Wow, what a night. One neonatal intubation, two pediatric codes, and one paracentesis (first one ever on a pediatric patient). And many admissions, one or two deliveries, and lots of walking back and forth from my guesthouse apartment to the hospital (only 3-4 minutes away) and little sleep. But I still showed up for work today. I should mention that there are no duty hours in Kenya for interns, residents, or consultants. There are only 4 Kenyan interns on pediatrics at any given time and so they take some mix of q2-q4 call. They elected to take call one weekend per month on Friday/Sunday so that another weekend per month they would have completely off. But they (and I) are expected to complete a full day's work after a call night and do not go home until after 5pm post call.
Although the census is lower on peds this week than last week, the acuity has remained high and there is a good mix of uncommon and more common diagnoses. We are currently treating patients with extrapulmonary TB, pulmonary TB, heart failure of unknown etiology in a 1 year old (no echo available until April), lots of kids with ano-rectal malformations corrected with a surgery called PSARP (not sure what it stands for), lots of kids with pneumonia vs bronchiolitis, lots of kids with protein energy malnutrition (Kwashiorkor), lots of gastroenteritis and dehydration. The less common diagnoses include florid Cushing syndrome - likely Cushing disease but there is no MRI imaging to diagnose it or surgery available to remove a pituitary tumor. So he will likely die of the complications of Cushings disease unless his family is able to save up enough money to travel to some private hospital in Nairobi that has the MRI and surgery capability. An 8 year old with leukocytosis, thrombocytopenia, anemia and bone pains with probable leukemia; there is no ability to do bone marrow biopsy or start chemotherapy here, so we have to refer him somewhere else. A 7 year old with likely ADEM after recent varicella infection. A 14 year old with new onset simple partial seizures with normal LP; we would like to obtain head imaging but there is none available here. The CT scanner will not be functional until June or July. A 9 year old girl with mitral stenosis and dilated left atrium of unknown etiology, possibly Rheumatic heart disease. An infant with salmonella meningitis who has decorticate posturing and is very sick. A 4 year old boy with 2 years of worsening anasarca likely due to MCD/nephrotic syndrome. Recently we have had several kids come in with organophosphate poisoning after ingesting a common pesticide used on the local farms; it is the most common means of suicide attempt here.
In the nursery, there are the typical NICU premies. Patients are still born at 24-25 weeks, but the survival is a lot less without synagist, surfactant, TPN, and advanced technologies. We have lots of PROM births requiring antibiotics courses for sepsis. The microbiologic and serologic diagnostic capabilities are minimal and the only serologies obtained for the mother are HIV and syphilis. No TORCH titers and GBS is not even checked. There is an infant in the NICU right now with suspected neonatal tetanus. He was born at home and came in with respiratory distress and hypoglycemia; was thought to have sepsis, intubated, then started having whole body spasms and trismus. There is lots of neonatal jaundice, although there are not a lot of phototherapy options, and some patients may get single phototherapy if all the double phototherapy isolettes are in use. This area has a higher incidence of spontaneous multiples than many other places and there is actually a set of triplets (originally quads) in the NICU. There is a lot of meconium aspiration and/or birth asphyxia because the women labor forever at home prior to coming or have a 'prolonged second stage' while laboring here but no c-section is done; they just labor until the baby delivers.
During my call night last night, I did a paracentesis on the boy with ascitis and anasarca. There was no one else to do it as all the medicine and surgical residents were busy and he was my patient. A visiting radiologist ultrasounded to find a pocket of fluid to drain and walked me through the procedure. It was fairly straightforward, put a needle in the abdomen while avoiding bowel and bladder, but it was nice to have someone present who has done at least a few of these.
Then, later in the evening, we actually had two simultaneous codes. One code is bad enough, as there is never enough assistance, timely completion of labs, or working equipment. The first code was respiratory distress and required bagging for hypopnea. I wanted to intubate and ventilate but was initially told that all ventilators were in use. Later, after surgery came to assist, I found out that a ventilator was available but it took over an hour for the ICU to be 'ready' to receive the patient. Meanwhile, someone had to continue bagging the patient. Since the nurses had other medications to give and other children were sick, I found myself alone in the room with only a sat probe to provide any vitals. I couldn't leave to get an NG tube, a suction, or other simple things, and it took a while for things to be brought to me. And everytime the nurses came in, they tried to cover the patient up because they were concerned she was cold while I wanted to see the chest so I could make sure she was still breathing! Since there was no EKG available on the wards, I tried to attach the defibrillator paddles to the patient to show a rhythm. But the paddles were adult size and too big for the infant and the room was too small to allow the bulky cart with the defibrillator to come in all the way. Thankfully there was oxygen and a bag and she responded to both. We finally got her transferred to ICU, intubated, and adequately resuscitated with KCl. Her K had been low all day and had been repleted in IVF but I was repeatedly told there was no free standing IV KCl for replacement during hypokalemia. Well, after some creative problem-solving by my back-up attending, I convinced the nurses to mix KCl for the patient and run it slowly over 2 hours via a peripheral line. Here in Kenya, infusions are literally counted by drops of fluid- so for her, 13 drops per minute was equivalent to 50ml/hr. I have no idea what conversion the nurse used, but somehow he set up a drop counter to set the rate of fluid infusion at 13 drops per minute.
As if that wasn't enough excitement at one in the morning, while I was alone bagging that child, another child on the floor coded. I had to convince a nurse to come bag the first child while I followed a second nurse who was running with the code equipment to the room of the second child. The second child wasn't in a private room- there were 7 other mothers and babies awake at 1am watching us code the child in the corner. This child's arrest was sudden and unexpected as he had been feeding well all evening. He had prolapsed colostomies after a recent GI surgery and was said to be dehydrated upon arrival several days ago. He received fluid boluses, 3 code doses of epi, 2 code doses of atropine. We tried the defibrillator paddles placed on his chest for monitoring a rhythm in him and were actually able to see a normal sinus rhythm but he had no pulses. So after coding his PEA for 30 minutes, we finally had to quit and call the death. There is no code team to call during a code, it's just me and whoever happens to be around who is willing to help. I had the intern bagging, I did CPR, a nurse searched for suction and finally located it for us, another nurse drew up medications, and the surgeons were present since it was a surgical patient. The medications are not in the concentrations or formulations typically used in the US, so some mathematical conversions have to be done which is challenging to order at 2am during a code situation. After the patient died, I met the family to tell them the bad news. Thankfully, a chaplain was available to come speak to them. I prayed with them. Their reaction struck me as very stoic and matter of fact, as if this is a common occurrence to lose a child. The father asked the reason for the death but the mother didn't even want to see the child. It was a very different reaction than I have witnessed after previous codes.
Needless to say, it was a very long night with more stressful situations than I would like to encounter in one call. But God provided people to help along the way and although the outcomes were not desirable in either case, we did the best we could with the resources and information we had at the time. I have only been here a week, but I have been challenged medically, emotionally, physically, and spiritually already. Please pray that I have the stamina to keep up this pace of working hard every day and working through the night 1-2 times per week. Please pray that I will have the resources available (both knowledge, people, medications, and equipment) to treat the patients. Pray for my interns and the long-term doctors as they are working longer hours than I am and doing it for much longer than 2 months and they can actually speak the language to interact with the patients. And pray that we will not be discouraged when bad outcomes happen but that God will be glorified in all situations.
