Little Boy
We began every morning at that same hour, using what we were pleased to call the Nairobi Aerodrome, climbing away from it with derisive clamour, while the burghers of the town twitched in their beds and dreamed perhaps of all unpleasant things that drone — of wings and stings, and corridors in Bedlam.
— Beryl Markham, West with the Night
Nairobi was hot and chaotic and had myriad types of petty crime. Navigating the city required alertness. Most of the time, I was cocooned in the passenger seat of a Flying Doctors’ ambulance. The drivers took an almost matronly interest in my well-being, reminding me to keep the windows rolled up and the doors locked. It was 2008, an unsettled time in Kenya; a few months earlier, there had been riots following a contested election. Deep tribal resentments, worsened by a long tradition of graft, set off a wave of ethnic killings and had shut down tourism. The UN Secretary General had to intervene and establish a power-sharing government. The entire country was walking on eggshells.
Due to its massive population squeezed into a city designed for far fewer people, Nairobi was continually frenetic. At all hours, the streets were packed with cars and bikes and matatu, the shared vans whose destinations were painted brightly on their sides. All of us drove bumper-to-bumper past children in the median selling bottles of water which had been purchased in the distant past from a shop and since refilled from the tap, then cleverly re-sealed. Drinking it was certain to result in intense diarrhea. Every inch of the city was occupied; there were rusting sedans up on bricks in front of makeshift car repair shops and popup tarpaulins laid out on the concrete, displaying secondhand clothes, cheap Chinese extension cords, electric kettles, and phone chargers. Everyone carried parcels, cube-like bundles of stuff wrapped with plastic and string, and groceries. The city hummed.
The Flying Doctors logo on the door of the ambulance and on my uniform jacket seemed to provide a halo of protection from the hawkers. Everyone in Nairobi knew what the Flying Doctors did, and they appeared to take pride in what had become a hometown success story. But even without the uniform, I was rarely, if ever, hassled. Most Kenyans were gentle and decent; some were noticeably formal—perhaps a consequence of the schools, which offered a strict British public-school approach to education. Good humor and warmth, however, seemed to be a national trait. It was easy to feel welcome.
This umbrella of goodwill began on my very first day in Africa, when Pato, one of Flying Doctors’ full-time drivers, met me in the hectic baggage claim at the Nairobi airport with a sign. Pato had left his ambulance double parked outside the International Arrivals doors, its blinkers flashing. He seemed exempt from the attentions of the otherwise fastidious parking officers. Throwing my duffel bag into the back of the vehicle, next to the stretcher, I jumped in the front, and we managed to escape the gauntlet of hawkers and ersatz taxi drivers and drove into the city.
Pato was a slight but serious fellow of about thirty years old. He was one of the best ambulance drivers I’ve ever met. He wiggled the vehicle through gaps in traffic and snarled roundabouts, and he seemed to work all hours without complaint. On this first ride, we were headed from Nairobi’s international airport to its smaller regional airport, called Wilson Airport. Wilson was the Flying Doctors’ base and the site of Kenya’s Aero Club, which would be my home for the next month.
After central Nairobi’s extreme energy, it was a relief to enter the gated airport grounds and drive past the guard shack to the Aero Club. Home was to be a simple bungalow, which contained a hard bed, a mosquito net, and a TV that offered only local Kenyan channels—mostly soap operas, local news, and excessively loud ads from local shops. The club was comfortable enough, but it was an anachronism, a dusty legacy of times past when white Africans would fly into the city for weekends from their rural farms and estates. The club had a long bar, a dining room, and a few rooms available for rent. On Fridays, the place would fill up and the garden would burst with noise. But most nights were silent and empty.
I quickly established a routine. Flying Doctors provided a bicycle, and I would bike the mile between the Aero Club and the Flying Doctors’ hangar using the protected service road inside the airport. The bike was an old-fashioned single-gear unit, and I felt daintily Victorian heading back and forth in my uniform shirt and work boots. I would head to the base in the mornings. Usually, there would be a mission being organized or a range of administrative tasks to be done at the hangar: equipment checks, medication reviews, and paperwork.
My first rescue came soon enough: on my first morning in Africa, we were headed to Tanzania. I had a short time to get ready.
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I first saw them waiting for the planes at the edge of the dirt runway in Tanzania. There were seven people, five of them children; all were injured to various degrees, but from a distance it looked like the kids were all moving. Except one. On the grassy earth, unconscious, lay one little boy.
Slowly, the story came together for me. There had been a celebration in Tanzania, just across the Kenyan border, the night before. Not far. The family had dressed up in their nice clothes, excited for a night out, and driven several hours to the party. They had eaten well and laughed with friends. When it got late, the mom and dad belatedly said goodbye to their hosts and carried their tired kids to the car. On the way home to Kenya, the children quickly fell asleep—like any kids would—lulled by the sound of the car engine. The night sky was pitch-black; it is unlikely that the car’s headlights were able to fully pierce the dark. The mom and dad opened a window to the fresh night air and kept the radio low, to avoid waking the kids.
Without warning, disaster struck. In a blind instant, the SUV hit—at full speed, and without braking—the back of an unlit tractor wending down the dark roadway.
The children’s mother later told me that after the explosion of noise and airbags and broken glass, there was only lingering smoke and a profound silence. Then, in the back of the vehicle, the children began to scream. The adults, seated in the front, were most damaged; they had broken their arms, their legs, their backs, and their pelvises. Protected in the back, the children had fared better and been left bruised and pummeled, but not seriously injured.
Except there was one child who hadn’t been in the back. He was a little boy who had been sleeping in his mother’s arms. The mother didn’t remember the airbag. She said that, upon impact, the little boy had been launched from her arms into the windshield. When the dust settled, there was a crater in the glass. The little boy, sprawled on top of the dashboard, was unconscious.
What happened next was ugly. The noise of the crash had roused the locals, mostly subsistence farmers. Despite the dark and the lateness of the hour, people emerged from nearby huts and shanties and began milling around the car. Some tried to help; others only watched. While the stunned family crawled out of the wreckage through one of the SUV’s doors, thieves entered through the broken windows. They helped themselves to bags, phones, wallets, and everything else of value.
One good soul called the local tiny hospital for an ambulance. And, knowing that their wounds were severe, the injured husband managed to dial Flying Doctors in Nairobi directly, using a borrowed phone.
Hours passed as they waited for the clinic’s ambulance. When it arrived, the family —the wounded parents, the unconscious little boy, the panicked children—were taken to the small rural hospital nearby and were told that they must wait for treatment until morning. The doctors at the hospital couldn’t do much, and Flying Doctors wouldn’t fly until dawn.
Notified of the mission early that morning by the control center, I sat in a taxi that had idled in the dark outside the Aero Club as I finished my shower and found a uniform shirt, my boots, my crew ID badge, and my stethoscope. The hangar was busy. The flight coordinators had decided to send two planes for the seven patients, and the crew were busy stocking both planes. Nurse Michael and I would go on one King Air, and nurses Asher and Kione would take the other. The team moved with lightning efficiency; maybe twenty minutes had elapsed between my alarm clock and wheels-up.
Once in the air, the second plane stayed not far off our wing for most of the flight. Dawn arrived as we crossed into Tanzanian airspace, and I could see the rural homes awakening, movement in the fields, smoke starting to rise from cooking fires. Descending toward the crude runway cut into the savannah, the pilots of our plane circled several times to make sure the field was free of livestock and wild animals before lining up for a landing. We flew just above the trees, then lowered quickly into a clearing, which was really nothing more than a length of red earth scratched into the grass. We landed with a bump, decelerated quickly, and taxied over the rough ground to the far end of the strip. The pilots made a sharp turn, pointing our nose back toward the strip, and we hugged the edges of the field to give the next plane room to land.
The King Air is a big twin turboprop. Its wingspan is almost sixty feet. With its bright spotlights on, the second plane approached the strip at an angle to compensate for side winds. On its wings, warning lights alternated, right and left, flashes of bright white. Despite the plane’s width and speed, the pilots descended with total confidence above the trees and touched down without incident at the nearest edge of the field.
It’s hard to convey the immense power of that moment. I was struck by the sheer improbability of landing a massive turboprop like the King Air on such a small strip of grass, the confidence of the pilots, the absolute stability of the descent, and the plain competence of the entire operation. I was strangely moved by this moment of grace. The emotional detachment I carried on missions faded for a brief moment; I was simply awed by the awesome execution.
Once Kione and Asher’s plane pulled next to ours, it was time to work. After the pilots shut down the engines, we grabbed the equipment bags, and the four of us approached the muddy road next to the strip where two ambulances from the hospital had been waiting for us. As we got close, I could see several bandaged bodies lying on the grass next to the white vehicles; there were others sitting up next to them. When we got to the ambulances, we immediately opened the rear doors; inside, there were stretchers with more bodies on them.
They teach us that our priority, when walking into this sort of situation, is to make order from chaos. You need to quantify what the situation is: you must sort the injured into groups, prioritize the care each patient needs, and then—finally—make a plan for how to deal with the injured in relation to the greatest needs and the available resources.
There were seven patients. Our priority quickly became triage; we needed to figure out who was hurt and how badly. The protocols meant that those without a pulse (called “black”) would receive no care; critically ill (“red”) patients would become immediate priorities, followed by the moderately ill (“yellow”); and then the “walking wounded” (“green”) would be treated. We had one red, two yellow, and four green patients. Kione and Asher would manage six patients: they would start IVs, splint bones, immobilize necks, and bandage bleeding wounds. Michael and I would manage the sole “red” patient: the two-year-old boy who had been launched into the windshield and was now minutes from death.
He was a beautiful, strong little boy. He wore a stained diaper but no shirt or shoes, and he was covered in dirt and glass dust. The hospital hadn’t had the resources or experience to provide any care, so the ambulance attendants had simply laid him on a bare stretcher, on his back, in one of the ambulances.
We always begin with an assessment of three things: airway, breathing, and circulation. Can the child maintain a patent airway? Is he breathing on his own, or does he need support? Is his heart pumping blood to his other organs? And can he maintain an acceptable blood pressure? Once those things are assessed as stable, we do a systemic but brief head-to-toe exam to look for injuries. Then we formulate a plan. We are rigid about approaching severe injuries in the same way every time; otherwise, it’s too easy to be distracted by, say, a gruesome broken bone and neglect the truly life-threatening airway problem. For emergency doctors, this way of doing things is reflexive—like breathing.
Michael and I didn’t like what we were seeing. The boy was unconscious, not crying at all, and there was a trickle of dried blood that ran from his mouth to his ear. He was maintaining an airway, barely, and was working hard to breathe. With concern, we watched him struggle to take frequent, shallow breaths. He had bruises on his head and his abdomen, which was puffed out and firm. This was a serious injury.
We slid an immobilization device under the child. Michael picked up both and, holding them as flat as possible, delicately carried the boy to the plane. Once he was on our stretcher, we connected the monitor and checked the boy’s vital signs. The numbers weren’t good; they supported our initial impressions of shock and respiratory failure.
There was a lot that needed to be done immediately, but our priority was to support the boy’s breathing and protect his airway. We had to keep him from choking on blood and vomit. We also had to ensure sure that he was perfusing his organs with oxygenated blood. Michael bent down and started two tiny IVs in the boy’s fragile arm veins.
There is nothing worse than having to resuscitate a child. Kids are built solidly, and their heart and lungs are powerful. Their bones flex; they’re not brittle like an old person’s. Their bodies resist injury. When children are seriously sick or injured, they hold on for the longest time, until they can’t, and then they crash. Adults tend to wither, incrementally and visibly; with them, you have time to prepare for what’s next. Not so with children.
Injured kids run against the natural order of things. Their innocence and their vulnerability impose a huge responsibility on a doctor. We must do more than our best; our work must be flawless because the stakes are so high. For most emergency physicians, pediatric resuscitations are rare. We know how to do them, of course, and have practiced again and again. But they are uncommon, and each resuscitation we conduct occupies a permanent place in our heads and is relied upon to guide the next resuscitation.
Fixing kids doesn’t come automatically; we don’t retain that muscle memory. Because we do pediatric resuscitations infrequently, every step requires concentration and deliberate thought, and we become unavoidably emotionally involved. To counter this, we use checklists and easily remembered color-coded charts to make thinking as effortless as possible. Even pediatric emergency doctors, who see kids all day, infrequently deal with crashing children. That’s a blessing.
With the plane’s doors open, I rooted through our uncommonly used pediatric airway bag and prepared the equipment for an intubation. We needed to put in a breathing tube and place the child on a ventilator. We unrolled a color-coded measuring tape and, based on his estimated weight, I selected a tiny laryngoscope and an even smaller endotracheal tube. Michael prepared the transport ventilator and placed an oxygen facemask on the little boy, running it on full to allow his body to build up as much of an oxygen reserve as possible.
Next came the complex drug calculations: such a small child required a fraction of the adult dose—and often different medications, as well. I wrote down the calculated doses on an IV bag wrapper, and Michael checked the concentrations in the medication vials and double checked the volume of fluid he had drawn up.
We were precise, so careful. Intubating a child is a fraught procedure with little room for error. Every detail differs from adults—the shape of the airway, the floppiness of the pharynx, the way the head needs to be tilted just so to maintain patency. When all was in place, we did one final check of our equipment to make sure the light on the laryngoscope was bright and the tube was the right size and had been lubricated. Finally, we were ready to go.
To insert a breathing tube in a patient who still has a gag reflex and is breathing, doctors need to follow a discrete sequence. First, we give the patient a strong sedative, an anesthetic. Then we administer a paralyzing drug, which allows for an easier intubation and allows the ventilator to take over breathing completely. Once the drugs have taken effect, we can look into the throat and pass the breathing tube safely. We do things methodically and consistently.
Michael first pushed a strong sedative and then a paralyzing drug into the boy’s IV. After a moment, the baby twitched, and then his strained breathing stopped. I inserted the laryngoscope—basically a handle with a blade of steel—into the boy’s flaccid mouth. I looked for his vocal cords but could see only saliva. Michael and I began to suction aggressively, using the battery-operated machine, and soon blood and saliva filled the clear suction tubing. Within seconds, the alarm on our monitor started to go off: the boy’s oxygen saturation was falling. I had expected this to happen. The little boy, who already was so hurt and compromised, didn’t have the lung reserve to go more than a few seconds without breathing, and he had quickly run out of oxygen.
I put down the laryngoscope and placed a pediatric bag-valve mask directly over the boy’s mouth, the usual way we get oxygen levels back up to the point where another attempt at intubation would be safe. I began to squeeze the pediatric-sized bag, to push air into the lungs. But when I looked at his chest, I realized that nothing was happening. I was squeezing the bag, but no air seemed to be entering the boy’s lungs. The pulse oximeter began to fall further. There was still no chest rise.
“Bag, Michael,” I yelled, as I cupped the facemask with two hands to make a better seal. Michael squeezed the bag aggressively, but nothing was happening; air wasn’t moving into the lungs. I could hear the heartrate monitor beeps coming slower and slower, a truly ominous sign. The little boy was approaching cardiac arrest. I was confused. Why was the air not entering his lungs? Only seconds had passed, but they were dire. What was wrong? I felt a familiar sick feeling in my stomach—the one I get when things spin out of control. Now, I’m truly frightened. This was the worst possible situation. Was there an airway obstruction? Did I need to insert a high-pressure needle jet into his trachea to push air below the obstruction? The situation was unravelling fast.
I thought of blowing into the facemask, mouth to mask. For a second, I stared at Michael. He stared back at me. Then I gasped: “A bag—get me another bag. Michael, get another bag—any bag.”
Michael reached into the adult airway bag and grabbed an adult sized BVM, which was way too large for this child. Without an alternative, I popped the kid’s facemask onto the adult bag and squeezed the large bag delicately, with two fingers. I was trying to deliver small volumes of air; too much could cause serious lung trauma.
Michael and I waited. We each held our breaths. At first, there was nothing. And then it happened. His small chest rose. It was working. It was the bag—the bag was the problem. We were now able to push the desperately needed oxygen into his lungs. The monitor started to beep more rapidly, the pulse oximeter climbed, and, within a minute, we were fine. Praise the heavens. Minutes later, I was able to pass a tube, which slid easily between the boy’s vocal cords into his trachea, and then we connected him to our ventilator.
The pediatric bag, it turned out, had a defective valve. Perhaps it was a manufacturing error, or maybe it had been assembled incorrectly after cleaning. Either way, we hadn’t caught it in our routine equipment checks.
We now had a good airway. We started an IV drip of sedatives and added a long-lasting paralytic to get us through the long plane trip to Nairobi. We closely watched the monitor to follow his end-tidal CO2 and oxygen levels. We placed a foley catheter, gave fluid and medications, and gave antibiotics for the fever he was running—which, given his firm abdomen, we suspected was due to intestinal trauma and peritonitis.
That kind of situation ages you. Fast. To hold a child’s life in my hands, manage a rare procedure, plus troubleshoot a strange complication at a critical time required all my mental energies. I was physically exhausted.
With the little boy stabilized, we gave the OK to load the aircraft. Michael and I would take the little boy and his three sisters, and the other flight would carry the adults and the remaining child. We made sure our equipment was loaded and secured, and then the pilots taxied to the end of the grass strip. The planes, one at a time, accelerated at full speed and cleared the trees at the end of the runway before banking sharply and gaining altitude. Once we were in the air, I looked around the plane at the sedated boy and his three older sisters. The girls were mostly unhurt and were happily sucking mints and drinking lemonade, paying rapt attention to Michael and me as we kept their little brother stabilized. I thought about the tenuousness of life and how often we can be blind to that fragility, especially in our own families. By all accounts, the SUV had been destroyed. The odds of seven people surviving such a crash were long.
When we landed, we could see that the entire Flying Doctors’ fleet of five ground ambulances had been mobilized, along with extra nurses who had been on desk duty in the control room. I watched through the plane’s window, mesmerized by the ambulance’s emergency lights which lit the tarmac like a discotheque. With care and no little amount of relief, we carried the patients to the ambulances, climbed aboard, and began a convoy to Kenyatta Hospital, through the busy streets of Nairobi.
When we arrived, we entered the hospital through its dark concrete entranceway and transferred all seven patients to the hospital staff, who were waiting for us in the ED resuscitation rooms. There was a flurry of activity in the resuscitation room where the little boy lay. The nurses in white uniforms leaned over the stretcher, their white caps hair-clipped securely, as they checked his IV lines. Surgeons hovered and pushed on the boy’s abdomen and made a decision to bring him to the operating room immediately.
This was our moment of transition. Our work was done; we had gotten our patients to the hospital safely and then relinquished them to the next team. This was a simple matter of process; it was what Flying Doctors did. But still, it was hard to leave. Our Flying Doctors team regrouped, the mass of us heading for the ambulances in the bay and then back to Wilson. We needed to restock the ambulances and the equipment bags and prepare for the next trip. Michael put the defective pediatric bag valve mask in a plastic bag to begin a patient safety investigation. With luck, we would learn something important from this error.
A few days after that call, I was reading in the bright sun outside the hangar at Wilson when Jana, one of the nurses who had worked in dispatch on that fateful night, walked by my chair and stopped. She had just returned to Flying Doctors’ headquarters from Kenyatta Hospital and wondered if I had heard the good news about the little boy. All was well, she said. In the children’s ward, she had seen the boy walking the halls, slowly, holding his mother’s hand. His abdomen was bandaged and covered in tape, but he was alive and already up and moving around.
The surgeons had taken him to the OR soon after we arrived and had fixed his torn liver, sutured a torn section of intestine, and undertaken a splenectomy to remove his pulverized spleen. They had continued the regimen of antibiotics we had administered, as he had developed a nasty infection in his belly. A day after he arrived at the hospital, he was taken off the ventilator. The floor nurses were optimistic that he would be discharged home after a few more days of observation.
I smiled and thought about how our lives had collided and how he was just getting started in life. It occurred to me that he would never know how close he had come to dying. Years from now, maybe when he is sitting at home with his family, someone will point to his scars and ask how he got them. He won’t remember; he will have been too young when it all happened. Any recollections he might have when he’s older will probably be of his parents or sisters. He’ll have no idea the two of us ever met. We’ll certainly never meet again.
As a frequent witness to the epilogue to these sorts of disasters, I can tell you that one’s life can change in an instant. It’s not a platitude. It’s the way these sorts of things work. Your life can be irrevocably altered by the smallest mishap, the smallest miscalculation in timing. One event unleashes a sequence of subsequent decisions and responses, and everything hinges on getting those decisions and responses right.
We are fragile beings. Most of us need to maintain an illusion of control, an affirmation that we are masters of our own destiny. Only rarely, when terrible things happen, and if we are honest with ourselves, will we admit that some heartbreakingly important moments fall one way or an awful other based on nothing more than the smallest whims. Just capricious fortune. The universe will remind us that it’s all so tenuous.
