Maxime Billick

The boy had skeletal arms, skin stretched tight over protruding ribs, and a balloon belly like a comical fat suit. I was working at a rural hospital in northern Ghana for the month. The rotation fulfilled my medical school clerkship requirement of “rural family medicine,” but in truth, it was an intense mishmash of internal medicine, pediatrics, obstetrics, surgery, and all the associated subspecialties.

During my time there, the boy visited the hospital frequently for paracenteses. The first time we met, his ascitic fluid was thick and bloody – watered-down tomato juice. He remained inflated despite three litres drained, but we were able to palpate the rough nodular surface, the crannies, the mountainous landscape of his liver that extended far beyond the normal margins. It was clear that he had hepatocellular cancer.

He lay stoic as the peritoneal fluid flowed. His eyes were wide and almond shaped, exaggerated by his thinness. His eyelashes curled 360 degrees to overlay upon themselves. With high angular cheekbones, plump round lips, and the delay of puberty that often comes with chronic disease, he was delicate and pixie-like.

The paracentesis initially improved his symptoms, but several days later he returned for another fix. Again we drained it. Again it was bloody. This time he winced as we stuck him with the needle. I expected his belly to deflate like a popped balloon.

A week later he reappeared moaning in pain. Legs increasingly edematous. Belly beyond comical. Farcical. Unreal. Unfair. The boy was singing a soft wail that pierced my ears and sliced into my bowels, twisting them until I felt queasy. The staff physician had decided it futile to continue the taps; it wasn’t sustainable. The boy’s father was at his side. His mother had shed a single tear the day prior, before hurriedly wiping it away. Apart from that, they were calm.

Lost in my own questions concerning paracenteses and utility in HCC, pain medications and palliative medications, potential next steps, I failed to notice his whimpering soften. There were no breath sounds when I pushed my stethoscope into his back or when I balanced it on his bony ribs. His chest was still. My face inches from his. I ran my index finger over his eyelashes like a comb. No blink. I pressed the fleshy part of my fingers into his wrist. Was that a heartbeat? I swear I felt a pulse. But nothing was beating. When I listened over his heart, silence. I felt my own pulse, not his. My own life source flowing through him and back to me. I waited and watched. Not the full, painful five or ten minutes we do at home, but about two or three. He had no blink reflex, no obvious last gasp, no heartbeat, no final wail of pain, just an unnoted slide into death and silence.

And seconds later from outside in the hall, his mother cried the scream he couldn’t produce. The howl of pain and irreplaceable love and loss; of regret and anger and bitter, bitter agony.

I was arrested by my role as a student and a visitor in a sociomedical culture vastly different from my own. Concerned about my role as a potential neo-colonizer, I was hypersensitive to the complexities engendered in these interactions. In layman’s terms, the fear of doing the wrong thing was paralyzing. Yet in the space of contemplation and inaction, not only did I fail to provide a soft transition into death, but I let the patient-physician bond fall to the wayside.

As medical students and physicians, we become part of our patients’ stories, of how they live and how they die. We might be powerless to change the final outcome, but can change the journey. While contemplating the boy’s next best medical step, I forgot about the person in front of me.

I was wracked with guilt. But guilt stymies; it doesn’t incite positive action. Since then, because of him, I have made a strong commitment to listening to my patients, to really hearing them, and to recognizing that inaction may be as – if not more – injurious than making the wrong decision.

I won’t ever forget those eyelashes.