanted to tell them how sorry I was that we couldn’t do more, that we didn’t have more resources, and after the time we had spent together how much I regretted that one of us wasn’t able to be there at the end.
The grandmother took my hand and repeated the same Sango phrase as before. I stepped into her outstretched arms and the mother moved forward into mine. The tide of tears that I had been holding back for days rose up and engulfed me. In our tangled embrace we all cried and the divide I had previously felt dropped away and in that moment we were just three people united in grief for a lost child.
The only weight that remains now is from the privilege of being able to have shown I cared, that Benedict’s life was worth fighting for and she mattered. The burden of responsibility is no less heavy, but I am better able to bear it.
Emma Pedley is an Emergency Department and Intensive Care Unit nurse who wrote this blog while on her second mission working for Medecins Sans Frontieres/Doctors Without Borders (MSF) in Central African Republic. Her first MSF mission was in South Sudan.
*Names have been changed to protect patients’ identities.