Days 28 - 32
Cliff Notes version:
Monday – long report from the weekend; finished data entry on the May charts; got the April charts from the A&E to start
Tuesday – clinic in the morning, charts in the afternoon. Fairly routine day.
Wednesday
I anticipated that today would be a long day, because it was our admitting day. It was pretty uneventful for most of the day – I went to clinic for the first few hours with Dr. Kung, and saw some REALLY cute twins, although it was kind of creepy too because they dressed exactly the same – but right after Dr. Kung came back from clinic, around 4:45, she came out of the office saying that there was a really sick new admission. I was in the middle of entering charts, but I really wanted to see the patient, so I jumped up and followed her.
It was an almost textbook case of congestive heart failure, which, oddly enough, does happen in kids, though it’s relatively rare. The baby lived with an aunt, and the mom only visited on weekends, but she could tell that something was wrong with the child over the weekend – a cough and puffy extremities, which progressively worsened over the beginning of the week to shortness of breath and rapid breathing. The baby had initially gone to SLH, a regional hospital near their home, but they had referred to us when they saw how sick the child was.
Things were complicated a bit because a sibling at home was currently three months in on anti-tuberculosis therapy, which fit the time frame for the baby to have contracted it and be showing symptoms. Unfortunately, our X-ray was still out of commission, but we had a film from SLH, and lung sounds pretty clearly pointed to fluid build-up in the lungs. Combined with the edema, the child’s respiratory distress, and weak distal pulses, everything pointed to heart failure.
Luckily, the head of the pediatric department, Dr. Mazhani, is also a cardiologist, and he hadn’t left for the day yet. We called him in to consult, and he performed an echocardiogram on the spot, after some rearranging of the beds to find an outlet that worked in a spot that also had an oxygen hook-up. The best ejection fraction he could measure for the child’s heart was 33% ☹
After the echo, I placed a TB skin test, in case the child could be stabilized and also needed TB treatment, then Dr. Kung started an IV. I secured it and bootlegged an arm board (made of tongue depressors, tape, and cotton swabs for padding) to tie to the baby’s arm to keep it straight. The mom didn’t speak much English, but a combination of pantomiming and two-word phrases seemed to communicate pretty effectively that I wanted her to keep the baby from pulling the IV out. She was very scared, so I tried to reassure her, but the situation was pretty bleak. The baby needed to be in an ICU and get a dopamine drip to maintain systemic blood pressure, because as the heart tired it would bottom out the child’s BP. PMH doesn’t have a pediatric ICU, and Dr. Kung explained that the ICU is run by anesthesiologists “who don’t like kids,” and they didn’t have any beds anyway. The nursing support in the paeds ward is too inconsistent for them to continuously monitor the baby if we were to start a drip ourselves, so we had to make do with diuretics and oxygen. Tiny and Dr. Kung also called a cardiologist they knew to see whether they could transfer the baby to a private hospital with an ICU. He was “still eating his supper” (it was well past 6:30 by this time), and not in a hurry to come in, so Dr. Kung gave me a ride home.
Thursday
Came in early to do a gastric aspirate on the sick baby from last night, but miraculously, Tiny had arranged the transfer overnight and taken the child to Bokomoso, a district hospital about an hour away. We got updates throughout the day that the baby was improving on dopamine, though not out of the woods yet. Yay!
MK and Lina presented their designs during morning report; Finished April chart entry!
No comments:
Post a Comment