Wisdom

Monday, October 14

I awoke early this morning.  I am a little embarrassed to acknowledge how great I slept because the quality and duration was secondary to the fan blowing on my face and electrical power that lasted all night long.  I want to be tough and unphased by a lack of modern convieniences. Alas, this is not the case. I am more of a classic American than I want to admit. I love cool air and electricity.  

Morning report was a tough one to endure.  Lots of admissions and several deaths. I think there were four in the medical ward.  The clinical officers continue to be overwhelmed with the lack of staff. In fact, when report was over all the clinicians stayed for yet another meeting.  Right now there are only two medical officers and only one has been present for the last three weekends so there was no medical officer on call for the weekend and patient care is of concern.  However, if you over run your existing personnel then eventually they leave, too. On top of that, you have financial issues that keep the hospital from hiring and make the salaries not very competitive.

In the middle of the meeting, two of the medical students entered and called out for me.  They said that I was needed in the outpatient department with a child seizing. I called for Marleen to come along as she is in pediatrics with me this week.  Along the walk, they told us of a small patient who had been seizing for more than 10 minutes and had not been responsive to medications.

We walked into the room and found the little infant visibly seizing.  His eyes were closed, foam at his lips, and arms and legs rhythmically flexing.  He had already received two doses of diazepam. I called for the nurses to draw up the dose of phenobarbital while we got more history.  The patient was 2 months old and had been healthy until this morning when he had some fever and fussiness. Then the seizures had started on the way to the hospital.  We gave the phenobarbital and waited. The baby continued to seize. We had positioned him safely and had him on oxygen. Given the concern for meningitis we got him ready for a lumbar puncture.  Marleen did this attempt and just got blood. The baby continued to jerk. I went around to the opposite side of the bed and slipped on sterile gloves. I prepared to do the lumbar puncture but then noted that the patient had become apneic.  He was not breathing at all. I quickly repositioned him and started to stimulate him and he took a brew breaths. We got the bag and mask ready but he had some respiratory effort. I called Dr. Catherine to join us. I have never had a patient to continue to seize after this many doses of medication.

As the baby continued to seize, mainly just movements of the feet that were visible, we proceeded with giving both ceftriaxone as the treatment for meningitis and another dose of phenobarbital.  We gave a bolus of IVF and continued to monitor blood sugars. Catherine arrived and we reviewed all of our steps. She was amazed as well. The difficulty was that the patient now had maximum doses of the seizure medications we usually give.  The baby was having some respiratory effort but with the seizing it was ineffective and the oxygen saturations were trending down. I started to give breaths with the bag and mask and the saturations came up. I would continue this for awhile but as seizing waned he would start to make better respiratory efftort but then would have times of apnea requiring me to bag him again. I gave constant breaths for over 30 minutes. As a team, we prayed openly for this little one.

We were all looking up seizure protocols and the intern was sent to the pharmacy for the next two medications.  None to be found. We were stuck. A few minutes later the pharmacy called that they had found a few vials of the medication although one was expired.  We gave paraldehyde next. I have never in my life given this medication. It is given as a shot and is supposed to be drawn up in a glass syringe as it melts plastic.  As we did not have a glass syringe, we drew it up and gave the dose in less than 3 seconds. The seizures seemed to decrease some but the patient had some unusual sustained contractions and continued with the apnea.  

The patient stopped any visible seizure activity right before the next dose was given.  He was apneic for a while. Then had 4 gasps with a long apneic period in between. Usually, this type of breathing signals that the respiratory center of the brain has been compromised.  I fully expected and even stated that I expected the saturation’s and heart rate to start going down as well. Then he started having hiccups. I was conintuing to give him breaths with the bag and mask.  We inserted an NG tube to help draw some of the air off his stomach. His saturations improved some with this. Then he started having some better respiratory effort. Although a little apprehensive, I moved him over to a nasal cannula.  We watched for several minutes. Vitals were stable although oxygen saturations were in the 80’s.  

Then we decided to transfer him to the ward.  He had initially been febrile but now was cold and really needed to be visualized.  So, we decided to put him in the small room with the heater. I went to make sure the space was ready and an oxygen compressor was available.  Well, we had a child with typhoid fever in that room to be on isolation. So we had to do a little be shuffle-move the patient with the abscess to the main area and the one with typhoid fever to the isolation bed, and then clean the room for the new patients.  We finally got the patient into place around 10:30. In total, he had seized for over an hour and a half and had required bag/mask ventilation for about 45 minutes. We did not have positive expectations for this little one.

Fortunately, Sam and clinical officer Catherine had done rounds and there were just a few patients they left for me specifically to see.  We saw those. One was Immanuel from the children’s home. He is still running a fever despite three days of antibiotics for pneumonia. He also appears to have a viral herpangina so I think that is the fever cause but I added another antibiotic just in case.  We also had a new admission with a gastroenteritis and pneumonia. We also checked on Florida with nephrotic syndrome. Her blood pressures are now lower and stable and we decided to check a urine and based on that discuss a discharge. We legs are still edematous and she may take weeks to improve.  

It was then lunch time.  I failed to mention that the Dutch students have rotated wards and so we now have Laura and Joneke with us for the next two weeks.  We all headed back to the inn talking through what they had seen this morning. We did as much teaching as possible but with rather emergent circumstances it was not the typical rounding.  I still am infatuated with the cuteness of the children who walk the path in front of me as I eat. Lunch passed quickly and Melissa has not heard anything from USCIS. Tomorrow is actually a holiday here, Mother’s Day, so I think she was really hoping to hear something today before the day off.  

When we returned for the afternoon, it was really about just checking up on patients.  I had watched one of our patients with severe malaria through the morning and noticed he was not very alert.  He did respond to pain and open his eyes some but was certainly not alert enough to drink or stay hydrated. I wrote him for IVF.  This is the kind of thing that concerns me. A clinical officer had rounded on him, the medical assistant had done vitals, the nursing students had done lab and checked his IV access, and his assigned student had been present at the bedside, and yet no one had raised a concern about lack of intake and need for fluids.  We also checked on the patient with the parotitis. It finally was significant enough on Friday for the surgery team to incise and drain. He appeared much better. We checked on the X-ray of a HIV positive patient for concerns about TB and followed a lot of lab.  

Florida’s urine showed that it was stable and so I was able to write for her to go home continuing on the same medications she has had here.  She will follow up in the peds clinic next week and hopefully by then will show some improvement.

Wisdom, the name of the baby with seizures this morning, has actually done well.  He did have some fever again but no further seizures. We have written a lengthy plan for if anything should happen.  Before we left for the night, he was starting to have some spontaneous movement and even cried some when his IV was replaced.  I was able to have a sweet moment with the mom with a nursing student to translate offering sympathy for the very difficult day she had.  I was also able to give solid praise to the nursing student who sat by this baby’s side all day despite the bedside heater. It was great to see.

Ecclesiastes 2:26 states “ To the person who pleases Him, God gives wisdom”

So tonight,we give thanks that God is pleased with us and that we have Wisdom!