Monday, July 14, 2008

Just Another (Not?) Normal Day

This morning before I left the house, the lights flickered.

I don't even know where to begin. So, I will just go chronologically.

I arrive at 7:30, and first assess my three month old with jaundice who is going to have a liver biopsy at 8 am. I run the blood form to the blood bank so that the fresh frozen plasma is ready for her biopsy (it'll keep her from bleeding out after the biopsy-her liver dysfunction is keeping her blood from coagulating normally). Also, at 8 am, AL is suppose to go be seen by the ENT doctors, so I make sure to have seen both of them by 8 a.m. It is 745, and in my neurotic need to make sure that everything goes smoothly this morning I plan to remind the nurses that AL needs to be headed out the door to be at outpatient clinic. Unfortunately, the nurses have just begun singing, and their shift report will happen afterwards, so now I feel screwed knowing that nothing will be ready until 845.

Moving on... I go back to the blood bank after seeing KP. KP is my two month old who had heart surgery shortly after birth due to a congenital heart defect. Goal number five for today is to find a small size nasal cannula so that he can get weaned down on his oxygen, and hopefully get transferred back to the referral hospital. Much to my delight, a nasal cannula has magically appeared since I left yesterday. But, unfortunately it is not pointing into his nose but rather is pointing at his chest. [As an aside, I have been using adult size cannulas and trying to snip them shorter to fit children.] Now, KP is quite dependent on supplemental oxygen and he tends to get a bit fussy, and a bit blue without his supplemental oxygen. I checked his pulse ox while putting his nasal cannula into his nose, and let's just for the record note that it was way less than 70; his goal is to be greater than 70. In fact, it was very far from 70. Let's just say we set a new level for LOW pulse ox-and the reading was real/legitimate, it correlated with the heart rate I calculated. But, he quickly perked up into the 70s range with the oxygen. I taped to the cannula in place to prevent oxygenation attempts via osmosis through his chest. [Another aside, I'm getting really use to seeing sats in the low 80s, and in fact, I actually haven't been alarmed recently. I may have to have some re-entry training to get alarmed by low sats when I return back to the US].

I run to the lab and pick up the fresh frozen plasma. Biopsy time. In the room where we draw blood is where we are going to do the conscious sedation for the liver biopsy. The lights flicker-the power is threatening to quit. That wouldn't be good. Biopsy in the dark doesn't sounds like fun to me. I know, I know, where's my sense of adventure?? Regardless, iIt actually went quite smoothly.

I head out and check on my remaining patients. I glance at my watch after the biopsy is over, and get a little anxious realizing that it is creeping up on 9 a.m. AL still has not gone to the ENT clinic. I remind the charge nurse (aka sister) and she tells me that someone will take him shortly. I finish seeing my remaining patients, including my 8 year old friend to was discharged on Friday. It is now about 10 a.m. The senior residents have gone to one of the other wards to see a patient, so I have not rounded with them, yet.

One of the senior residents comes into the Ward and I tell her my plan is to round on my patients with her and then I will take AL to ENT clinic myself. I've been told this isn't necessary, and that I could be there for hours...

So, we finish rounds and I find where I have to go, which happens to be about a 10 minute walk. I debate carrying AL, but decided that wheeling him in a small mobile-crib-like-thing is better. And Jesus, let me tell you that this made such an intense squeaky noise that people down the road looked back in order to see what was so damn loud. Let me describe the noise. Take 500 children with long finger nails, let them scratch their nails on a pristine chalk board at the same time that 300 vultures devour small animals at the same time that 200 kettles start whistling. It was that loud, I don't exaggerate.

For the next 45 minutes, we would generate plenty of stares. Not only did the hideous noise from the crib force people to look, but the fact that this white doctor was carrying a black African child-I felt so Angelina/Brad/Madonna-generated plenty of additional stares. I managed to find my way to the ENT clinic, conveniently located on the 3rd floor. I grab my friend and up the stairs we go. And then I was slightly horrified to see about 30 people in a tiny hallway waiting to be seen. Not that I really care about waiting at this point, but lunch time is approaching, and I'm hungry. Oh, and one more minor detail. AL is on LASIX, a great diuretic. And it kicked in. For a minute, I wondered if I peed myself, but no, it was AL's soaking diaper. And I didn't think to bring a new one.

We got our number, number 80, and I decided what the hell, I had nothing better to do than to hang out with AL and 30 of my closest friends waiting for the ENT docs.

But, thankfully membership has its privileges, and we were taken by the next available doctor after about 20 minutes. And to my non-surprise, the ENT doctor quite quickly decided that AL needed his adenoids out. And to my pleasant surprise, he scheduled the operation for Wednesday-in TWO days. I hate to admit, but after two weeks of a frustrating lack of progress, I felt a bit giddy that AL was finally on the path to some useful treatment. Of course, then I freak out realizing that I haven't seen family at AL's bedside for a week now, and who's going to consent for the surgery? Maybe AL and I will go drive around Soweto looking for them! (Not).

We take the long way back to the Ward, and we had a nice stroll. I actually contemplated going via the cafeteria and sitting out in the warm sun having a play lunch with my pal, but decided that if the prof walked by, this may not be well received.

Then things go slightly downhill from here...

A patient was transferred to our Ward this morning as a TURF. Meaning that this kid has previously been taking care of on our Ward. And therefore the way the system works is that any child who is readmitted, goes back to the ward were they have been admitted previously. It lends a new meaning to the term turf wars. Anyway, this new kiddo, KM, was assigned to me. So I go in and read through his chart... After the past two weeks, I felt like I was beginning to develop a bit of a thickened skin and that not much would really surprise me at this point. I was wrong for two reasons.

Reason one: one of the ward sisters behind me says "doctor, do you know this baby? I think this baby is dehydrated." She was not talking about the Turf Kid I was seeing. To which I replied, after barely glancing at the baby, "no, I don't know him but I can look at him in a minute, or you can ask one of the other doctors." Now, the definition of dehydration can be interpreted in different ways. That baby was de-hydrated, in the eternal sense. He was one of our severe malnutrition kids. Who at some point in the past hour or two had actually died. And that was it. No calling a code, no resuscitation, no getting excited. This is life, plain and simple.

Death #4.

Reason two: Now, back to KM. KM is 1 year old. He has been admitted twice before, once for failure to thrive, and once for pneumonia. He weighs four kilograms. He weighs a kilo more than his BIRTH WEIGHT. He should weigh at least 10 kilograms by now.

He is not in good shape. I made a list of his problems, they include:
1--pneumonia
2--tuberculosis exposure
3--failure to thrive/marasmic-kwashiorkor
4--social neglect
5--anemia
6--thrombocytopenia
7--hyponatremia
8--hypoalbuminemia
9--sepsis/leukocytosis/elevated CRP
10--immunization delay
11-thrush
12-deformed ears (which is important because there could be renal deformities)
13-hypotonia (likely because of NO muscle mass)
Any, by report he is HIV negative.

He is a train wreck. And honestly, I am not sure I have ever used the term TRAIN WRECK for a pediatric patient before. For an adult, sure, all the time. That is normal for adult medicine admissions, and normal medicine admissions usually have more than 5 problems. Train Wreck.

Problem 14 would be the profound sense of helplessness I feel when thinking about this kid.

Shit.