Absurd. Throughout the day, this seems to be the word that kept coming to mind when thinking about how the past 24, 30 hours had been. Our call yesterday was just absurd.
For the record, I came home from work, and went right to bed. That was at 5pm. I don't think I have ever gone to bed, by choice, at 5pm. When I woke up an hour ago, I decided I should take out my contacts and try to be slightly productive...
I don't even know where to start..
5 pediatric resuscitations. I know there were 5, because I counted them.
Let me tell you about #3 and #2.
#3: I'm walking past the bench that kids sit on when they are waiting to get admitted. The bench had been empty ALL morning long (the ominous sign), and then we got nailed, and moms kept walking in with relatively sick children. Resus kiddo #2 was stabilized, I'd just finished admission paperwork, and had grabbed the next kid to admit, and was walking into a room to grab an admission packet when I happened to look at this child being held by mom. And this child looked dead. He had that unnatural waxy skin look to him. So, I did the right thing, I kept walking pretending I had never seen the sick kiddo, let him be somebody else's problem! Kidding. So I stopped, and quickly listed for a heart beat, which was there, and was less than 60. 60 kind of being the magical number for if this kid was going to get chest compressions or not... I grabbed the kid from mom and headed to the resus room, and grabbed the other senior resident at the same time. Time for ABCs. She started to bag, I started compressions, and others arrived. One of the medical students started bagging, she prepared to intubate, and I grabbed the first needle I saw I and miraculously got the inter-osseous IV on the first attempt (slightly pissed this kid was sent for admission without IV access from the ED-but this anger was retrospective). After a fluid bolus and some bagging, the heart rate picked up, but kid refused to breathe effectively on his own so he got intubated and went on the last available ventilator. This is an issue... Not having vents, but having more sick babies means it's time to make decisions about who else will get vented, and also means it is time to start calling around and find out what hospitals in Jo'burg have vents and will accept kids..
#2: Somewhere around 8pm, I went to do an arterial gas on my kid who had been the second resus of the night. This child had been treated for meningococcal meningitis and discharged the week before, and came in severely acidotic and dehydrated. She got the full resus, but managed to escape the vent. So, I arrive at the bedside, and before jabbing her, glance at the monitor. And her hear rate is in the mid-70s, and her sat seems to be in the mid 70s as well. These are both bad numbers, being sick, her heart rate should be more than 110, even 120, and her sat should be well above 90.. What the hell is going on. I send for the other resident as I poke the kid for blood. As she arrives, the kid drops her hear rate to 20, and then NADA. Zip. Zero. Zilch. We momentarily stare in disbelief at the monitor thinking that this is a cruel joke, but as she listens, and I feel, the child really is not breathing and no heart beat. We start coding the kid. And here, I honestly wish I were back home where there are code teams so somebody else could do chest compressions while we tend to the other details. It really sucks to be powerless. We run the whole algorithm, debate all the possible causes and are pushing meds, I get the kid intubated and as I bag, bloody secretions are aerosolizing and covering the child face. The absurd thing, at one point there is a 3 or 4 year old child behind the glass window of the room behind us who smiles and waves as I glanced in his direction. The medical student wants to throw I the towel at the 10 minute mark ("But we've been doing this for 10 minutes" she tells us). We watched this kid code, he was bagged immediately, and has had effective chest compressions, I try to explain to her why we will continue-(but really I'm half tempted to jump over the bed and strangle her, though I know the other senior resident has first dibs). It's futile. And we call the code after almost 40 minutes. It's really frustrating. This is a child, whom we admitted hours previously (after a vigorous resuscitation correcting fluid and electrolyte abnormalities) who was being followed closely, and who fucking still died with us watching. Literally, with us watching.
It's approaching 10pm. The bench is still full. I'm hoping to head home soon, so have stopped admitting new patients and am drawing bloods, doing IVs, spinal taps, etc on the kids who will be admitted. I'm in the procedure room when I hear the door open, and immediately I hear really sick breathing coming from the infant being carried by the senior resident. I pass of the kid I was taking blood from, and we watch as this kid goes into a horrendous coughing fit. This is an easy diagnosis. This child has pertussis. I have a 4 week old with pertussis on the ward, who looks exactly like this kid. Well that's not true, this kid in front of us is in quite a bit more distressed. This night sucks, and isn't fun. I'm never going to get out of here, so I offer to admit the kid. This kid is "HIV exposed." Will we intubate him if needed. Again, no vents or ICU beds at our hospital...
There are still 4 waiting for admission, and it's 1130. I grab what should be a pretty simple admission. The pedi ED note basically says 3 week old female with vomiting. This is a slam-dunk admission. I can get a history, spinal tap, bloods, bladder tap, and IV, and write orders on this kid in 45 minutes if I am really lucky! But the history is more complex than simple vomiting. The exam shows mild respiratory distress, fairly unremarkable abdominal exam.. So I feed the kid some clear rehydration solution in hopes of proving that this kid really isn't projectile vomiting. But of course, when the kid vomits (old milk from 3 hours ago, and no bile) all over the place, the mom shrugs, as if to say, I told you so... (there is more to this, but I want to be in bed in 10 minutes). My admission differential is vomiting due to pneumonia/uti/NNS, maybe due to abdominal pathology (possible pyloric stenosis but kid is young for it, obstruction)..
So I finally leave just before 1am... And arrive back at 5:30 this am..
#4: The child with pertussis got too tired breathing an hour or two before I got to work, and I walk in to find him intubated. And being placed on a stretcher headed for another hospital who have graciously accepted him for admission.
#5: 8:30, just as we start to round on the 23 admission from last night, one of the kids admitted for kwashiorkor has just coded. He doesn't make it.
Flash-forward to 3pm. It has been a marathon day. We admitted sick, sick kids last night. Have spent the better part of the day drawing blood, doing LPs, starting IVs, getting essential studies such as ultrasounds, EKGs etc done and trying to basically stabilize the ward before we leave for the afternoon. Nobody has left the ward to go eat all day. We have been so busy with the kids who were admitted that we won't discharge any of the old kids who could have gone home today, because we've basically run out of time to sit and do the paperwork to get them out the door. And we all just want to leave. We are pushing to get out at 4...
And at 3pm, my vomiting 3 week old comes back from ultrasound. And she has radiological proof of pyloric stenosis. It's a small mental victory. When I was tired and grumpy last night, I still managed to stick to the fundamentals of being a good clinician. I took a good history, included a broad differential, and made a plan to evaluate with that differential in mind. I was actually shocked it was PS, I had thought that is was going to be more infective etiology. It's an affirmation about being thorough and systematic.
Goodnight.
