Me: Grandma, how is the baby's caca?
Caca is the appropriate term for it. I've seen more variation in Caca than I ever thought was possible. I've seen the classically pasty white stools of biliary atresia. The malnourished kids have liquid yellow caca (which kind of reminds me of egg drop soup). So, asking about caca is routine. It's routine elsewhere too, here is really no different. In fact, I remember being told once, when you need time to think about what other questions to ask, as about bowel movements as a stall tactic.
Grandma: Oh Doctor! The caca is very, very nice.
That's it. Nice caca. Now I've heard it all. Grandma loves this boy. So much that even his caca is great. It's almost like she is describing a place I should visit. Oh Doctor! Clarens is very, very nice. Or a bottle of wine. Or a cheese. But caca...
This saying has been playing over and over in my head. Last night as I was running on the treadmill I laughed as I thought about me asking her that question in the admission ward. Oh Doctor! The caca is very, very nice.
I headed in a bit earlier than usual today, looking forward to getting out maybe a bit early and enjoying an afternoon run.
Today, was caca. And there was nothing nice about it.
I walked into the ward, looked into cubicle 10 to see if the 2 year old had made it through the night. His bed was empty, but with ward shuffle, there could be a chance he was still alive, though it would be a miracle, but not necessarily a good one. As I sat down to check labs, one of the nurses came over to me.
Sister: Doctor, there is a resus going on.
Me: Where?
Sister: In the resus room. (Which seems like a good place to do it).
I had walked past the room on the way into the ward, the door was closed, so I didn't think anything of it. This is also our procedure (blood draw, IV, spinal tap) room. So I head to the room. And of course, I put 2 and 2 together, and wonder why the 2 y/o is in the resuscitation room, certainly his file clearly indicated he was "not for" active resuscitation.
And as I step into the room, I see an exasperated pedi registrar (senior resident), and 4 month old infant. Caca. Not nice caca.
Me: What's the story?
Her: low sugar, can't get an IV. dehydration.
Me: who is this kid? (I can't figure out why he is in here, though he looks familiar)
Her: it's your ward, do you know this kid?
Me: (grabbing the chart) yes.. (we'd reviewed him at 4pm, he was in with pneumonia, went back on oxygen in the afternoon, but was fine otherwise).
Her: Is he for active resuscitation?
Me: (I hesitate to say yes, because in my mind some days all these kids are still for active resuscitation). Yes, he's negative (HIV), he was getting better, and was likely going home in a day or two.
Her: This is the fourth resuscitation of the night.
Me: damn, that's not good.
Her: On this ward.
Oh caca. Really, really not nice caca.
We fumble for an IV. It's getting drastic, this kid is literally crashing before our eyes, and we don't have an IV. We tackle from opposite ends. There is still an airway, there is still breathing, there is still circulation (barely) but there isn't glucose, and there isn't enough fluid in the system. She's trying for a femoral line, and I'm going for an intraosseous (needle into the shin bone). And we both are striking out. So we literally switch sides. I'm working on the central line, she on the intraosseous. I ask the nurse to find some glucagon (like this kid is going to have any glycogen in the liver...). Glucagon doesn't ring any bells to the staff... I ask her to call to casualty and find some. Also, asking to drop an NG and give the kid some oral until we get an IV.
His breathing is slowing down.
Caca.
Time to make the decision.
Me: It's time to intubate.
Her: he is definitely for ventilation
Me: yes.
Her: Ok, can you grab a tube?
So I reach to the emergency trolley. And that's when I see the failed third resus attempt. I'm caught off guard. Apparently, that kid had just died when they literally whisked this kid into the resus room, and literally there wasn't time to do anything but move the body off to the side.
[I hesitate to write that part. But to me the reason to mention is that this hospital is amazing. You have incredibly sick kids being take care of by a staff-both nurses and doctors, who work against such tremendous odds at times, and when the shit hits the fan sometimes you are literally moving from desperate situation to desperate situation, and there wasn't even time to remove the body from the resuscitation room].
There is a trend here to nasally intubate kids and confirm placement/finish placement with forceps using the laryngoscope. I don't understand this method. To me it just takes longer. It's a tough intubation.
I offer to try, and she agrees. I haven't intubated an infant in a long time. But as I insert the laryngoscope, the cords drop into view and I get the tube it. I'm so surprised that I actually got the tube on the first try that I damn near inserted the thing the whole way.
We start bagging the kid. By this time, others should be around, and she gets on the phone and calls for back up. Who arrive.
We start full CPR. Get IV access (finally an IO), but it's really too late.
By the time we decided to stop, the entire team, is in this room. It's sinking in that in addition to the kid who we knew was going to die, that 3 others died as well. One of those wasn't too unexpected. But 4 deaths overnight takes a toll on morale. I absolutely must point out here that these kids were sick. All of them would have been in the pediatric ICU back home, or at least would have been moved there well before demise. There isn't any sense of wrong doing or negligence at all, but rather a sense of defeat by the level of poverty, the disease burden, and the lack of ability of the system to fix these kids.
The day ends when I discharge the child with the nice caca. I see the grandma walking out, carrying her grandson on her back, as is custom here, and I think about the nice caca and laugh to myself. Thank god this day is over.
