So the last time I blogged about M - the 17 year old girl with WPW syndrome - she had a third & finally successful ablation on my Birthday. I then went to Borneo for a holiday & she went home unmedicated to start the rest of her life without any further life threatening arrhythmia's.
Life is - as I have discovered here - a series of disappointments.
The Sunday that I arrived back in BTB I got a text from L - my VA - saying that M had not eaten rice for 4 days & was very sick. I told her to come to the referral hospital on Monday so I could see her. I had a very sleepless night. They hadn't come earlier I later found out, despite me telling them to seek medical advice early, because they couldn't afford the transport, they didn't like how they were treated at the hospital when I am not there & they hoped it would get better by itself - after all they had been told she was cured.
On Monday M arrived at OPD looking swollen, pale & jaundiced. Her heart rate was 240/min. My heart sank. I went to tell ICU about her admission & was told - we don't have any ECG paper. I asked if they had requested any replacement ECG paper. They flapped their hands in my face & told me to go away they were busy - ask Dr ON, the deputy director, if its so important to you. By 'busy', they were sat watching TV, writing paper work.
We got an ECG at OPD which confirmed the diagnosis of an broad complex tachycardia - her WPW - & so I called Jn in PNH to organise for Amiodarone to be sent up. Jn had her own fun trying to find IVAmiodarone and finally could only find 2 boxes of ampoules that were 3 months expired. I joked with her that the nurses would probably refuse to give it. In the past 2 years I have never once seen them even check expiration dates on medications.
Meanwhile despite a very low BP, M was walked over from OPD to ICU and was left standing in the corridor until I kicked up a fuss. The staff remained in the staff room. My post holiday glow had evaporated.
Now that I have a contact in the states - the cardiologist that did ablations 2 & 3 - I emailed him & asked for his advice. He replied almost immediately saying he knew a friend who worked at the NGO trauma hospital in town - Handa - and had skyped her. They had a defib machine there. Previously, in September I had been told it was old & had never been used so had discounted it as an option but apparently it was now available, it was still untested as never used.
I went to see it & it did seem to be working - it charged very slowly, as if the little men inside on their bicycles peddling up the charge were as exhausted as I feel currently. As M was stable (IV fluids had treated her dehydration from 4 days of not eating) and Amiodarone had worked for her last time, I opted to keep her at the referral hospital & load her with Amiodarone but if she deteriorated we could transfer her for a DC cardioversion. It felt good to have options for a change.
The Amiodarone didn't arrive until late as although J got it on a Taxi by 1pm in PNH, the taxi then waited another 4 hours to fill up with passengers.
The following morning the nursing staff refused to give the Amiodarone as it had expired - is this my hubris? After a lot of discussion & explanation they started the loading dose - M's BP dropped, her respiratory rate increased, she looked dreadful. I wanted to transfer her to Handa Emergency Hospital but the hospital management team were not happy with this & would not allow use of a hospital ambulance to transfer her, however she was hardly in a fit state for a tuk tuk or moto.
They showed me 3 defib machines the hospital had - none of which I knew about, none of which worked anyway - and I convinced them that the only hope for this 17 year old girl was a synchronized shock. They agreed if I could find a method to privately transport her they would sign her out as self discharged.
Handa arranged for an ambulance to come pick her up that afternoon.
M's renal function wasn't so good, she wasn't really producing urine, she had bilateral pleural effusions & was becoming increasingly oedematous. I had poisoned her.
When the ambulance arrived the staff from Handa wanted her to walk to the ambulance. I had to explain that she had no blood pressure, a heart rate of 240/min and was in heart, renal & impending liver failure. They still wanted her to walk! R & I got a trolley & transferred her ourselves.
At Handa, Dr G took one look at M & felt as engaged in saving her as I have for the last 6 months, she has this effect on people. After a brief assessment in their OPD they transferred her to the Operating Theatre where I was shown the changing room & told as I was much more experienced in delivering DC cardioversion I should do it. Now in the 2 years I have been here no one has ever deferred to me or acknowledged any of my skills - it was quite intoxicating. You'd also think that after 2 years without doing a DC cardioversion I may feel a little rusty or apprehensive. In truth I was just concerned about whether they had scrubs that would fit me - thankfully they did.
She converted after a 100 joules shock - the longest part of the whole procedure was waiting for the machine to charge. Sedated with midazalam & fentanyl she woke up on delivery of the shock & murmured "that's better".
Later that evening Dr G called me to tell me she was back in a SVT but the rate was 140/min & she was stable. We decided to wait for the IV Amiodarone infusion to work but at midnight I got another call telling me she had dropped her BP so they were taking her back to theatre for another DC cardioversion. Another sleepless night.
Jn was coming up to BTB for a meeting & was bringing with her $200 worth of Flecainide tablets that would hopefully keep M in normal sinus rhythm when she went home.
Dr C in the states wanted her to also take a B-blocker. Both of these medications need to be taken twice a day & cost $60 a month.
M stayed for monitoring for 3 more days at Handa & will go home on medications for a review at Handa in 2 months time. She lives a long way away & has no money which makes her follow up a difficult balance between cost & well being. The last of the donations friends gave me has been spent on Handa's inpatient bill of over $200.
M receives free (if inadequate) medical care at the referral hospital because she has a poor card so her care is paid for by a health equity fund, however Handa as an NGO hospital does not have government system & its own poor patient fund is currently empty.
Dr C wants to have a 4th attempt at doing an ablation either next year in Phnom Penh or to bring M to Korea or USA where there is better equipment. I'm not sure how M & her family would manage an overseas trip but it may well come to that is the technology is not available in Cambodia.
Dr CM the Cambodian Cardiologist who did her first ablation wants her to come to PNH when a French team of Cardiologists come for them to have an attempt at a successful ablation.
In the mean time M needs medication & regular check ups to ensure that she remains in a normal rhythm & doesn't die waiting for a cure.
All of this costs money. After 26 months volunteering that isn't something I have an awful lot of.
I have struggled with the morality & ethics of spending so much money on one individual in a country so wanting & full of need. But all I can reason is that without mine & others intervention, M - an otherwise bright & healthy 17 year old girl with her whole life ahead of her - would be dead. Her Mum has come to the same conclusion & told me so yesterday, right after she had told me that she will give me her daughter if I can fix her. This makes me & L very upset to hear such abject despair.
There's no other way to say it than here - no money, no life. M needs money so that she can stay alive & then she needs money for her cure. I am committed to achieving this for her but could really do with a little support. If any one would like to help me to help M please let me know.
Thank you.
Life is - as I have discovered here - a series of disappointments.
The Sunday that I arrived back in BTB I got a text from L - my VA - saying that M had not eaten rice for 4 days & was very sick. I told her to come to the referral hospital on Monday so I could see her. I had a very sleepless night. They hadn't come earlier I later found out, despite me telling them to seek medical advice early, because they couldn't afford the transport, they didn't like how they were treated at the hospital when I am not there & they hoped it would get better by itself - after all they had been told she was cured.
On Monday M arrived at OPD looking swollen, pale & jaundiced. Her heart rate was 240/min. My heart sank. I went to tell ICU about her admission & was told - we don't have any ECG paper. I asked if they had requested any replacement ECG paper. They flapped their hands in my face & told me to go away they were busy - ask Dr ON, the deputy director, if its so important to you. By 'busy', they were sat watching TV, writing paper work.
We got an ECG at OPD which confirmed the diagnosis of an broad complex tachycardia - her WPW - & so I called Jn in PNH to organise for Amiodarone to be sent up. Jn had her own fun trying to find IVAmiodarone and finally could only find 2 boxes of ampoules that were 3 months expired. I joked with her that the nurses would probably refuse to give it. In the past 2 years I have never once seen them even check expiration dates on medications.
Meanwhile despite a very low BP, M was walked over from OPD to ICU and was left standing in the corridor until I kicked up a fuss. The staff remained in the staff room. My post holiday glow had evaporated.
Now that I have a contact in the states - the cardiologist that did ablations 2 & 3 - I emailed him & asked for his advice. He replied almost immediately saying he knew a friend who worked at the NGO trauma hospital in town - Handa - and had skyped her. They had a defib machine there. Previously, in September I had been told it was old & had never been used so had discounted it as an option but apparently it was now available, it was still untested as never used.
I went to see it & it did seem to be working - it charged very slowly, as if the little men inside on their bicycles peddling up the charge were as exhausted as I feel currently. As M was stable (IV fluids had treated her dehydration from 4 days of not eating) and Amiodarone had worked for her last time, I opted to keep her at the referral hospital & load her with Amiodarone but if she deteriorated we could transfer her for a DC cardioversion. It felt good to have options for a change.
The Amiodarone didn't arrive until late as although J got it on a Taxi by 1pm in PNH, the taxi then waited another 4 hours to fill up with passengers.
The following morning the nursing staff refused to give the Amiodarone as it had expired - is this my hubris? After a lot of discussion & explanation they started the loading dose - M's BP dropped, her respiratory rate increased, she looked dreadful. I wanted to transfer her to Handa Emergency Hospital but the hospital management team were not happy with this & would not allow use of a hospital ambulance to transfer her, however she was hardly in a fit state for a tuk tuk or moto.
They showed me 3 defib machines the hospital had - none of which I knew about, none of which worked anyway - and I convinced them that the only hope for this 17 year old girl was a synchronized shock. They agreed if I could find a method to privately transport her they would sign her out as self discharged.
Handa arranged for an ambulance to come pick her up that afternoon.
M's renal function wasn't so good, she wasn't really producing urine, she had bilateral pleural effusions & was becoming increasingly oedematous. I had poisoned her.
When the ambulance arrived the staff from Handa wanted her to walk to the ambulance. I had to explain that she had no blood pressure, a heart rate of 240/min and was in heart, renal & impending liver failure. They still wanted her to walk! R & I got a trolley & transferred her ourselves.
At Handa, Dr G took one look at M & felt as engaged in saving her as I have for the last 6 months, she has this effect on people. After a brief assessment in their OPD they transferred her to the Operating Theatre where I was shown the changing room & told as I was much more experienced in delivering DC cardioversion I should do it. Now in the 2 years I have been here no one has ever deferred to me or acknowledged any of my skills - it was quite intoxicating. You'd also think that after 2 years without doing a DC cardioversion I may feel a little rusty or apprehensive. In truth I was just concerned about whether they had scrubs that would fit me - thankfully they did.
She converted after a 100 joules shock - the longest part of the whole procedure was waiting for the machine to charge. Sedated with midazalam & fentanyl she woke up on delivery of the shock & murmured "that's better".
Later that evening Dr G called me to tell me she was back in a SVT but the rate was 140/min & she was stable. We decided to wait for the IV Amiodarone infusion to work but at midnight I got another call telling me she had dropped her BP so they were taking her back to theatre for another DC cardioversion. Another sleepless night.
Jn was coming up to BTB for a meeting & was bringing with her $200 worth of Flecainide tablets that would hopefully keep M in normal sinus rhythm when she went home.
Dr C in the states wanted her to also take a B-blocker. Both of these medications need to be taken twice a day & cost $60 a month.
M stayed for monitoring for 3 more days at Handa & will go home on medications for a review at Handa in 2 months time. She lives a long way away & has no money which makes her follow up a difficult balance between cost & well being. The last of the donations friends gave me has been spent on Handa's inpatient bill of over $200.
M receives free (if inadequate) medical care at the referral hospital because she has a poor card so her care is paid for by a health equity fund, however Handa as an NGO hospital does not have government system & its own poor patient fund is currently empty.
Dr C wants to have a 4th attempt at doing an ablation either next year in Phnom Penh or to bring M to Korea or USA where there is better equipment. I'm not sure how M & her family would manage an overseas trip but it may well come to that is the technology is not available in Cambodia.
Dr CM the Cambodian Cardiologist who did her first ablation wants her to come to PNH when a French team of Cardiologists come for them to have an attempt at a successful ablation.
In the mean time M needs medication & regular check ups to ensure that she remains in a normal rhythm & doesn't die waiting for a cure.
All of this costs money. After 26 months volunteering that isn't something I have an awful lot of.
I have struggled with the morality & ethics of spending so much money on one individual in a country so wanting & full of need. But all I can reason is that without mine & others intervention, M - an otherwise bright & healthy 17 year old girl with her whole life ahead of her - would be dead. Her Mum has come to the same conclusion & told me so yesterday, right after she had told me that she will give me her daughter if I can fix her. This makes me & L very upset to hear such abject despair.
There's no other way to say it than here - no money, no life. M needs money so that she can stay alive & then she needs money for her cure. I am committed to achieving this for her but could really do with a little support. If any one would like to help me to help M please let me know.
Thank you.
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