Perspective
Reflections on an Untimely Death
Could volunteers from the United States have prevented a Nicaraguan woman's demise?
By Therese Zink, M.D., M.P.H.
Breathless from running to find me, her black eyes wide with panic, Lupita, the translator, blurted, “She’s having a heart attack.”
Immediately, I knew that Lupita was talking about Célia.* I had checked on Célia 20 minutes earlier. She had been resting quietly in the inpatient ward of the small Nicaraguan hospital where I was volunteering. The room smelled of ammonia as a woman mopped the lackluster ceramic tile floor. Fluorescent lights hanging from the water-stained ceiling flickered and buzzed as they illuminated the dingy yellow room. Scattered around it were cracked, white plastic chairs. Six rusty bed frames sagged under plastic-covered mattresses. Each held a patient surrounded by their family, hovering like patrons at the stall selling corn-on-the-cob down the block. Family members provided sheets and blankets, and fed and nursed their loved one—tasks the nurses were too busy to do.
Célia’s bed stood in the far corner under a grimy window. Her sister kept watch.
Earlier in the day we had done a hysterectomy for cervical cancer. The anesthesia had worn off, and she was restless, complaining of back pain. I asked the nurses to give her a pain shot. They sent Célia’s sister to the pharmacy to buy diclofenac, a cousin of ibuprofen. When I last saw Célia, she had received the shot and was sleeping peacefully, her frizzy brown hair, fair by Nicaragua standards, uncoiled over her pillow.
As one of two doctors and several nurses who had volunteered for the medical team of a Minnesota nonprofit, I was here to screen for cervical cancer. We collected Pap smears, then carried the slides home in our luggage to be read by pathology technicians at the local university. Follow up and treatment were provided on future visits. The nonprofit sent a delegation to the community three to four times a year.
Nicaragua has national health care, but the wait to be seen is long and services are limited. Physicians are salaried and provide care in government clinics, but most see patients privately as well, often in the physician’s home. If patients pay, they can be seen more quickly. However, the local gynecologist directs public patients to his private clinic, where he charges them for services that should be free. The local director of our organization, Luis, says, “Este doctor es corrupto!”
The nonprofit had worked with this rural Nicaraguan community for more than 12 years. As a resident of the town for most of his life, Luis understands the needs of the community and guides the nonprofit in partnering with the locals; he knows their priorities. Prior to our arrival, Luis hand-delivers appointment times to patients. The dates that our brigade will be in town are announced on the radio. More than half of our patients walk several hours or bounce on a bus for the better part of a day to see us.
Of all our patients, Célia had the most troubling diagnosis. She came to her appointment on a Tuesday afternoon. Paul, our team’s gynecologist, sat with her and explained the results of the colpo-scopy performed during an earlier visit. Lupita helped him explain why he needed to remove Célia’s uterus. He drew pictures showing where the cancer cells were located and how they could spread unless surgery was performed.
“Este muy gravid,” Lupita stressed.
Célia’s sapphire blue eyes were serene as she heard this news. “Tengo dos ninos. No quiero mas ninos,” she explained in a soft voice. At 35 years old, she didn’t want any more children. She asked a few questions and then agreed to schedule her surgery for the following morning. I completed her history and physical and wrote admitting orders. She went home to gather a few things and settle her children, returning later that evening with her sister. The next morning, the local nurses prepped her for surgery.
Paul removed Célia’s uterus without a hitch.
Now Célia was three hours postop. What was happening? I sprinted through the courtyard, down the drab hallway, remembering her smile when I’d checked on her before surgery and the reluctance in her step as I’d helped her onto the table in the operating room.
Célia’s brown chest was bared; the local internist pressed his palms between her breasts performing cardiopulmonary resuscitation. The breasts that had fed her sons were exposed for all to see. Her wide blue eyes stared, lifeless. To my horror, no one was giving her mouth-to-mouth resuscitation. There was no emergency cart, no mask for mouth-to-mouth, no oral airway. A nonfunctioning oxygen machine stood next to the bed.
Adrenaline coursed through my body, but my muscles froze. How to join in? I should give her mouth-to-mouth, put my lips to her lips, but I could not. My feet seemed glued to the floor. Other patients and their families gawked. How to create privacy? I didn’t know enough Spanish to ask how to help or to ask for the tools I needed. Finally, in seconds that felt like hours, the local staff moved her into the operating room and the anesthesia technician put a breathing tube down her throat.
Now I could assist. With my stethoscope, I only heard breath sounds in the right side of her chest, so I directed the anesthesia tech to pull the breathing tube back from her right lung so that air could pass equally into both lungs. As I helped him tape the tube in place, a surgery nurse attached leads to Célia’s chest so we could check her heart rhythm. The monitor showed a straight fluorescent yellow line. We checked to make sure all the leads were attached. Still a flat line. Another nurse wheeled over the defibrillator. The internist applied the pads to her chest and called, “Claro.” Everyone stepped back. Célia’s body jumped with the voltage.
No change—flat line.
The local gynecologist arrived and joined the effort. Over the years, Paul had tried referring cases to him, but he had not managed them appropriately, either repeating procedures in his private clinic so he could charge patients or telling them that our Pap smears were incorrect and reassuring patients that they did not need the treatment that we had recommended. Given this “corruption,” we quit sending patients to him and worked with the hospital to identify gynecologists in another community with whom we could work. What were his intentions now?
I took over CPR, my palms pressed against Célia’s warm sternum, trying to squeeze her heart: one and press, two and press, three and press … circulate the medications, stimulate her heart. It was a relief to see the Nicaraguan team follow the familiar protocol.
Wake up Célia, I mumbled under my breath. One and two and three and … At 4:45 p.m., Paul materialized, breathless and disturbed. I filled him in as I continued to push on Célia’s chest.
“Maybe a reaction to the med or a blood clot,” Paul said and fingered his collar. “Or bleeding from the surgery site.” He pulled on a latex glove and reached into her vagina to check for bleeding. The cloth sponges were barely moist with blood. His relief was palpable.
We ran the code for 30 minutes and pronounced Célia dead at 5 p.m. The Nicaraguan team clustered together on the far side of the gurney and conferred in Spanish. Given our tenuous relationship with the gynecologist, we worried that he could damage our reputation and make it impossible to continue our work here. Paul and I needed to know what the Nicaraguan team was saying. I grabbed Lupita by the elbow and traipsed over to the group. “Lupita, please translate,” I urged. Paul followed us.
They were discussing internal bleeding. The local gynecologist wanted to check Célia’s abdomen for blood. Someone handed him an 18-gauge spinal needle and 50-cc syringe. Authoritatively, he bared Célia’s abdomen and shoved the long needle in just above her pubic bone. If there was blood, it meant that Paul had missed a bleeding vessel.
Paul watched as if he was preparing to take an exam, sweat beaded on his forehead. He stared at the syringe, a slight twitch in his upper left eyelid.
The local gynecologist drew back on the plunger. No blood. A collective sigh.
I asked Lupita to help me tell the Nicaraguan doctors about the timing of the pain shot, given barely 30 minutes before Célia stopped breathing. Perhaps she had had an allergic reaction.
“But no hives,” the local internist pointed out in Spanish after lifting the white sheet to examine Célia’s body for red blotches.
“True, but sometimes hives are absent with allergic reactions,” I replied. “Perhaps a pulmonary embolism,” Paul said. Célia’s legs had been up in the stirrups for two hours. If we had been in the United States, we would have wrapped her legs with elastic bandages to prevent blood clots; but here we had no such bandages. In addition, Célia had been on oral contraceptives, which could have increased her risk.
The local physicians continued to converse. Lupita motioned to me, then mouthed, “Célia’s sister.”
Paul and I trudged into the courtyard and collected our thoughts. During the day, the area bustled with patients and staff. Now all was silent except for the janitor, who pushed a pile of trash with his broom: dirt, crumpled papers, and empty plastic bags that had contained juice. Beyond a brick wall the trash smoldered. Whiffs of smoke floated by. After surgery, I had tossed a clear plastic bag filled with bloody gauze and paper drapes into the orange and gray embers. A few turkey vultures poking through the garbage at the edge of the cinders fluttered in surprise.
As Paul explained the possible reasons for Célia’s death, Célia’s sister hung onto a friend, burying her face in the friend’s shoulder like a small child. She wailed and blurted words I couldn’t understand between sobs, her thick body shuddering as if she had teeth-chattering chills.
Then she straightened her posture and pushed strands of dark hair from her face. She rattled on in Spanish, too fast for me to understand.
“They are worried about a coffin. They are poor,” Lupita said.
“How much does a coffin cost?” Paul asked.
“Two to four thousand córdobas,” Lupita answered.
About $100 to $200 U.S. dollars. Paul and I looked at each other and nodded. “Tell her we’ll take care of this,” Paul said.
We agreed to meet at the hospital later that evening with the money. The sister and friend hurried off to secure a coffin.
We returned to the operating room. The local team had decided that the death was caused by either an allergic reaction to the pain medication or a blood clot. Autopsies were not performed here. They reassured us that there would be no further investigation. The local gynecologist helped Lupita and Paul write a note for the medical chart.
Within half an hour, two men carried a tan metal coffin into the back hallway where Célia’s body lay draped with a sheet on a gurney. Her Mickey Mouse-patterned quilt, polyester dress, and cotton panties and bra were folded at her feet. Paul and I pulled out the IV lines and breathing tube and removed the pads from her chest. Then we helped the nurses lift her naked body into the coffin lined with imitation white silk. I struggled to support the weight of her legs, her body odor already musty. A nurse double-checked Célia’s wrist for a pulse, then covered her with the sheet. She directed me to tuck the faded quilt and clothes into the coffin at Célia’s feet. The lid clicked shut.
A glass window in the upper part of the lid was covered by a small door with a tiny knob. Lupita tugged open the little door and looked inside. I followed her to see what she saw. The window framed Célia’s wide face and her halo of frizzy brown hair.
Two men lifted the coffin and carried it through the halls of the hospital. Adults and children sat and stood. Some were waiting to be seen, others were visiting loved ones. Everyone’s eyes followed the coffin out the front door.
The men set the coffin on a concrete bench just outside the building. Passers-by gathered, taking turns opening and closing the little door to peer inside at Célia, as Lupita had done. Patrons from the corn-on-the-cob stand wandered down the street to look through the window in the coffin lid.
I stood near the front doorway of the hospital watching the parade. Were they showing respect? Or were they curious, checking to see who had died? Was anyone saying that this was the woman the U.S. doctors had taken to surgery? No one glanced toward me. This was so different from my experience of death in the United States.
The stream of locals opening and closing the door in the coffin lid continued for about 10 minutes. Then a large white pick-up truck with “Ministry of Health” painted on the door pulled around the corner and parked at the curb. Two men hoisted the coffin from the cement stoop, loaded it into the back of the truck, and hauled it away.
After the crowd thinned out, Luis pulled up on his motorbike. His face was contorted as he chewed his cheek and played with the snap on his helmet. He’d heard rumors. I summarized the events for him. He worried about what this meant for our work. “I’ll watch for reactions as I visit the communities these next weeks,” he told me.
I walked alone the five blocks to the restaurant for dinner. Finally, with a moment to myself and no one to take care of, my mind flooded with thoughts: Why had I hesitated to put my lips to Célia’s and breathe into her lungs? Was I afraid of catching something? My cheeks burned at the thought. Or was I afraid to insert myself too quickly into the code? The internist was in charge, this was not my world. If I had given her mouth-to-mouth, would it have made a difference? Would Célia have lived? In the United States, a death so soon after surgery would raise concerns about malpractice; but here no one brought it up.
Following a dinner of rice, red beans, and chicken, Paul, Luis, and I returned to the hospital with the money for Célia’s coffin. Célia’s friend waited near the doorway of the inpatient ward, the site of Célia’s code. There was no hint of the earlier drama; once again all six beds were occupied, each patient tended by family and friends.
We sought privacy again in the nearby courtyard. Paul expressed his sadness about the outcome of the surgery. Luis translated. “Lo siento mucho …”
Célia’s friend described Célia as allegre … she filled the world with joy. “It was Célia’s time. These things happen. Sólo Dios sabe.”
Our absolution. Here it was accepted that some things ended badly, despite all good intentions.
Paul took a step back, perhaps still slogging through his guilt. Tears welled in my eyes; suddenly the dust from the street scratched the back of my throat. I prayed silently for the two motherless sons, the elderly mother now preceded to her grave by her daughter. Célia, her wide smile, frizzy hair, and sapphire blue eyes, only 35 years old. Swallowing hard, I struggled to control my tears.
Luis handed Célia’s friend the envelope with money for the coffin. More condolences and goodbyes, then our small group separated. Luis sped home on his motorbike.
Lost in our thoughts, Paul and I ambled back to the hotel, stepping in and out of the light cast on the dirt street from the open windows and doors. A soft rain dampened the ground and stilled the dust. MM
* The patient’s name has been changed.
Therese Zink is a family physician in Zumbrota, Minnesota, and a professor in the department of family and community medicine at the University of Minnesota.