Typhoid fever, caused by the bacteria salmonella typhi, is a form of dysentery (infectious bloody diarrhea) spread through contaminated waste that has been part of our lives since likely pre-history. On record, we know it dates back at least to the Hellenistic period during the plague of Athens of the Greek Peloponnesian War, where DNA samples from mass graves showed salmonella fragments. It’s said that during an impending Spartan invasion, the Athenians retreated within the walls of the city, which led to overcrowding that overwhelmed the city’s water and waste control. The disease classically presents with a ‘stepwise’ fever pattern that gradually increases in temperature over a series of days. This is commonly accompanied by abdominal pain, nausea, and sometimes bloody diarrhea but more commonly constipation. Some cases can also show a characteristic ‘rose spot’ rash that makes it visually distinct for medical textbooks. It can range from not so severe to causing full blown septic shock and death. Particularly concerning about its transmission is that it can spread from host to host through bodily waste, sometimes even carried by individuals without symptoms, like in the infamous stories of typhoid milkmen (depositing residue without knowing on milk bottles) or typhoid Mary, a personal cook for upper class families in New York who became the first documented example of asymptomatic transmission of an infectious disease after inadvertently infecting over 50 people causing three deaths. While the overall burden of typhoid has improved massively with modern sanitation practices, it continues to be a globally relevant source of morbidity with over 12 million cases in 2015 and somewhere close to 150,000 deaths per the Global Burden of Disease study. I never saw a single case as a resident in the US or a trainee in Ireland, but here in Butaro, however, we had four or five at a time from the first day I was on service.

Our 28 year old patient’s story from my first morning repeated itself on a daily basis with different faces in the bed. Some of them read like the textbook and came with the characteristic fever and others didn’t. Some had heart rate elevations and others not so much, which I learned was part of typhoid’s interaction with the immune system that can dysregulate the typical heart rate increases that come with escalating fevers. Some came with diarrhea, at times bloody, and others with constipation. One even came with a near coma that gradually improved to confusion and then normalized over several days. When it came to diagnosis, most of our typhoid cases were diagnosed clinically and only sometimes later confirmed with lab results of typhoid bacteria grown in blood or stool. This is because the bacteria doesn’t always cross from the gut to the bloodstream, and in patients with constipation, there was no chance to take samples of the stool. When treating typhoid, the blueprint is relatively simple, antibiotics to clear the infection and supportive treatment with fluids plus pain and fever control. Despite this, not all of our cases were success stories, like one that suddenly got worse on us on my fourth day with the team.

He had been admitted a few days earlier. I remember the student, soft spoken like so many Rwandans, presenting him at morning report.

‘He is a 38 year old male who presents with a one week history of fevers, flank pain, low urine output, and constipation’ she said. ‘He denies any diarrhea, vomiting, chest discomfort, productive cough, or new rashes. On examination when I saw him at 10:00PM last night he was tender to palpation in the abdomen and noted to be febrile and diaphoretic (sweaty) with an elevated heart rate and blood pressure in the normal range.’

This case started a little ambiguous, the first presentation from the student actually sounded like it pointed more towards urinary obstruction and kidney infection. As we typically did in the mornings, the staff grilled the medical student on her differential diagnosis and initial management plan. In an attempt to gain some diagnostic clarity before rounds, Alex took one of the students to scan the urinary system looking for an obstruction only to find a normal bladder and kidneys, with some fairly impressive dilated loops of bowel. In this patient, our workup for urinary infection was unrevealing, and the patient’s constipation, pain, and dilated bowel steered us towards a clinical diagnosis of typhoid as a result.

On the second day of his admission it seemed like his abdominal pain was no better, and his abdomen was marginally more bloated. Still, he looked okay and we hoped that as the treatment took effect his bowel distension would settle and he would improve. At this time, he was still passing gas despite not having defecated for several days, so we ordered an X-ray of his abdomen to evaluate for a possible obstruction. Throughout this, his vital signs were unchanged and he looked sick but stable.

The next time I saw him though, he looked sick as shit.

The following morning, I had a usual start after morning report doing some reading while the clerks did their pre-rounds. I usually wandered to the wards just before rounds to check in with the clerks to see if they had any patients they wanted help doing ultrasounds on. As I walked in, everything seemed fairly normal, and after doing a lap I came around to our patient’s bed to see two of the students at his bedside, tinkering with the automatic pressure cuff. The patient himself was breathing heavily, and sweaty, with tired eyes. He looked bad.

‘You guys doing okay?’ I asked. ‘What’s his BP?’                   

‘We’re not able to get one,’ they said.

‘If the automated cuff isn’t able to, let’s get a manual cuff instead,’ I told them

I came close and pressed on his belly. It was tense. One of the students, Nelly, with big hair, started telling me more.

‘We had ordered an X-ray of his abdomen yesterday but it was not done,’ she said. ‘When I came by this morning his blood pressure was low and we made a plan to get him to the X-ray soon, but now we are not able to get a reading anymore.’

‘Right,’ I said. ‘What do you make of that?’

‘I think he is going into shock,’ she answered.

‘I would agree,’ I said, ‘Let’s get some fluids and run them wide open.’

Just then, the medical officer came by. After having seen the patient earlier he called the surgical team to come and evaluate him for a possible obstruction.

‘They told us to get the scan and they will come evaluate,’ he said.

‘We don’t have the ability to get him anywhere for anything right now,’ I said. “He needs surgical evaluation immediately. Did you tell them he’s unstable?’

‘I told them we have concern for bowel obstruction.’

‘Okay, but did you tell them he has no readable blood pressure? He cannot go anywhere. They need to know that and they will come see him right here right now. There is no hope for a scan, he’s an impending cardiac arrest,’ I said. I had urgency in my voice and he went back to make another call.

In the meantime, some of the other staff were arriving. Alex and Zahir were now getting involved, assisting the clerks in getting the fluids attached and positioning to move the patient onto a bed that could leave the ward. Kelsey was within earshot as well at the nurse’s station. A crowd was beginning to form.

I got one of the ultrasound machines and maneuvered around to assist one of the clerks to get a view from the side of the abdomen. Clear as day, we saw free fluid in the abdominal cavity.

‘This is the guy we scanned two days ago,’ Alex said. ‘We were looking for the kidneys I remember. Definitely didn’t have any free fluid at that point.’

One of the most feared complications of a bowel infection is when the bowel becomes inflamed and distended to the point that it gets blocked. This can lead to increased pressure, which in the worst of circumstances can cause the bowel to tear open, leaking the infection into the surrounding space within the abdomen. This is referred to as a bowel perforation, and without definitive surgical treatment to wash out the infection and fix the tear, it is fatal.

Our patient was perforating.

The medical officer came back and told me he spoke with surgery again and they were asking for us to get the patient to radiology for a scan. I had my doubts that the message was delivered the way I wanted it to and took my concerns a rung up the ladder.

‘Kelsey,’ I said walking over to the station, ‘We can’t get a pressure on this guy and he looks toxic with new free fluid in his abdomen. I think there’s a good chance he perfed. Apparently surgery was called and they are asking us to go for a scan before they’ll evaluate him but he’s peri-code and can’t go anywhere. Would you be able to press them to come see him?’

‘Yes, that’s weird,’ she said. ‘I know the surgeon on today, I’ll call him now.’

Over the next ten minutes a small horde of people came in and out of the frame. All the clerks and every nurse on that side were now assisting. Pumping the fluids as fast as we could wasn’t seeming to bring about much change, and even now with the manual cuff, the students were not able to get a reading. Watching several nurses try to wedge a wheelable bed next to the action, I told them to hold off, we weren’t going anywhere until the surgeons came to feel his belly or until we had a viable blood pressure.

Then his eyes rolled back and he went unresponsive.

‘Nelly, can you check his pulse?’ I said.

Fumbling what she was holding, she pressed on his neck, her eyes focused. Someone else felt his groin..

‘Either of you guys got one?’ I said.

‘No.’

As is my nature, I found myself standing at the head of the bed now running the arrest.

‘Let’s get on the chest,’ I said.

Turning to my right, I singled out the clerks and went through my protocol from head to toe.

‘Francis, can you please get some gloves on, you’re up next for CPR. Marie, can you guys please start keeping time and let me know when we hit the two minute interval,’ I said.

The nurses were now taking up positions, or at least trying to, amidst the sudden change in energy from tense concern to stress and adrenaline. In my periphery I saw the makeshift code cart.

‘Let’s get a bag mask and one of you at the head please, and can we get pads and the defibrillator set up?’ I said to one of the nurses. ‘And can you please start prepping the first dose of epi,’ I said to another.

‘It’s not here,’ I heard someone say.

‘The defibrillator is not here or the pads?’ I asked.

‘Both.’

Right, I thought. Someone will figure that out surely.

I looked up and saw the clerk making good depth on her chest compressions although she was probably going too fast. I let her know and snapped my fingers in rhythm to help her slow it down. My go-to track at 100 beats per minute played in my head.

Staying alive, staying alive. Ah, ah, ah, ah stayin’ alive, stayin’ alive.

At this point the surgeon was arriving with his resident. Information was exchanged and they also gloved up and got close to help us push meds.

Things were happening but they were fairly sloppy. The cart was out of epinephrine, so someone had to run and get more meds before we could push anything. When the defibrillator arrived, we couldn’t find any pads to go with it. After another several rounds of CPR, another machine arrived after Zahir ran to another ward and plopped it near the head of the bed. This one had manual pads we don’t see in the US anymore like in the old ER TV series. When the surgical resident finally got the pads onto the chest, we realized they weren’t plugged in, and it took another few minutes of troubleshooting before we were able to get a line projected on the monitor. It was like the Three Stooges.

At the following pulse check, we all looked at the monitor together and saw a flat line.

‘Asystole,’ someone said.

‘Back on the chest.’

This carried on for a time. Every two minutes we checked a pulse and someone else got on the chest. Every three minutes we gave epinephrine. One of the surgeons even took a blood sample and rushed for rapid gas analysis to see if there was anything else we could try. I even asked for a few ampules of bicarbonate in case his blood was acidic from the underlying sepsis.

With every passing minute, our patient became harder and harder to salvage. Even if we did get a pulse back, the likelihood of getting him on the table for a major surgery in this condition was almost zero. It became apparent, like it sometimes does, that more CPR would only prolong the inevitable and make his exit from this world more traumatic in the process.

‘How long have we been going for?’ I asked Marie to my left, our timekeeper.

‘Now 24 minutes,’ she said.

‘Alright everyone,’ I said aloud. ‘We have a 38 year old with an asystolic arrest in the setting of suspected bowel perforation. The likelihood of meaningful recovery at this point is low. I would like to call this code at the next pulse check if we again see a nonviable rhythm. Does anyone have any objections?’

I looked around and got my answer without a need for words.

‘Pulse check,’ Marie said.

Francis pressed a gloved hand on the patient’s groin and squinted.

‘No pulse,’ he said.

That was that. He was dead.

Cardiac arrests are a part of medicine. We learn to grow comfortable with them, for better or worse. Those of us more critical-care inclined actually relish them, as they present a stimulating and kinetic challenge where we can perform great miracles or fail trying. I myself grew into a reputation of being a bit of a code-junkie in my residency, always looking to get close to the action. 

That wasn’t always the case, though.

The first arrest I was involved in as a final year medical student sent me places I had never been before. It was a patient I had been following for a little bit over a week, a 50 something year old Irish guy who fell while dancing at his granddaughter’s christening and hit his head on the sheetrock floor. He developed a severe brain hemorrhage, made worse by his anti-platelet drugs for a long history of coronary artery disease and heart failure. He also vomited during intubation and developed a severe pneumonia sepsis as a result. I remember every day I would see him, intubated and fully sedated, examining all corners of his bed and reading through every line in his chart. I knew so much about him, what he did for a living, how many daughters he had, his medical conditions, and the years of his many procedures. Exploring his chart deeply enough I discovered details that were of use to the medical team and built some favour with the registrars as a go-getter student. Then he started getting worse, and on the tenth day of his admission his heart gave out and he arrested. I remember I stood nearby during the code and put on gloves just to visually signal my readiness, and one of the registrars pulled me into the chaos.

‘Squeeze this bag, then count to six and squeeze again. Not too hard,’ he said.

I bagged a few times and he nodded.

‘Keep on it.’

I watched his glazed eyes reverberate up and down with each forceful compression of his chest and realized that in that moment I never once heard his voice. I didn’t know anything about his temperament, or if he would have liked me. I didn’t know what he enjoyed or who he admired. Despite knowing so much about him I knew almost nothing about who he was.

Then his daughter arrived and laid on his chest. The attending gestured for everyone to stop, and we slowly filed out.

‘It’s okay daddy,’ his daughter said, fighting back tears. She ran her fingers through his hair. ‘You fought so hard.’

I walked out towards the nurses station and my vision went blurry. I sat back on one of the desks and felt a lump in my throat.

That guy just died, I thought to myself. Holy shit.

It was only after a few minutes of standing there visibly distraught that one of the neurology attendings who had been caring for him noticed and pulled me aside. I still remember him, he was short and stocky, and bald, with small wire glasses and a soft spoken Irish accent. He was a stroke doctor, and probably hadn’t run or been involved in active code for over a decade. Something compelled him to sit with me though, and for the next ten minutes, we talked. He helped me unpack what I had just seen and I still remember that conversation however many years later.

‘We always have to ask ourselves if we delivered the best possible care for this patient,’ he said. ‘Oftentimes, even despite that, this is the outcome. That’s part of why I think t’s always important to talk to the family early. They knew how sick he was. They were ready.’

I carry that lesson with me still.

The beautiful part of all of this, is that now I get to be that neurology attending.

‘Thanks to everyone for helping,’ I said aloud. ‘We can set time of death for 11:10. All the students, please take five, get some water and forget about your other duties for a few minutes. Then I would like us all to meet outside to have a discussion.’

So I gave them some time to reflect on their own, before we all gathered in a circle just outside the ward. For all except one, this was the first code they had ever been involved in.

The details of our conversation and their personal reflections I will keep between us. The theme of our discussion though, was that the code itself a clusterf*ck of epic proportions and everyone felt the patient deserved better in the events leading up to the arrest.

‘I think we failed this patient,’ one of them said. ‘We ordered an X-ray yesterday and it didn’t happen. When we came in this morning the patient was already in shock.’

An astute observation.

The reason we failed this patient was multi-fold, I explained to them. A lack of resources means machines and scans themselves are in high demand with low supply. Poor staffing makes it hard to have someone free to transfer the patient down. A medical framework where everyone gets on a bus to leave for campus at 5:00 regardless of what’s happening on the wards doesn’t help. It turns out our patient’s blood pressure started dropping well before he was seen by us before rounds, meaning a lack of communication between nursing and doctors, or a failure to recognize a worsening patient also played a role. When the medical officer first saw him in the morning before he was too far gone, there was a window to act, but still had 40 other patients to cover and review before rounds. You could write a list a mile long.

‘There were so many elements at play that led to this outcome, and the goal of this university is not only to make you all competent clinical physicians, but also to create the next generation of leaders in Rwanda. I want you guys all to remember this and think about where we failed. Right now you are students, you have to watch and learn, yes, but there will come a time when you are Dr. Adeline or me, and you will have the ability to influence these networks to create better systems,’ I said.

Everyone took their chance to speak and then we paused to reflect in silence. After a few moments, I broke them the news.

‘Okay then, time to start rounds.’