Wonderment makes staying up all night worthwhile. The combination of a viral illness and chronic sleep deprivation has created a wall that I hit yesterday at 6pm before my call night. I lay down to take a nap before the enviable sleepless night started. At nine I went into round on the ICU patients I knew to be sick from earlier that day.
The first man that I checked in on was a 28 year old male who was brought in by his neighbor eariler in the day. Our patient had become remorseful about ingesting a bottle of organophosphates in a suicide attempt and had asked for help just before collapsing. In casualty he was unresponsive, had pin point pupils, an unrecordable blood pressure, pulse of 42 and an O2 saturation of 70%. The intern took on the case as if she had seen this before…she had…many times: gastric ravage, activated charcoal, atropine, and a quick trip to the ICU. There he was started on an Atropine drip (by the visiting resident from Idaho, the dose she gathered from a Google search on organophosphate ingestion.) By the time I had seen him, he had been intubated and had received about 6 times as much atropine as he probably should have (based on an article that I found). His pulse was 130, blood pressure 170/120+, urine output decreasing. I turned off the atropine and watched him for several hours in hypertensive crisis. In the mean time, I treated him for possible acute alcohol withdrawal with some valium that seemed to help things a little. I stopped by to check in after my ward rounds to find his pupils fixed and dilated, no tone or reflexes, his respiratory rate matching the vent all night. Meg, the other resident had already been talking about extubating him to free up a bed. His hope for his own life was contagious, I got it that night. Come morning, though, it was time to move the hope onto another patient. This is how it goes.
Watching his blood pressure was actually in the background of the main focus of the night which was an exchange transfusion of a three day old who had sepsis and suspected ABO incompatibility; an indirect hyperbilirubinemia of 27. Before last night, I had yet to use the page in the Children’s handbook regarding exchange transfusions. Exchange transfusions had existed for me only in the form of a fleeting image when I thought about dying babies in someone else’s care. The image was composed of a sterile U.S. ICU with a million people surrounding a fancy dialysis-like machine all knowing what they were doing. That image was about to be destroyed. I called THE pediatrician (the only one available in Kijabe, on call all the time) who gave me a list of supplies to gather: B+ blood, reusable 2cc syringes, a “tiny” NG tube and a minor surgical tray. Dr. Meissner walked us through placing an umbilical catheter. We then began the process of the transfusion that would continue for the next 7 ½ hours. It required withdrawing 5-10cc of blood from the child and replacing it with fresh blood each time over 5 minutes, all the while keeping very close track of the blood pressure, oxygen saturation and giving small fluid boluses as needed. My image is now a half dozen cheerful, sleepy people gathered around the prehistoric incubator shedding a purple bili light into the small ICU to save this tiny patient from kernicterus.
What was soon identified as the “grunt work” of the exchange transfusion was done all night by the tired intern and clinical officer who developed very arm and back, which freed me up to assess and infant born at 34 weeks born with mec and after PPROM. By this time in Kijabe, I was ready for spinabifida, mec aspiration syndrome, congenital abnormalities, or some other dreadful problem… but the baby actually did well weighing in at 2.5kg with APGARS of 8 and 9. A sigh of relief. I went back up to the ICU…
…to a 12 hour infant born vaginally with a double nuchal cord and required 25 minutes of resuscitation earlier in the day with O2 sats that never toped 70%. C-pap was attempted but the baby was judged by the pediatrician to have asphyxic brain death—she was, we were taught, doing the “rowing sign.” They had withdrawn c-pap and discussed with the mother the imminent death of her daughter. That discussion was at 5:30pm. Her mother sat in the room praying for a miracle; she was still sitting in the room at 2AM with a daughter saturating in the mid 40s. Was this a miracle or was it suffering? What would have happened to this baby at Swedish?
There were several other admissions: the inevitable motor vehicle accident brought in a man with several fractured ribs and a flail chest. A man—who shares my birthday—was transferred from an outside facility in hopes of a spine surgery to decompress his T4 tuberculosis mass that had rendered him paraplegic for the past 4 weeks. A 77 year-old Massai gentleman with known hypertension, diabetes and history suggestive of a left CVA…there is usually one per night that I feel comfortable with. Sort of… this Massai man does not exactly fit the diabetic hypertensive stereotype we have in the US. He has been farming all of his life, has no TV or processed foods and weighs 110 pounds.
I slept much of the day today. It has been a wonderful rainy, restful day with Liam by the fire. Tomorrow is Saturday. After round, we are heading to Naivasha for the day to see some more animals with some new friends the Davis’. Rich Davis is a general surgeon who just graduated from residency and is here for at least 5 years. I have such tremendous admiration for him.