Sorrow and Joy
on Shona in Sierra Leone (Sierra Leone), 07/Feb/2011 17:19, 34 days ago
Last week I spent most of my time in ER. Patients who are triaged as emergencies come straight to ER to be assessed and receive initial resuscitation and management. Children then tend to stay in ER until they are stabilised before being transferred to ICU or one of the other wards.We had a great team of nurses on with us last week; experts at cannulation and at telling parents off for waiting until their child was so sick before bringing them in to hospital.Alas it was a fairly depressing week as many of our patients died. A 2 month old septic baby. Another 2 month old septic baby (whose 3 older siblings had all died before 1 year of age; I felt so desperately sorry for his mother). A 1 year old child with septic burns (she received 24 hours worth of IV fluids in 12 hours– did this make a difference? I wonder. I don’t know).And finally a 1 year and 1 month old boy (Saloneans say ages in years and months, rather than 13 months as we would say at home) who was malnourished. He was moribund when he arrived– not breathing and heart rate of 30/min. (For non-medical people reading this, these numbers are not good). We started CPR while trying to cannulate. To my amazement, his heart rate improved with CPR alone (no adrenaline was given, although we do have it here) and he started breathing again. We were struggling with access so in went an intra-osseosus line. He received dextrose, and fluids and his perfusion improved markedly and breathing much more regular. (Clearly if this child had been in the UK he would have been ventilated by this point. We manage with fluids and nasal cannula oxygen).There was a clear plan for further IV fluids, antibiotics and antimalarials. I also stood a nurse next to him with instructions to “watch him like a hawk” while I was at a meeting. (There was also another doctor with him). I came back an hour and a bit later to find that the IV fluids had not started, nor had he received his antimalarials or his antibiotics. Why oh why? The IO wouldn’t run the fluids but was fine for giving antibiotics. He never got another line inserted before he died.It would have taken a miracle for this boy to survive. Usually when children arrest here, I continue CPR for a short time and then withdraw care (none of them have ever responded before in the way that this child did, and there are no PICU facilities available anyway). When he responded to initial resuscitation I really felt we should do everything we possibly could do (simple things like giving fluids, antibiotics and antimalarials). I was shocked that the meds had not been given. There are a multitude of reasons why they had not been given– ER was very busy, nurses coming late to work, the complicated pharmacy system, no one thought to call me, or another doctor, for help, or maybe the nurses and doctor knew anyway – that this child was going to die, so why waste time trying to get a line in him and give his meds when you could be doing something else. I find this so difficult, coming from a place where every life is so precious, and where parents demand that everything that can be done will be done.Something which did bring me joy last week was a patient called Joy. Critically unwell with cerebral malaria the week before (alternating fitting with being unconscious), her parents had been praying (very loudly, in fact they were drowning out every other noise in the place) for her recovery. She received her medicines. She stopped fitting. She had an LP to exclude meningitis. Her father came to find me the following week. There she was, sitting up, laughing and waving to me. It was magical and brought a tear to my eye. Musu the very dedicated staff nurse on ICU was also delighted to see her recovery.