#11: Impossible Ethical Triage

If you had to decide to pay for a patient's medications, patient's testing, or a patient's operation, which one would you pick? Or would you instead pay for equipment at the hospital that benefits ALL patients indirectly, but none individually? What do you do when you cannot pay for everything, and so every decision to fund one thing is a decision not to fund another? The last few days have made it clear that I am flying blind. I do not know if I am making the best decisions, if I am stewarding money wisely, or if I am letting my emotions override strategy. I am just doing my best. I want to walk you through two cases that have weighed on me immensely: a malnourished 13-year-old boy, (possibly only 8, as I will explain) who fell from a moving tuku tuku and could not walk, and a 20-year-old mother who developed severe post-cesarean sepsis after delivering a baby who did not survive.

These cases have forced me to really wrestle with what it means for me to maximize my impact here. In speaking with my father, we thought it was reasonable that I set aside about 100 dollars a month of our family’s money to help pay for specific treatments for our most complicated and critical patients who cannot otherwise afford care. That number sounded clean and manageable on paper. In reality, it has placed me in a role I am not qualified to hold. I feel like I am thrust into playing God with who I choose to provide funds for and who I choose to neglect.

These are the questions I am asking myself in every case:

1. Should I only intervene with funds when a patient’s life is clearly at risk? Or if a patient has already become critical, is it not even worth it because their death may simply deplete funds that could have saved someone else?

2. What if my money is best spent not paying for individual treatments at all, but instead improving the hospital in ways that strengthen care for everyone?

3. What if the patient, and the patient’s family for that matter, start to take a much less active role in their care and recovery because they feel like charges are being covered? This is always Dr. Hillary’s biggest concern when we offer to pay for treatment. He believes that all patients must pay something for their care. If we provide free care, we not only risk being taken advantage of, but we also put our patients in a passive position where they are much less likely to prioritize their recovery and treatment. If they don’t recover, they may start to think that the hospital will just pay for more things.

The first case that forced these questions into reality was a boy who fell off of a moving tuku tuku, a small truck used to transport construction materials. He came in unable to walk for a day with no bowel movements and in a great deal of pain. As I am getting more comfortable with the culture I am living in, it has become easier and easier to read socioeconomic status as soon as a patient walks in the door. Hygiene of the patient and the family members is often a strong indicator. Clothing. The condition of their shoes. The smell of sweat and soil and long days without access to water. Whether they own livestock. Whether they can provide even a simple "button phone" (aka flip phones) number. From my first view and smell of the elderly father, I knew this family hardly had the ability to afford walking in the door to our hospital.

Another confusing aspect of this patient was his age. When I asked him, he told me 8. The father told us 13. We do not know what is the truth. If he is 13, then we are dealing with severe chronic malnutrition. The child is 17 kgs, looks wasted and is clearly suffering from more than a fall from a tuku tuku. Looking into this boy’s eyes, I could see how he was scared and in pain, but not asking for help. He was quiet, resigned to his fate, and I did not see a single tear. Men in Uganda are harshly stigmatized against crying. I have even seen that with Luke when he falls and gets hurt. He will do almost anything but cry.

At the time, I thought the accident had just happened. I thought we could be dealing with dangerous levels of bleeding, a spine fracture, a pelvic fracture. The father came with only 40,000 UGS (around 11 USD) in his pocket. With that money, we were able to do an ultrasound scan. Dr. Hillary waived the consultation fee as we often try to do for patients who cannot afford to be at our hospital. The ultrasound thankfully showed abdominal organs that were relatively normal in size, shape, and echotexture. However, upon scanning the lumbar region of the back, we found that there could possibly be an ischial fracture or a spinal fracture. The room -- filled with Dr. Phillip, Dr. Hillary, me, Nurse Nicholas, the patient, and the patient's father -- went silent with conern. As we talked in English, which the child and the father did not speak, we all knew that the next step was an x-ray. The abdomen was distended and we needed to know more.

In America, I am almost sure this would have looked very different. We would have done blood work, urinalysis, HIV testing to look for immunocompromisation, TB testing, typhoid testing, malaria testing, and more. In America, we treat first and then case managers are assigned to impoverished patients to manage their bills. A chaplain might also be assigned to guide the family spiritually and emotionally. Here, every test is a complicated financial decision. The x-ray cost about 10 dollars. I really did not hesitate. I went ahead and paid for the scan. If the patient’s life comes down to the difference of 10 dollars, I do not know if I could live with myself if I did not offer the money.

The x-ray results came back clean. No spine fracture. No hip fracture. In the efficiency-driven part of my mind, I almost wanted there to be a fracture of some kind to justify the use of my money that could have been allocated elsewhere and had a bigger impact. In the x-ray, we did see visible constipation of the colon, which the doctors presumed was from pain. Dr. Tom prescribed an inexpensive, but reliable treatment plan that included medications for pain, inflammation, and a laxative. The total came to about 22 dollars, but of course....the father could not pay.

So they left. Without any medication. No better than when he had arrived. The father said he would be back tomorrow while he tried to look for the money. Watching the boy be carried by a family member onto the back of a motorcycle taxi, crying in pain, with two people already on it, hurt me deeply. Why did I choose to pay for the x-ray that was ultimately not useful when I could have helped to pay for the medications and allowed the boy not to go home crying in pain, still unable to walk? How did my choice help anyone? The reality is that it did not. I made a bad call. I did not prioritize paying for the thing that would most help this boy. I feel like I failed.

The father and the boy came back the next morning. I picked the boy up in my arms and tried to avoid causing him any pain. He was too light. Thirteen-year-old boys should not weigh 17 kilograms. The father had found funds from around town through friends and family or by selling a chicken, but we have to realize that this likely places his family into debt and even deeper poverty. There is not much further down they can go before they reach the absolute poverty floor.

While I was checking in on another critical patient and trying to find a corner to cry about the heaviness of the choices I am making, Dr. Hillary impressed me yet again by doing a pro-bono second examination of the boy in the reception area, concerned that he still could not walk, and trying to come up with solutions. In intense kindness, he gave free pain medications and told the patient and his father to rest in the ward for the day without paying inpatient fees. Emergency patients are usually the least able to afford treatment. Stable patients with sufficient means sometimes try to negotiate and finagle our system. The poorest rarely negotiate. They leave quietly and in silent resignation and embarrassment about their financial state. 

While I was reeling from the ethical dilemma of ten dollars, I found out that our 20-year-old female septic shock patient was declining. She was admitted with a late-stage obstruction during labor on February 4th. We performed an emergency cesarean section. The baby was in very poor condition. I used a bag valve mask on that neonate for an hour. An hour of squeezing air into tiny lungs that would not respond. I never got the baby to cry. I could see her small, fast, labored breaths, desperately trying to breathe with lungs that were failing her. She was premature and her lungs were not fully developed. She had meconium aspiration syndrome. The doctors presumed she also had malaria from the mother and necrotizing enterocolitis. The baby died when she was around three days old.

The mother was discharged around four to five days after the operation. We knew she was critically ill. We knew she was going to develop sepsis and come back. But she could not afford prolonged hospitalization fees. Her vitals improved slightly the morning we discharged her, so we crossed our fingers and let her go home.

She came back with green and white pus pouring out of the cesarean incision site. She was not yet in full septic shock (low BPs, high HR), but she was critically close. The incision had not healed at all. In fact, she had a burst abdomen, meaning that we were looking at her intestines protruding from the incision site. This was a very serious emergency.

We treated her with Metronidazole, Gentamicin, and Cef-Sulbactam for a few days and tried to dress the wound twice a day. But, the pus kept draining. Her vitals worsened. She needed another surgery where we opened the abdomen and cleaned. Someone asked me, "Do you want to cover the payment?" and I said "yes," intending to continue the sentence with a "but...," but it was already decided. I should have been more intentional with my words and thought more about where my money was best allocated, but within 10 seconds, I had roped myself into paying for this surgery. The operating room was prepped. We performed the exploratory laparotomy that same day in the pediatric ward, which we use for isolation. Sepsis can haunt a hospital for months. If we are not careful about autoclaving and isolation protocols, every single mother we take to the operating theater could develop infection. How hard for this mother to stare at an empty children's crib every day, fighting for her life from the same infection that took the life of her neonate.

It was a shoddy operation. We poured sterile saline into the abdominal cavity and suctioned it out in an effort to remove as much pus as possible. It felt like trying to clean the inside of a car engine. You do the best that you can, but you cannot see everything. Plus, you cannot take out every part and find the source of the problem. You eventually close the patient knowing that you are leaving bacteria behind.

For three to four days after the surgery, we were optimistic. The room stopped reeking of necrotic tissue and sweet-smelling bacteria. The fevers went away. She was ambulating well around the grounds. There was no pus leaking from the incision site. I even started to question whether I should have paid for the operation at all and instead should have just paid for stronger antibiotics. Maybe the case wasn’t that serious??

Then her fever returned last night. 38.5℃ through the night. Pale yellow pus oozed out of the incision when we palpated it. The infection is back and likely stronger than ever. When she left the hospital after the cesarean, she stopped using Cef-Sulbactam. That gap likely gave bacteria the perfect opportunity to mutate and develop resistance. I consulted my cousin Patrick, who is a doctor living in the DRC. He had ideas, but some we do not have the capacity to implement and others would not change management. We cannot perform cultures in our hospital, so we cannot truly know what organism we are fighting. We suspect much of the infection may be in the retroperitoneal space, which is difficult to localize and even more difficult to treat definitively with the resources we have. We could attempt imaging, but even if we localize pus, our options remain limited. We are considering Ciprofloxacin, one of the few antibiotics we have not yet tried. If she dies, the money spent on that exploratory surgery will feel like it was in vain. 

I don't know what will happen….It feels like we are just waiting to see if she will push through and trying to find any inexpensive treatment that will help.

These two cases have forced the same questions into my hands again and again. Am I paying for the right thing? Am I helping the right patients? Should I be paying at all? I feel like I am doing everything blindly. I am experiencing all of this for the first time. Maybe it will be easier the twentieth time I see a case like this....maybe I will learn from these current cases and do better in the future. Right now, however, it really does feel like every choice I make is the wrong one. 

I am not God. As you all know, I am so far from perfect. But with these critical patients, I sometimes feel forced to play God and decide who lives and dies.