I had a cheery Christmas on the Thai border, the Boxing Day afternoon in the ER was particularly cheerful, as is the rule which states that sad & terrible things always happen at Christmas time in Emergency departments.
A patient was admitted Christmas night with breathlessness & collapse. She was 33 years old & 4 days before had delivered twins. The MA on duty had recognized that she was seriously unwell & had wanted to transfer her to the provincial hospital but the director would not give permission so she was kept in the ER over night on oxygen.
When I saw her the next morning I was concerned about her & after discussion managed to persuade them to transfer her. J & R went to discuss nursing training with the head nurse whilst I stayed in the ER to keep an eye on her whilst I worked on my laptop - I had a bad feeling about her. The hospital ambulance took over 2 hours to mobilize & just before it finally arrived to take her she cried out & arrested.
I called for help, no one but me was in the ER. This actually required phoning R to come back. For the next hour 2 nurses, a Medical Assistant (MA), a student nurse, R, J & I tried to resuscitate her. I showed them how to do effective chest compression, they intubated her. We used up their supply of adrenaline & we got a return of spontaneous circulation. From her history it was most likely that she had a massive pulmonary embolus but I was worried that if she had a pericardial effusion, which was tamponading, this was something I could do something to reverse. Whilst she was still arrested I asked for a spinal needle & was preparing to do a pericardiocentesis when we got an output. I wasn't so keen about sticking a needle into her chest, without USS, if she wasn't arrested.
On a previous visit to the maternity ward I remembered seeing an USS machine locked in a cupboard. I asked if I could use it to do an ECHO on this patient. If I'd been at the provincial hospital they would have been resistant or said it wasn't possible but I was here so a student nurse rushed off to get it. The ECHO showed she didn't have a pericardial effusion but did have right heart strain making the most likely diagnosis a PE. She then arrested again. This time I was able to show the effect of adrenaline on her heart & why we give it as an inotrope. The staff were beginning to see you can do a lot more than scan a pregnant woman with this machine.
She was now dependent on adrenaline to maintain a cardiac output & wasn't self ventilating. The decision was made that there was no point in transferring her as she wouldn't probably survive the 2 - 3 hour journey.
She had a 4 year old daughter which J suggested should come & see her mum before we withdraw treatment. R got very angry with us & walked off. J was confused, normally R is so caring - neither of us knew what we'd done but concluded it must have been something really culturally insensitive.
She died 10 minutes later. That afternoon we were all a bit subdued. I sat with R & asked what we had done to upset/offend him. Nothing as it turned out, it was actually a lot worse than that. The daughter was from a previous marriage. R had heard the patient's relative discussing how the stepfather was an alcoholic & they couldn't afford to keep & feed the twins - which will now no doubt die without their mother - they were sure that the daughters fate was equally grim, perhaps she would be sold to Thailand, perhaps she would be abused. R heard all of this & just felt overwhelmed with hopelessness at being unable to save the mother. He didn't want to cry infront of the staff.
Now J & I were feeling even more upset about the events of the morning. We worked in silence in the now empty ER all afternoon. It was getting late when a man rushed in with a 19 year old girl in his arms - she was dead. She had started coughing up blood 30 minutes before, choked & collapsed.
The second resuscitation of the day started, apart from this time, as it was 5 pm, there was no doctor - just me, 2 nurses & 2 student nurses as well as a depressed J & R. We did our best but there was an electricity cut so no suction, no light to see what we were doing. We managed to get in 2 large IVs and give her 3 litres of saline. Intubation without suction was more of a challenge. Having exhausted the ER's adrenaline supply that morning we started on the medicine wards expired ampoules. After 30 minutes of resuscitation & in the half light we stopped.
We found out that she was from the south of Cambodia but was working here to send money back to her family 400 kms away. She was here all alone with no close relatives. She had been diagnosed with TB 2 weeks previously & had been commenced on treatment & discharged only 2 days previously. It was profoundly sad.
One of the nurses was crying. I suddenly felt a great connection with her. We had both tried & failed to save the lives of two young women. It felt so tragic & hopeless I wanted to cry too. I mentioned to R how upset the nurse was & how unusual it was to see this in Cambodian health workers. "Esther" he told me witheringly "she's crying because she's just found out the girl had TB & she's told me that she is worried that she will now catch it."
One Boxing Day, a few years ago now, I was working a run of six nights in paediatric ICU. Two children died of meningococcal sepsis, the day doctor didn't turn up to relieve me so I had to stay on until 11 am to do the ward round. When I went to my car, it had been broken in to, causing £150 worth of damage - the thief had taken just a packet of wine gums & some loose change.
Reflecting on the ghosts of Christmas past, my run of nights in PICU was beginning to seem like one of the happier ones. Writers block followed.
A patient was admitted Christmas night with breathlessness & collapse. She was 33 years old & 4 days before had delivered twins. The MA on duty had recognized that she was seriously unwell & had wanted to transfer her to the provincial hospital but the director would not give permission so she was kept in the ER over night on oxygen.
When I saw her the next morning I was concerned about her & after discussion managed to persuade them to transfer her. J & R went to discuss nursing training with the head nurse whilst I stayed in the ER to keep an eye on her whilst I worked on my laptop - I had a bad feeling about her. The hospital ambulance took over 2 hours to mobilize & just before it finally arrived to take her she cried out & arrested.
I called for help, no one but me was in the ER. This actually required phoning R to come back. For the next hour 2 nurses, a Medical Assistant (MA), a student nurse, R, J & I tried to resuscitate her. I showed them how to do effective chest compression, they intubated her. We used up their supply of adrenaline & we got a return of spontaneous circulation. From her history it was most likely that she had a massive pulmonary embolus but I was worried that if she had a pericardial effusion, which was tamponading, this was something I could do something to reverse. Whilst she was still arrested I asked for a spinal needle & was preparing to do a pericardiocentesis when we got an output. I wasn't so keen about sticking a needle into her chest, without USS, if she wasn't arrested.
On a previous visit to the maternity ward I remembered seeing an USS machine locked in a cupboard. I asked if I could use it to do an ECHO on this patient. If I'd been at the provincial hospital they would have been resistant or said it wasn't possible but I was here so a student nurse rushed off to get it. The ECHO showed she didn't have a pericardial effusion but did have right heart strain making the most likely diagnosis a PE. She then arrested again. This time I was able to show the effect of adrenaline on her heart & why we give it as an inotrope. The staff were beginning to see you can do a lot more than scan a pregnant woman with this machine.
She was now dependent on adrenaline to maintain a cardiac output & wasn't self ventilating. The decision was made that there was no point in transferring her as she wouldn't probably survive the 2 - 3 hour journey.
She had a 4 year old daughter which J suggested should come & see her mum before we withdraw treatment. R got very angry with us & walked off. J was confused, normally R is so caring - neither of us knew what we'd done but concluded it must have been something really culturally insensitive.
She died 10 minutes later. That afternoon we were all a bit subdued. I sat with R & asked what we had done to upset/offend him. Nothing as it turned out, it was actually a lot worse than that. The daughter was from a previous marriage. R had heard the patient's relative discussing how the stepfather was an alcoholic & they couldn't afford to keep & feed the twins - which will now no doubt die without their mother - they were sure that the daughters fate was equally grim, perhaps she would be sold to Thailand, perhaps she would be abused. R heard all of this & just felt overwhelmed with hopelessness at being unable to save the mother. He didn't want to cry infront of the staff.
Now J & I were feeling even more upset about the events of the morning. We worked in silence in the now empty ER all afternoon. It was getting late when a man rushed in with a 19 year old girl in his arms - she was dead. She had started coughing up blood 30 minutes before, choked & collapsed.
The second resuscitation of the day started, apart from this time, as it was 5 pm, there was no doctor - just me, 2 nurses & 2 student nurses as well as a depressed J & R. We did our best but there was an electricity cut so no suction, no light to see what we were doing. We managed to get in 2 large IVs and give her 3 litres of saline. Intubation without suction was more of a challenge. Having exhausted the ER's adrenaline supply that morning we started on the medicine wards expired ampoules. After 30 minutes of resuscitation & in the half light we stopped.
We found out that she was from the south of Cambodia but was working here to send money back to her family 400 kms away. She was here all alone with no close relatives. She had been diagnosed with TB 2 weeks previously & had been commenced on treatment & discharged only 2 days previously. It was profoundly sad.
One of the nurses was crying. I suddenly felt a great connection with her. We had both tried & failed to save the lives of two young women. It felt so tragic & hopeless I wanted to cry too. I mentioned to R how upset the nurse was & how unusual it was to see this in Cambodian health workers. "Esther" he told me witheringly "she's crying because she's just found out the girl had TB & she's told me that she is worried that she will now catch it."
One Boxing Day, a few years ago now, I was working a run of six nights in paediatric ICU. Two children died of meningococcal sepsis, the day doctor didn't turn up to relieve me so I had to stay on until 11 am to do the ward round. When I went to my car, it had been broken in to, causing £150 worth of damage - the thief had taken just a packet of wine gums & some loose change.
Reflecting on the ghosts of Christmas past, my run of nights in PICU was beginning to seem like one of the happier ones. Writers block followed.
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