the rest of the day

I feel like all I ever write about are the sad cases we see here...please know that a lot of kids get better too! One of my favorite kids to see these days is named Bianca. She's about 12 years old, and was admitted about a week ago with severe anemia (and cardiac decompensation, as a result of the anemia), mild malnutrition and pneumonia. She looked pretty miserable when she first came in, but after a blood transfusion and a few days of IV antibiotics she's now all smiles every day. She loves school & keeps asking me when she can go home and go back to school. In the U.S. she would have gone home days ago, but here we'll keep her probably until the end of this week or early next week to finish her 10 day course of antibiotics, and to repeat her labs and xray to convince ourselves that she doesn't also have TB (her Mantoux was very positive). She's a bright spot in my days.

Another little girl, St. Therese, is about 4 years old. She was admitted with severe malnutrition and kidney failure a couple weeks ago, and spend a lot of time in the ICU. She always looked miserable and I never saw her smile...until today. She's been doing a lot better recently. Today her dad was here with her, and he was holding her and she was smiling and laughing...super encouraging to see.

The wackiness today started early. Like I mentioned before we put 2 kids in the ICU on heparin drips. This was after much discussion with many people, including the hospital director. One child is a 5 year old boy with unrepaired tetralogy of fallot (a congenital heart defect), endocarditis (with 2 clots on his valve), and a severe pneumonia that's not getting better despite being on tons of antibiotics. We're concerned he's throwing off little clots (microemboli from the valve) to his lungs, so we want to treat him with heparin to see if we can get rid of the clots. In the U.S., placing someone on a heparin drip is usually based on a strict protocol that requires checking a PTT every 4-6 hours (at least initally) then making incremental adjustments to the drip rate to make sure the patient isn't getting either under- or over-anti-coagulated. Here we can only get a PTT once a day, on weekdays. So that's the first issue, but we'll just make it work.
The second issue is that in order to write for the heparin drips, we had to do about 10 calculations that had our heads spinning. In the U.S., I could just write:

Heparin 240 units/hour IV.

(skip this next part if you're not a medical person...it's way boring)
Here, I had to write exactly how I wanted the heparin mixed, which meant finding a vial of the heparin they stock here to figure out what concentration it was (5,000 units/mL), then I had to figure out how much of the heparin I wanted to mix in a certain quantity of dextrose water. After some calculations I picked 2 mL in 200 mL of dextrose water, which means I'm putting 10,000 units of heparin in 200 mL of dextrose water, meaning it now contains 50 units of heparin per mL. THEN, I had to decide how much heparin I wanted to give the child (in his case, 20 units/kg/hour), calculate how many mL of my specially-mixed heparin solution that would be per hour, THEN convert it into microdrips per minute, of all things (which involves a whole other set of calculations), because they don't have infusion pumps here. After double and triple checking the calculations we convinced ourselves we'd done it right. What a nightmare. I miss my old hospital's heparin protocols!! (and the pharmacists, who usually do all these calculations for us...). You really have to become a sort of "jack of all trades" here, to some degree.

Shortly before lunch there was a baby in the ER who stopped breathing, a little 1.6 kg beautiful 15 day-old baby girl who was born about 2 months early. She'd been doing fine until yesterday, though, so I'm not sure what's going on now, though she most likely has a bad systemic infection or pneumonia or both. She was so blue when I first saw her, but pinked up nice after some bagging (btw, for you medical people--we bag with room air here, and while I know it's not ideal, it works fine). The other doctor tried to intubate twice but it went in the esophagus. Then I looked and I could see why that happened. This baby had one of the most anterior airways I've ever seen. Add to that the fact that we didn't have a stylet for the endotracheal tube, meaning that even though we could see the vocal cords it was impossible to advance the tube into the right place because it was too flexible. Add to that the fact that we again didn't have a working suction machine (and this baby's throat was full of thick secretions), so we had to use a bulb syringe to get them out. I tried once and put it in the esophagus. The second time I looked I tried & tried but couldn't get it to go through the vocal cords.

It was so frustrating...I couldn't believe that this baby was going to die for lack of a small piece of flexible metal wire (the stylet). As long as we were bagging the baby, she was ok, but who's going to stand at this baby's bedside and do that for the next 24 hours or longer? I asked if we had something, anything to put inside the tube to make it more rigid. Someone found an old, twisted stylet full of kinks, but it was too short for the tube...so we cut off about an inch of the tube and made it work. I tried to intubate the baby again but again it went in the esophagus (or at least I think it did). By this time I was absolutely dripping in sweat...I felt so helpless that none of us could intubate this kid...I've never had such a hard time intubating a baby...ever. I put the stylet back in the tube and tried again...praying the whole time...and this time finally got it in the trachea. Hearing the lungs fill with air (and watching the baby's lips turn from blue to pink) was a huge, huge relief. I feel so bad for this little baby's momma. She watched the whole thing and I know she understands how precarious her daughter's condition is. I talked to her after and told her we'd try to do what we could, but that if her baby couldn't breathe on her own by the next day we probably couldn't do anything more for her. Every time I looked at her throughout the afternoon, she was quietly crying. So hard to watch.

The crazy thing is that not 2 hours later, somehow the tube came out (I was worried that would happen, because it wasn't taped well), so we had to repeat the whole scenario again. The good thing is that I knew what this baby's airway looked like, and we had the stylet, so it was much easier. We taped the tube in like I've never taped a tube before. That thing's not going anywhere...at least I hope not.

I'm sorry for all the medical minutia...part of the reason I write it all out is as much for me as it is for anyone else. I want to keep track of what we're doing here, especially related to intubations, because so much of what I'm going to be working on (project-wise) over the coming months is related to intubations and ventilator use. More on that later.

Love to everyone...good night!