Beyond the bedside.

Abstract

His small body lies there. Limp. Lifeless. Limbs assume a flopped out, semi-flexed position, without strength to resist the pull of gravity below. His fontanelle, normally flush with the surrounding skull, creates a diamond-shaped depression at his vertex. Skin, doughy from lack of fluid hardly retracts when I pinch it between my two fingers. His small heart beats vigorously. Half-closed, sunken eyes show he is fast losing a desperate fight for life. He has a name, but it could be Deng, or Lual, or Dut, such is the frequency we see patients in this condition. His family have travelled by foot from a village several hours away. They have come late. Almost too late. His peripheries are cold, blood vessels constricted in an effort to maintain perfusion to his vital organs. Tourniquet-ed limbs are pulled into position seeking a small vein. He bears several puncture marks over his scalp. But there is not enough blood flowing to feed the small plastic cannula that could save his life. We have no time. He barely flinches as I drive a large needle through his skin and into the bone in his leg. Pushing and twisting until a ‘pop’ indicates that I am in the marrow below. Fluid flows through bone into venous tributaries to feed his thirsty tissues. Several hours later, he shows signs of improvement – his eyes start to glisten, he stirs when he is handled, his skin and lips appear plumper. His heart has slowed. A bag of fluid has saved his life. Six years later, I still often think of the Dengs and the Duts. They have defined my career path – from the remote, dusty walls of our hospital in South Sudan to our Paris-based Médecins Sans Frontières (MSF) headquarters. Every year 5.9 million children under 5 die.1 Over half of hospital deaths occur within 24 h of admission, highlighting the importance of rapid, effective evaluation and treatment.2 Most of these deaths could be averted with simple, affordable interventions: in the case of Deng, a bag of fluid to treat hypovolaemic shock. But getting the right treatment to the right person at the right time requires functioning systems, co-ordinated logistics and trained health personnel – often severely lacking in the settings in which MSF works. Caring for a critically ill child requires a holistic approach, evaluating and responding to all needs with the available resources and contextual constraints. The majority of those working in our projects are national staff and investing in their professional development is crucial to improve patient outcomes. Standardised trainings based on locally relevant guidelines provide consistency, increase staff capacity and improve standards of care. The MSF Paediatric Emergency Hospital Care course was first introduced last year. Throughout 5 days of exercises, case studies, skills stations and simulations, it is a joy to witness participants expand their knowledge as nurse–doctor teams work together to manage their patients. In the process, I am a facilitator rather than instructor (Figs 1, 2). They learn from me, but – more importantly – they learn from each other, and from themselves. By fostering a culture of construction, rather than instruction, this process continues beyond the training as they pass on their new skills and knowledge to their colleagues. After all, it is they who will be looking after Deng long after I am gone.