The ‘black cloud’, it is a title no medical personnel wants to carry or be associated with. In medicine it is reserved for the person who seems to have the worst cases, the most dramatic and crazy cases, or seems to have the most cases period. And then on the contrary few are labeled ‘white clouds’ meaning they typically get fewer cases or easier ones with less emergent procedures. And when a ‘white cloud’ and a ‘black cloud’ are on together every one wonders who will ‘win out.’ In the USA or Africa it is the same. Every team has a few physicians with each label and everyone else on the team silently or not so silently dread being on call with the ‘black clouds’ and breaths more easily when on call with a ‘white cloud’. Believe it or not there actually has been research done regarding this (PubMed "Black cloud" vs. "white cloud" physicians - Myth or reality in apheresis medicine?). Surprisingly (or not), there actually is no statistical correlation. So, why then in a scientific field that so heavily relies on ‘evidenced based medicine’ and statistically relevant data do we disregard the science and still have these superstitions? My personal belief is that we all need something or someone to blame. When the train wreck of a case comes in and you do everything right and everything just like you were taught, but the child still dies and you have to tell the family you tried but you were not successful. How do you deal with that internally? It is much easier to say, well it was because so and so was on and he is a black cloud. You can imagine it is not a great feeling to be labeled a ‘black cloud’ and can be quite discouraging. Is it because I’m cursed? It is because I’m not as good and so everyone dies when I’m on call? Is it because the Lord is preparing me for something worse later on? As you can see, Satan can use this little superstition to play many games with our heads. It is a constant battle in medicine whether we chose to notice it or not.
To be clear, I am not endorsing this kind of labeling. I very much believe and am confident in a God who is 100% sovereign over every single detail in every single patient that comes in and who is there to provide care for them. But, the underlying stigma remains. In residency I was labeled a ‘grey cloud.’ Not clearly one or the other. I definitely had nights that made for crazy incredible stories. I had nights and days that made for heart wrenching stories. And I had plenty of and mostly days and nights without anything going awry. But isn’t it just like us to only remember the bad days and nights? It is so much easier to remember the bad stories that gripped our hearts and every single mistake we may or may not have made. But do we remember all the times that God provided and came through? The times He did heal and how out of our 40 patients all of them but the 3 are getting better and should go home. Or do we focus on the 3 who inevitably take 90% of our time even though nothing seems to work? Are we defined by the 3? Of course, we should always in everything we do strive to be and do our best. Our goal is always that 100% of our patients would get better and go home to their families healthy.
But that is not up to us.
And there’s the rub. No matter how you look at it, medicine tries to make everything about you; if you’re good enough or not, if you’re smart enough or not, how many patients you’ve lost or saved. As if any of this were up to us! We all need a daily, or even hourly reminder that NONE of this is about us! His ways are higher than our ways, and His thoughts are higher than our thoughts (Is 55:9). “God is in Heaven and does whatever He pleases” (Ps 115:3). He alone holds the keys to life and death (Revelation 1:18). “The Lord gives and the Lord takes away, blessed be the name of the Lord” (Job1:21). And maybe even more encouraging to a Christian physician (or any person really) fighting the lies of being a ‘black cloud’: “The people who lived in darkness have seen a great Light and for those living in the land of the shadow of death, a Light has dawned.” (Matthew 4:16); “That Light shines in the darkness, and yet the darkness did not overcome it” (John 1:5); “I have come as Light into the world, so that everyone who believes in me would not remain in darkness” (John 12:46); “For you were once darkness, but now you are Light in the Lord. Live as children of Light” (Ephesians 5:8); “God is Light, and in Him there is no darkness at all” (1 John 1:5).
Praise the Lord! He is LIGHT! And darkness CANNOT overcome Him! Death is not the end, and it has been defeated. And for each of these precious children, made in His image, He has the ultimate victory even in their stories. For He made each of them, crafted them in their mother’s womb. And He has brought ultimate healing not only to their bodies, but for some even to their souls. He has truly overcome the darkness right before my eyes but I do not always see it.
As you can imagine given this introduction, things have continued to be difficult here the past week. We did have a few calmer days, but each of my call days have come with very difficult cases. Last Monday early in the morning our child fighting Malaria passed away. Her case was hard for many reasons. She was the only girl in the family and her father and brothers wept over her. It also seems crazy to think that we are still losing children or anyone to Malaria in the 22nd century. But here we are. Overnight when I was on call we received a patient from another hospital who had sickle cell. She was in a sickle crisis and needed more respiratory support than this hospital could give. They intubated her and sent her to us. But when she arrived we were fighting a losing battle. We noticed that with every breath we gave her air was leaking into the skin and tissues around her neck, down into her arm, and even down around her heart (as seen on xray and CT). We had to give her breaths, but with each one the problem grew worse. Every breath literally saving her and killing her at the same time. Essentially we think that her trachea (air way) had been punctured when she was intubated making air leak into everything around it. We tried everything we could think of and brought in several other physicians to try to help figure out how to save her. But she passed away about 6 hours after arriving at Tenwek.
The next day we had a 10m old baby come in from another hospital also needing more respiratory support. The story was that 4 days prior she had fallen off the bed and when mom went to catch her a pot of beans that were cooking splashed in her face. But her entire face, ears, and part of her scalp were burnt pretty badly. But that didn’t account for the fact that she now needed to be intubated and had fluid collecting in her lungs. She was so sick when we received her that we could not get a single IV in her. We literally had someone trying to get a line in each of her 4 extremities while I bagged her. Peds surgery came and put in a central line and a chest tube and she seemed to stabilize for the time being. But something wasn’t right. Her facial burns were bad, but not enough to cause everything we were seeing. So, we checked her liver and kidney function and found out that she was already in fulminant liver and kidney failure. She was already getting acidotic. So my team went back to the family and asked more questions. And then we found out they had been treating her with ‘herbal’ medication for some time prior to her arrival. Herbal medication poisoning is way too prevalent here. Essentially the local medicine man gives the family a bag of leaves (who knows what they are) and they are told to grind them up and boil them in water and give them to the child. This is what lead to the demise of the first child who passed away after I arrived. The herbs lead to liver failure and then to Stevens Johnson Syndrome and he passed away after aspirating his food. In this patient it had not only injured her liver but also her kidneys at least. I still don’t know where the fluid in her lungs came from. Most of the day she stayed the same, but I had a horrible feeling about it. I was on call last night and went to see her before going to bed. We changed a few things that seemed to help, and we were treating her acidosis as aggressively as we could. For a minute I thought maybe she might turn the corner but she had not had any urine in almost 36 hours and her liver and kidney functions all kept worsening no matter what we did. This morning started with her heart slowly dropping but responding to CPR and 2 rounds of epinephrine. Her acidosis and kidney and liver functions continued to worsen despite all we did. So, this morning we had to tell the family that she most likely would not live through the day apart from a miracle from the Lord. We prayed with them, and they decided to make her DNR (Do Not Resuscitate). Then I was informed that I kiddo we admitted at sign out yesterday for a small oxygen requirement suddenly passed away on the floor overnight. He had CP and just had a little more work of breathing yesterday so the father brought him in. I looked over his chest xray with my medical officer and we noticed that his heart had been slowly enlarging over the past few months based on prior xrays. It was too late in the day to get an ECHO so we would have to wait until Monday. He was only requiring a small amount of oxygen and otherwise doing well, so we decided to treat him symptomatically until we could get more information on his heart. But overnight his father noticed that he no longer had a pulse. We are not sure when it happened or what happened. But CPR was done for a while with several doses of epinephrine but ultimately he passed away early this morning.
This morning as I was processing all that happened overnight I realized that I have only had 1-2 call shifts where all my patients lived through the night and into the morning. With the one last night there have been 7 children pass away since I arrived and one on the brink. But the Lord has been gently reminding me this morning of all the ways He has provided and brought healing during my time here. My initial baby with pneumonia now 11 weeks old, will hopefully be extubated in a few days. For about a week and a half after he arrived I thought he was going to die on me almost every single day. But at one point he was so close to death our team just stopped everything we were doing and prayed over him. We prayed for God to intervene and work a miracle. And God did. He ‘suddenly’ stabilized and has been improving since. Multiple kiddos with TB, or HIV, or bad meningitis or even fungal infections in the brain, kids with nephrotic syndrome (kidney disease) have all improved. Tiny little premature babies are thriving and growing and feeding well. And even several others that have had poisoning of various types, some herbal medicines and some accidental, have improved and gone home healthy.
So, despite the temptation to make it a numbers game and calculate the mortality rate of my patients while I have been here, I’m choosing to praise the Lord for the ways He has brought healing. Healing on earth and ultimate healing in eternity. And praising Him because in Him I cannot be a ‘black cloud.’ No, I am His child, and therefore the Light is in me. And the Light that overcomes darkness. I will give my best, and continue to pray that the Lord makes me a better physician every day. But I am continuing to learn to surrender to how He chooses to bring healing and Light to these families and patients.
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