I've been taking care of a 2 and a half year old who came in with general edema. Every morning when I get to the ward, he is in a fair bit of respiratory distress. Significant retractions. Essentially he blocks off his airway when he lies flat. I wake him up, the retractions settle, and I prop him up. Yesterday morning I grabbed the Reg, as he was having some stridor. We did a blood gas, which sure enough confirmed a respiratory acidosis. Fast forward to this morning. The Reg was called to see him (I had already rounded on him, woken him up and propped him up, left a note-again wondering about some diuresis). The Reg commented that we'd have to keep a close eye on him. And that he was "not for."
Not for resuscitation, or essentially mechanical ventilation. There would be little chance of him getting into the ICU and on a vent if he was intubated for this respiratory issue. That's just a fact of life. There are limited resources, and the decision of who gets aggressive medical care, and who is "not for" is, in some ways simple, but at the same time complex. I've asked a bit. Does it depend on HIV status? Does it depend on TB status? Does it depend on nutritional status (or malnuts=kids w/ malnutrition). How is this decision made. There isn't a magical formula. If the overall prognosis is poor, then it's pretty clear that the kid is "not for."
Our ward is on-call (or Intake) tomorrow. That means that today was "grand rounds" in which we rounded on every patient on our ward (what may be about 30 or so). We rounded with 3 consultants. One of them, Prof (not the main prof of the peds) was superb. Such a smart man. Very jovial and pleasant on rounds, asking tough questions and working through the answers. One of the other consults had more of a pimp style. They were night and day different. With the one, I felt what interns and residents in days past must have felt, feelings of inadequacy etc. Although, I will admit that half way through the round, I had to think that it's fair I'm not too sure what's going on, as I've never managed such malnutrition/HIV/TB meningitis/New onset heart failure etc.. etc.. etc.. I recognize that I'm here to learn these things, and that if I don't have the answers now, that's fine. (I also though, I'm here voluntarily to learn, I'm not graded by them, but rather am grading myself, and thus far, I think I've learned a good bit).
Anyway, I peeked in on this kiddo before leaving. During rounds, the Prof took one look and this kid and it was obvious to him that this kid was in heart failure, and needed some pretty urgent diuresis. (which I've been asking for 2 days). I chased up some results from the computer and was pleasantly surprised to see that his is HIV negative. I found the Reg and passed on this info.
The kid is no longer "not for."
