They rushed the boy in on my first night shift (third day) in the Children Emergency Room (CHER), his grandmother, his ‘uncle’, and a Keke rider.

  An eye on the timer of my phone, my other eye on the drip chamber of the soluset beside us as I played with its flow regulator, rolling it up or down as needed; I was working under the watchful eye of my colleague, a short, fair lady with puffy cheeks named Chisom, practising how to set a drop rate when the Keke sputtered to a stop. One could hear its sound from the CHER proper.

  Like any good doctor, I hoped (briefly) this wasn’t a patient. Though my gut told me otherwise. I think I even muttered to Chisom, “God, please no.” Three patients were on admission at the time— a sickle cell crisis, and two AGEs.

  But, as one of my lecturers would say, there are three persons one can never deceive: God, the devil, and oneself. With the screaming drawing closer, almost with a faint musical quality to it (Chukwuebuka nwa’m! Chukwuebuka biko! Chukwuebuka nwa’m!) I couldn’t deceive myself, no matter what I hoped.

  Now, I could say that we all swung into action at once, the nurse, Chisom and I, and the registrar. After all, given the drama of the boy’s arrival, the five of us (the nurse on duty in the Paediatric Intensive Care Unit, a ward within CHER, joined us) found ourselves in the passage of the CHER, trying to get to the bottom of things. However, the nurses usually assess and triage first, so this phrase belongs to them.

  The nurse on duty in CHER swung into action at once. She told the boy’s ‘uncle’ who was carrying him as one would carry a bag of rice alone, to deposit him on the long bench facing the entrance of CHER proper while calming down his grandmother with the rest of us.

  The hefty, dark fellow held on to him, demanding the doctor come at once. The nerve of some patient relatives. I wanted to ask, waving my hand in front of his face: Hellooo... And we are? The registrar, Dr. Ugo, crossed the short distance between the mouth of the doctor’s call room (where he’d been standing) and the long bench. “Mama good evening,” he said, patting the grandma on the shoulder. “Oga, good evening.”

  “Good evening doc,” he said.

  He would have said more but the registrar talked right over him. I’ll translate the rest of what Dr. Ugo said. “Mama, there was something this oga did now that I don’t like—”

  “Doctor, kedu ihe o?”

  “My nurse told him to do something and he just ignored her...”

  Ewoo! We didn’t know that is how you people operate. Sorry o. She spoke in Igbo, talking at the same time as Dr. Ugo.

  “...I know emotions are high but all of us...” He pointed at each one of us. “...are here to help your child recover. I will attend to you, but you have to follow their instructions first.”

  Peter, lay that child on the chair, the old woman continued. The man joined her. Doctor, nurse sorry o!

  He told us to give them the list of emergency items while the nurses assessed the boy. “Check his SpO2 first,” he said, as Chisom and I returned to the Emergency. “He’s already in respiratory distress.” There was flaring of the alar nasi and increased respiratory rate.

  I penned down the items while Chisom attended to two patients, administering some night medications. Yellow and blue cannulas, plaster, 2-, 5-, and 10-ml syringes, normal saline, soluset, drip giving set, water for injection, a packet of latex gloves. Chisom paused her task to go over the list for me. I’d missed out water for injection, plaster, and drip giving set, and had prescribed some items in wrong quantities.

  “Egbo, hope you added ceftriaxone and IV PCM,” Dr. Ugo called from the mouth of the door. I was correcting the mistakes I’d made in the prescription.

  “Chief how many?”

  “Four for ceftriaxone and one PCM. Also prescribe oxygen for them and fill form for urgent Hb. They should do it in A and E lab.” In a lower but still audible tone of voice he added that the boy would be transfused this night (I groaned inwardly at this) he was severely pale, but they should just do urgent Hb first.

  Chisom showed me how to prescribe oxygen. It’s exactly like prescribing any other thing, except you write INO2 instead. I included ceftriaxone and PCM, and items for transfusion in the first prescription. Handing over the form and prescription sheets to Ebuka’s (Emmy is short for this) ‘uncle’, I directed him to the pharmacy, A and E lab, and cylinder room.

  “Oga, the place where you will get card and bed sheet is also in that A and E,” the nurse added in Igbo.

  He nodded, but I wasn’t confident he’d understood everything. So, I accompanied him as far as the surgical A and E pharmacy. Other patient relatives were bunched up in front, purchasing medicines. The surgical A and E is right next to the CHER building and houses said lab, revenue, and records offices.

  “Do I need to buy everything on the list?” he asked in Igbo. “Money no dey.”

  “… Oga wait first. There be desk just for front inside here…” I pointed to the entrance foyer of the building. “…you go get card, hospital card, dem go give you hospital number. Then inside, inside, you go collect bottle for test, pink paper; you go come here collect things wey dey… Ehe, this list. You go pay for everything wey dey for am…” Then I singled out the sheet I wrote INO2. “…Dis one follow. Wen you pay finish, for dis one, you go walk down, down…” Gesticulating towards the main entrance of the hospital, I continued, “…reach main entrance of hospital, turn right, walk down, down again, and turn. Ask question o.” If you recall, my Igbo is anything but fluent. This was the reason I spoke broken. It’s the nearest thing in my arsenal of languages to Igbo.

  He asked again if he needed to buy everything. There was no money. I told him to pay for the hospital card first, that I’d ask Dr. Ugo and get back to him. Hopefully, he’d find his way around. Back in CHER, Dr. Ugo and the nurses were scrambling for an O2 concentrator to hook up to Emmy. He was lying on the bed nearest the door, naked save for underwear. An open sachet of water lay on the chair beside the bed. A wall fan on that side of the ward rotated this way and that.

  “Chukwuebuka nwa m! I ga dimma o,” his grandmom said, sponging his body with a wet rag.

  “Chief,” I said to the registrar, who was now rummaging a box of supplies at one corner for an appropriately sized nasal prong. “Chief!”

  “Doctor Egbo be talking. I am listening.”

  “Chief the man wanted to know the things he should buy, that his money won’t be enough for everything. Chief did you…?”

  “Yes. The thing is that we need everything on the list. You know some of these people will say they don’t have money meanwhile…” A nasal prong in his hand, he turned towards Ebuka’s bed. “…Nurse Chika is the O2 concentrator ready? I have found one.”

  She rewarded him with a flat stare, one O2 concentrator at the head of the bed plugged into a socket, another one behind it. The machine began to buzz as she turned it on.

  “So just stress that we need everything on the list. Money will come.”

  Had his answer been more positive, I still doubt I’d have taken it back to the man. I remained in CHER, first helping Chisom to keep one baby’s hand in place while she searched for another IV access; the previous one had ‘tissued’. She’d cut plaster and had drawn water for injection. The child’s mother held the light source. At the end, I found a suitable vein but she secured it. My confidence was still lacking. For very tiny children, at least.

  I also listened in on part of the patient’s history Dr. Ugo was taking. His full name is Ebuka Nnamani. He (the child) was apparently well until 3/7 ptp, when the grandmother noticed a fever. Fever was on and off, not worse at any time of the day, relieved temporarily by PCM. The next day, he developed loss of appetite, refusing to eat anything. For this ACT was procured, with little to no improvement of symptoms. On the same day, grandmother noted he looked more whitish than usual. With worsening body weakness, persisting fever, and fast breathing that began on the evening of presentation, patient presented to UNTH for expert care. No history of hospital admission, surgery, or blood transfusion prior to this admission. History of EAS was negative, though we ordered for a genotyping later, sickle cell disease being high up on our differentials. I also tested his blood using an MRDT kit, severe malaria being another major differential; negative. He is the only child in a monogamous setting of one man and woman. The father is dead though the cause of death couldn’t be ascertained. She declined to comment on why her daughter (the boy’s mother) wasn’t with them.

  Positive findings on examination were: obvious respiratory distress, severely pale, mildly icteric, febrile (37.80c), bilateral pedal fullness, HR and RR were raised, heart sounds s1 and s2 were heard- gallop rhythm, signs of respiratory distress (FAN, ICR, SCR), poor oral hygiene.

  Mr. Peter returned while Dr. Ugo was obtaining the child’s history. So, only part of this is from the back and forth between the registrar and Ebuka’s grandma. The rest I pieced together from his folder. Now, Mr. Peter… You know the meme; what I ordered vs what I got? In my mind, he should have come in carrying (at least) two white polythene bags weighing his arms down, like the branches of a tree in season. Breathing hard and sweating (he’d appear this way many times in the course of our shift. Also, the weather wasn’t helping matters) he entered with the prescription and haematology forms in one hand, looking perfectly innocent.

  Chisom and I intercepted him midway between the entrance and the doctor’s station. Dr. Ugo hadn’t noticed him yet.

  “Oga wetin na? Pesin chase you?” I said as a conversation starter. Then: Is this everything? I asked in Igbo that would burn the ear.

  In his defence, he showed me a patient’s card with the patient number scrawled atop. The haematology form was wrapped around a sample bottle. When I hadn’t returned, he’d turned to the pharmacists to cut out items. The pharmacists sent him back to “the doctor who gave him the paper,” unsure what to remove.

  “Dr. Egbo, Dr. Chisom, what’s wrong? Has he gotten the things?”

  I shared a look with Dr. Chisom. This is your problem, her expression seemed to say. The O2 concentrator continued to buzz. “Chief,” I said, snatching everything out of his hand and heading straight for Dr. Ugo. He was seated on a plastic chair beside Ebuka’s bed. My self-preservatory instinct was at work here. I wasn’t about to get disciplined in front of everyone.

  “Chief, he’s gotten patient number and sample bottle for Hb, but he’s still saying there’s no money.”

  At this, the old woman nodded her assent. She too was seated on a plastic chair. Please, we should help them, she said.

  “Give me the prescription form. Prepare things for setting line.”

  Unauthorized duplication: this tale has been taken without consent. Report sightings.

  “From?”

  “Get from the other patients. He’ll return when he buys.”

  The care-givers of the boy next to Ebuka (a patient with sickle cell disease who had come in with bone pain crises) loaned them a blue cannula, one water-for-injection, a 2 ml syringe, some latex gloves, plaster. I set up cotton wool, a gallipot quarter filled with spirit, and a makeshift torniquet on a tray.

  “Chief,” I said, dropping the tray on the table at the doctor’s station.

  He told me to put on gloves and set the line. Dr. Chisom would cut strips of plaster, draw water for injection, label the boy’s name and pt number on the sample bottle, open the cannula, and point the light source.

  “Doc…” Ebuka’s ‘uncle’ said.

  I recognized that tone of voice, the expression on his face for what it was. Doubt in my ability to secure an IV line on first try. I understood his point of view perfectly: who picks a registrar over a consultant? Who wants a sick relative to suffer the added pain of multiple pricks? On the other hand, how does one grow if one is denied the chance?

  I battled with some form of these thoughts as I gloved.

  Dr. Ugo said, “Oga what? I have asked one of my other doctors to set the line. I will be here in case any—”

  “Doc, that’s all I am asking. That’s all I want. I know he is also a doctor…” Again, their conversation was in Igbo.

  The registrar gave him a blank stare. “Oga if you keep distracting us, I will ask you to… to leave.”

  Thank God the fan was on. It was under the eyes of the registrar, Chisom, and patient care-givers (not only Ebuka’s) that I tied the ‘torniquet’ above the elbow the first time. We would collect the blood sample from the IV access.

  “Wait,” Dr. Ugo said. “Have you explained what you want to do to Mama? Has she given consent? It’s very important Dr. Egbo. Some people take it very seriously o.”

  I proceeded to do exactly as he’d said but Ebuka’s grandma waved me on. We should continue. She understood we were trying to save the boy's life. The registrar thought it better to set the line in a part of the body subject to less motion like the dorsum of the hand. So, I moved the ‘torniquet’ to the wrist.

  “Which vein do you want to use?”

  I pointed at a prominent vein to the left of Ebuka’s middle finger. I cleaned the area with spirit swab. Hand on the wings of the cannula, I looked to the registrar for confirmation. He nodded. I pierced the skin and advanced; Chisom had discarded the flash back chamber. Ebuka’ skin started to swell. He wasn’t strong enough to even cry out.

  “Dr. Egbo, wait. Wait. Go back a bit. Yes. Yes. Good. Draw back the needle a little.”

  No blood flowed through the cannula. It wasn’t inside the vein. He untied the torniquet and said I should remove the cannula. I stanched the blood flowing from the pierced site with a dry swab. See the blood they said he doesn’t have wasting, the child’s grandmother said. Other caregivers muttered under their breath. The nurses lent us a second blue cannula from the emergency tray.

  Still pressing the dry swab to the wound site, I watched Dr. Ugo establish the IV access on the dorsum of the left hand, collect the sample, and hand it over to Dr. Chisom.

  Chisom said he should take the sample to the lab immediately, before clotted. She also reminded him to get the prescription while returning.

  “Okay doc,” he said, squeezing the boy’s shoulder. Ebuka a n’eme k’idi mma. Eh. He left.

  For my part, I couldn’t stomach my failure. Hence, I remained there, stanching the flow of blood long after the bleeding had stopped. When the nurse finished conversing with Ebuka’s uncle (she’d stopped him as he was leaving, it seems) I retreated to the call room. I even forgot to clear the tray from the table. I must remember to thank Dr. Chisom.

  The man returned around after eleven. Hb was 5.3 g/dl. Our plan was as follows: group and crossmatch one unit of fresh whole blood and transfuse in two divided units one on the night of presentation and the other the next day, under furosemide cover; infusion PCM @ 300 mls 8 hourly; IV ceftriaxone @ 1.6g dly; complete ACT; do FBC, LFT, SEUCr, urinalysis, genotype, clotting profile.

  So that at least someone would be awake at any point during our shift, Chisom had proposed earlier that I sleep while she remain awake, attending to patients on admission from ten till three. I’d take care of the greater part of the shift from three till eight while she slept. If there was an emergency the person awake could wake the other person.

  Wanting to master things as fast as possible, plus the fact that I was a nocturnal creature thanks to medical school, I’d rejected the proposal. Not rudely, I must add. She could to go to bed whenever she wished. I’d remain awake. Initial gra gra, her expression had seemed to say, her lips in a down-turn.

  So, she attended to Ebuka, filling forms, administering drugs, setting up fluid, while I took care of the other patients. The nurse took Peter, Ebuka’s ‘uncle’ to task over having not returned with a porter wheeling in an oxygen cylinder. The O2 concentrator was dying. Last SpO2 with the nasal prongs taken out was between 83% to 85%. The registrar directed Chisom to write emergency on all the forms.

  “I’m coming. Me and Mr. Peter will go to the labs and oxygen room. Dr. Egbo don’t burn down CHER.” They left.

  By now, you should know how resourceful Dr. Ugo is. They returned bearing sample bottles for various tests. Mr. Peter couldn’t stop praising the registrar in front of everyone. Ebuka’s grandma joined in. I was embarrassed on my chief’s behalf. I witnessed Dr. Ugo perform a femoral tap. He was handing over the sample bottles (blood inside them) to Mr. Peter when two porters wheeled a cylinder of O2 into the ward. “Ebuka Nnamani?” one of them asked.

  All of us were in some form of slumber when the ‘weirdness’ began, the nurse, Dr. Ugo, Dr. Chisom and I. My colleague and the registrar were in the call room: only two beds were there, one for the registrar, the other for the HOs. I was seated at the doctor’s station in the ward, head resting on the table.

  Voices awoke me; Ebuka’s uncle and grandmother. Even after I put my head up, I could make neither head nor tail of their discussion. (And it’s not because they conversed in Igbo) I remember glimpsing a sample bottle and a form in the ‘uncle’s’ hand and the grandmother calling out “Doc” before I put my head down again. Conscience made me raise my head some minutes later.

  Hand on my head, I asked, “Oga what?”

  My eyes weren’t deceiving me the first time. Mr. Peter brought out a sample bottle. My first reaction was anger. These patient relatives sef! Why hadn’t they given this to Dr. Ugo when he was collecting all those samples? Now he wanted to stress me. “Oga why didn’t you give it to Dr. Ugo?” I asked, the anger bleeding into my voice. “He collected—"

  “Mba Doc. Peter kowara ya.”

  Mr. Peter explained that it wasn’t their fault. The lab scientists at the blood bank had given him the bottle for another sample. No explanation as to what happened to the first sample had been given to him. He wanted me to call Dr. Ugo or Dr. Chisom to collect the sample.

  I had half a mind to tell him to return to those scientists at the blood bank and tell them to come and collect the sample themselves. My eyes on Ebuka, dark and lean and small, hooked up to the O2 cylinder via intranasal prongs I thought: It was easy for them to talk, because it wasn’t their task. It wasn’t their blood being wasted.

  Anyway, I informed him that Chisom and the registrar were asleep. I would call either of them only if I failed to get the sample on first try. He asked if the nurse was awake. She was asleep.

  For me, collecting a blood sample is easier than getting an IV access. I gathered supplies, obtained consent. “Tell dem anything wey happen to dis blood, dey go come collect am themselves,” I said. Ebuka’s grandma made a face at that. I’d successfully drawn blood out from the right cubital fossa. I emptied it into the bottle and handed it to him.

  “Thank you Doc,” he said, rushing out.

  When he returned, I had to wake up my chief. They’d sent him back with another sample bottle and had requested that Dr. Ugo come himself.

  Are they drinking his blood? Ebuka’s grandmother asked when Dr. Ugo wanted to collect a third sample. It was after much pleading that she allowed him. Doc, this is the last one. You said he doesn’t have blood! You’re finishing the one he has! I was told to retrieve more D/W and N/S from the pharmacy. When the fluid that was currently dropping finished, I should hang another one.

  “Write a consult to the haematology team on call,” Dr. Ugo said when he returned, almost an hour later. “We’re inviting them to review the patient… include that the patient’s blood reacted with all donor blood groups during grouping and crossmatching and for—”

  “Chief, is that possible?”

  “I have never seen it before in all my years of practice except with this patient,” he said. “That’s why one of my chief’s used to say then in school (Prof Okeke) that in medicine, you should never say that something is impossible…”

  I nodded.

  “…It can happen in the case of autoantibodies, but I’ll get back to you when I read more on the topic.”

  “Chief, the blood?”

  “We’ll just continue with fluid until the haematology unit come. My concern now is the possible haemodilution… Just write the consult first.”

  “Yes chief,” I said, and set to work. He walked over to Ebuka’s relatives.

  I had a go-to consult template on my phone. The other HO in my primary unit in paediatrics had written it weeks before. I switched between the template and ChatGPT answers on this peculiarity of the case.

  Yes, it’s possible. Causes can be AIHA, high-titer alloantibodies, polyagglutination, and laboratory artifacts. There are special techniques to solve it, though I understood neither of them. A problem for the haematologists, I thought.

  Waking Chisom from sleep was no easy task. This was around two in the morning. She wasn’t too excited about it, but I needed the contact of the HO in haematology, to deliver the consult. Was there an emergency? I explained all that had transpired to her. Giving me the HO’s number, she expressed a desire that nothing should happen to the boy. Still awake, the HO asked that I send a picture of the consult to his WhatsApp.

  I was fast asleep when the haematologists came to review. As I understand, they collected more blood samples and gave them forms for some more tests. Many of those tests have not been done still. No money.

  An RTA patient presented around 7:30, just before the end of our shift. Asides this, whatever of note again happened to Ebuka was during the morning shift. I would hear all about it during the following night shift.

  I arrived at 4:10 pm to a sort of commotion in the CHER ward. It was around Ebuka’s bed. Men and women in scrubs or ward coats sweating, torch lights, noise, I thought the boy had died. Dr. James, one of the HOs for the morning shift, brought me up to speed during the hand-over.

  The consultants were attempting to secure another IV access, the efforts of the HOs, registrar, and senior registrar earlier having failed. They’d considered delivering consults to the PICU and CTU teams for central line insertion, but relatives had declined owing to financial constraints. The IV access Dr. Ugo had gotten yesterday had ‘stopped going’ in the afternoon. And all the boy’s skin had become tough and hard (I know no better way to put it). Glancing at him last night, at times I was reminded of the Kanevorians, with their tough, hard skin resistant to magic. But I banished the idea from my mind. It isn’t possible, is it?

  Except that Dr. Ugo has said that I should never say impossible in medicine.

  They’re considering one of these medicines to help with the haem… I don’t recall the name. But it’s expensive. All his medications have been converted to oral, for now, pending IV access, and he’s still on oxygen. We were unable to deliver a consult to the Dermatology unit, as the unit proper won’t be reviewing Ebuka until Tuesday.

  I know the teaching: Magical diagnoses are diagnoses of exclusion. But the boy will die if continue waiting. In fact, during the morning shift, the higher ups kept enquiring of the child’s parents. The father we know of, but the mother… The grandmother was heard saying (in Igbo) that “she has been begging her to leave that house,” many times, as she dialled up her daughter, angry. And afterward, after the SR and a consultant had spoken to the woman, “Nne o biko bianu. I nugo ha. Bikonu.” But from what I gather, it seems Ebuka’s mother isn’t all there.

  Something else I witnessed during my shift yesterday night was increasing complaints from the grandmother. They shouldn’t have come here. The questions were too much. They don’t have money. They should have just gone to nurse Bethelda. Mr. Peter told her not to say that nonsense again. If she had listened to him and gone to this ‘nurse’ in the first place, they wouldn’t be in this ‘mess’.

  We are in dire straits. An exception needs to be made in this case.

  Saturday, 8 Feb. 10:17

  ...

  Received. Thank you.

  Send a list of your male consultants in CHER.

  13:50