On Friday I had my first patient die since arriving in Asmara.

The infant was 7 months old and weighed only 4.5kg on admission. She was dysmorphic, but I was unable to identify a specific syndrome.

When we saw her first thing in the morning she warranted admission to a PICU. She was in moderate to severe respiratory distress and had extremely poor perfusion. Her extremities were cool from her toes to her hips and her skin turgor was poor. And she was hypoglycemic with a blood sugar of 17.

We gave her a fluid bolus (but did not write for anymore fluids after the initial 20mL/kg, because my attending thought it would be better to wait and see) and a bolus of glucose. By the time all of this was up and running she was in worse respiratory distress - now grunting and kussmaul breathing. But we did not have the ability to get a blood gas or to provide any more respiratory support than several liters of oxygen per minute via nasal cannula. The chest x-ray revealed only lobar pneumonia in one lung field, but thankfully no evidence of congenital heart disease or pulmonary edema. By giving her continued IV fluid at an unknown rate, antibiotics and some supplemental oxygen we had done all we could. We had to wait and see.

I went to lunch with a heavy heart. When I returned I found that the infant had begun vomiting bilious fluid and her skin had taken on a more dusky color. Her perfusion and skin turgor had improved to a small degree, but her breathing had become agonal. I decided to be more aggressive. Even though we had no ventilator and the staff was not accustomed to rescusitating infants - didn't I come to help? There was more I could do for this child and I thought maybe I could save her life. Because, as I stood there looking at her I knew that if I did not, she would surely die.

I asked what had happened to all of the supplies I brought. It turned out that they were still sitting in a closet, untouched. Even though we do not have a pediatric ICU, I know there is an adult ICU. Could they not use the laryngoscope and endotrachial tubes? What about the medications? Epinephrine, antibiotics and toradol can be used almost anywhere in the hospital. But I did not have time to further contemplate these things. I had a sick patient to attend to.

What a disaster!?!? I don't know what I was thinking. We didn't even have sufficient suction equipment available. I was able to intubate her (thanks to all my practice in the controlled setting of an operating room before I left home), but it was too late. I still don't understand why her color did not improve despite bagged ventilation with 100% oxygen. I attempted to suction through the endotrachial tube with an NG tube - but to no avail.

Not long after the rescusitation started I suddenly noticed that the CO2 detector was no longer changing color. I re-checked the placement of the tube, but it was still in place. My second assumption was the correct one - she no longer had a heart beat. Of course a monitor would have alerted me to a problem before she went asystolic, but I had no monitor.

After several rounds of CPR we pronounced this poor child dead.

I suppose we could have made more of an attempt to save her life, using medications to help with the rescusitation - but what was the point? We still had no monitors, no ventilator, no real support for a critically ill child.

I feel like a fool. I came here thinking I could make a small difference, in the lives of a few children. But I have nothing to offer. I have been trained to practice medicine in the United States. I don't know what to do without my modern equipment - blood gases, CT scans, monitors and ventilators. Effective suction for crying out loud!

But then again, that is really why I am here. To learn. To learn how to practice medicine without all the accroutements of the developed world. To learn about life in Asmara. To learn humility.