VSO's tag line is "sharing skills, changing lives" but the title of this blog reveals a more realistic interpretation after todays events.
In my 2 and a half months working in a hospital I Cambodia I have had to let a lot of things slide not just for my mental health but also because Rome wasn't built in a day (I am told) and hence I was pretty clear from all our training that the changes (if any) will be small and like a glaciers their progress often imperceptible.
Now you will all, I'm sure, remember the maternal death blog and if not then I'll remind you that from the moment I walked into the room I knew there was nothing I could do for that poor 23 year old woman who had already gone past the point of no return. It still smarts.
However today I had a whole new experience of a 21 year old girl being sent home by the doctors to die despite my attempts to persuade them to treat her with antibiotics, this one hurt like hell.
So, I rock up to the ICU medicine ward for the ward round today as normal and in the corridor is a young girl surrounding by family and looking very unwell. It shames me to write it but I have got so used to seeing patients suffering that although I noticed her I didn't stop to find out more.
Her emaciated and unconscious form did however prompt me to ask the duty doctor what was the matter with her. He started to tell me that she had previously had a moto accident and serious head injury. She had been treated initially at the NGO emergency hospital but as she had a brain haemorrhage that needed neurosurgery her family had paid for her to be transferred to Vietnam for a evacuation of the clot and then she had required a VP shunt (a tube going from her brain to her abdomen) after she developed hydrocephalus (build up of pressure in the brain).
Duty doc didn't get too far with the history though as I noticed that a group of 6 student nurses were gathered around the girl performing what I can only describe as a half hearted attempt at CPR. Half hearted mainly due to the fact that they are 1st year students in their 2nd week of training and as most of the senior nurses and doctors in Cambodia are not ALS trained I'm pretty sure the same goes for student nurses.
I disengaged myself from the history to walk over to her and asked the nurses what they were doing. Now to try and be positive about the situation (believe me this is a monumental struggle currently) the students had obviously recognized that the girl was a very sick patient which I'm sure you will agree is a start. However I had to point out to them that she had 'signs of life' (i.e blinking, swallowing, moving her limbs), breathing and had a strong radial pulse so CPR on this occasion was not indicated. I congratulated them on recognizing that a respiratory rate of 6/min is a bit slow and then all via my VA (volunteers assistant) Chan, I explained to them that what is normally more appropriate when someone has a breathing problem is to give oxygen, support breathing with a bag valve mask and generally avoid cardiac massage when they do in fact have a cracking pulse.
How effective I was at getting this message across I will never know because at this point the duty doc (slightly miffed at me walking off halfway through his presentation of the patient) had arrived to see what was all the fuss the barang was making.
At this point it was becoming increasingly clear to me that the likely diagnosis for this patient was an infected +/- blocked shunt which would explain her coming in 6 hours earlier fitting with a fever of 40ºC. It also started to become clearer that at least some of her respiratory depression was due to the whacking dose of IV Diazepam she had been given (wasted and malnourished after 4 months of illness she must only weight 40kg) to stop her fitting.
I noticed that she hadn't been given any antibiotics, strange as all patients will get an IV with fluids and often antibiotics whether they need them or not.
When I asked the duty doc what the 'plan' was I was told that there was no 'plan'. I then had to explain to my VA that there is ALWAYS a 'plan' even if the plan is palliation. So I asked again what the management plan was for this patient and received the same answer - THERE IS NO PLAN.
I then had a 15 minute conversation where I explained to the duty doc that 21 year olds didn't have febrile convulsions (the current working diagnosis although written on her chart was hypocalcaemia!) and in this particular patients case her pyrexia and reduced level of consciousness was much more likely to be due to an infected+/- blocked shunt. It was a tough gig but I finally persuaded him to do some blood cultures (a new shiny innovation at the hospital and a luxury only enjoyed by 4 hospitals in the whole of Cambodia) and start some IV antibiotics. Just when I thought I was getting somewhere the head of ward rocked up and slipped passed me hoping like a small child that if he didn't get eye contact with me I wouldn't see him.
Regardless I joined him on the ward round and when he finally gets to the sickest patient in the ward he turns to me and says "you intubate her" I am omitting the '?' because it really was more of a demand than request. I explained to him that as they have no ventilator, no trained staff, no resources, no experience of managing intubated patients and had yet to decide on a definitive 'plan' for this patient that I didn't feel intubation was currently appropriate. Dr L - "But her breathing is only 6 a minute". Me "Yes she has had a huge dose of diazepam which is a respiratory depressant". Dr L "You Intubate her!". Me "err, no! But I can certainly bag her whilst you decide with the family if they can afford for her to be transferred to a neurosurgical ICU in Phnom Penh or Vietnam?"
Then he went up to the mother - red-blotchy faced from 4 months of worry and distress - and told her that her daughter was a lost cause and she should take her home to die as there was nothing he would do for her here.
The family's neighbour (a midwife) followed him into the staff room, imploring him to keep her there, to give her antibiotics to see if she would respond to treatment. He refused her request. I explained that the least we could do was give her IV antibiotics for her shunt infection - the same response.
I went to talk to the family, the patient's mother grabbed my hands and thanked me in Khmer for trying to help her daughter, she was sobbing and raw and at this point I could have joined her.
Often on the ward I will suggest something and it is rejected but if I go back a few hours later it has been done - it is all about saving face. So when I went back after lunchtime I was fully hoping to see a bag of Ceftriaxone dripping into her and a chance for the diazepam to be metabolized given.
Not so, her bed was empty. The only nurse I could find (asleep in the staff room) informed me "p'tair" - she had been taken home.
I can't even begin to describe how impotent and frustrated and angry and guilty and sick to the very pit of my stomach I feel about this whole episode.
A patient had laid on a bed in the corridor for 6 hours without a 'plan', I had tried to advocate for a 'plan' that was within the limits of the resource poor setting we were in, and it feels to me that because I thought it was inappropriate to intubate her she was then sent home with one 'plan' - to die without even being given some paracetamol for her fever.
In my 2 and a half months working in a hospital I Cambodia I have had to let a lot of things slide not just for my mental health but also because Rome wasn't built in a day (I am told) and hence I was pretty clear from all our training that the changes (if any) will be small and like a glaciers their progress often imperceptible.
Now you will all, I'm sure, remember the maternal death blog and if not then I'll remind you that from the moment I walked into the room I knew there was nothing I could do for that poor 23 year old woman who had already gone past the point of no return. It still smarts.
However today I had a whole new experience of a 21 year old girl being sent home by the doctors to die despite my attempts to persuade them to treat her with antibiotics, this one hurt like hell.
So, I rock up to the ICU medicine ward for the ward round today as normal and in the corridor is a young girl surrounding by family and looking very unwell. It shames me to write it but I have got so used to seeing patients suffering that although I noticed her I didn't stop to find out more.
Her emaciated and unconscious form did however prompt me to ask the duty doctor what was the matter with her. He started to tell me that she had previously had a moto accident and serious head injury. She had been treated initially at the NGO emergency hospital but as she had a brain haemorrhage that needed neurosurgery her family had paid for her to be transferred to Vietnam for a evacuation of the clot and then she had required a VP shunt (a tube going from her brain to her abdomen) after she developed hydrocephalus (build up of pressure in the brain).
Duty doc didn't get too far with the history though as I noticed that a group of 6 student nurses were gathered around the girl performing what I can only describe as a half hearted attempt at CPR. Half hearted mainly due to the fact that they are 1st year students in their 2nd week of training and as most of the senior nurses and doctors in Cambodia are not ALS trained I'm pretty sure the same goes for student nurses.
I disengaged myself from the history to walk over to her and asked the nurses what they were doing. Now to try and be positive about the situation (believe me this is a monumental struggle currently) the students had obviously recognized that the girl was a very sick patient which I'm sure you will agree is a start. However I had to point out to them that she had 'signs of life' (i.e blinking, swallowing, moving her limbs), breathing and had a strong radial pulse so CPR on this occasion was not indicated. I congratulated them on recognizing that a respiratory rate of 6/min is a bit slow and then all via my VA (volunteers assistant) Chan, I explained to them that what is normally more appropriate when someone has a breathing problem is to give oxygen, support breathing with a bag valve mask and generally avoid cardiac massage when they do in fact have a cracking pulse.
How effective I was at getting this message across I will never know because at this point the duty doc (slightly miffed at me walking off halfway through his presentation of the patient) had arrived to see what was all the fuss the barang was making.
At this point it was becoming increasingly clear to me that the likely diagnosis for this patient was an infected +/- blocked shunt which would explain her coming in 6 hours earlier fitting with a fever of 40ºC. It also started to become clearer that at least some of her respiratory depression was due to the whacking dose of IV Diazepam she had been given (wasted and malnourished after 4 months of illness she must only weight 40kg) to stop her fitting.
I noticed that she hadn't been given any antibiotics, strange as all patients will get an IV with fluids and often antibiotics whether they need them or not.
When I asked the duty doc what the 'plan' was I was told that there was no 'plan'. I then had to explain to my VA that there is ALWAYS a 'plan' even if the plan is palliation. So I asked again what the management plan was for this patient and received the same answer - THERE IS NO PLAN.
I then had a 15 minute conversation where I explained to the duty doc that 21 year olds didn't have febrile convulsions (the current working diagnosis although written on her chart was hypocalcaemia!) and in this particular patients case her pyrexia and reduced level of consciousness was much more likely to be due to an infected+/- blocked shunt. It was a tough gig but I finally persuaded him to do some blood cultures (a new shiny innovation at the hospital and a luxury only enjoyed by 4 hospitals in the whole of Cambodia) and start some IV antibiotics. Just when I thought I was getting somewhere the head of ward rocked up and slipped passed me hoping like a small child that if he didn't get eye contact with me I wouldn't see him.
Regardless I joined him on the ward round and when he finally gets to the sickest patient in the ward he turns to me and says "you intubate her" I am omitting the '?' because it really was more of a demand than request. I explained to him that as they have no ventilator, no trained staff, no resources, no experience of managing intubated patients and had yet to decide on a definitive 'plan' for this patient that I didn't feel intubation was currently appropriate. Dr L - "But her breathing is only 6 a minute". Me "Yes she has had a huge dose of diazepam which is a respiratory depressant". Dr L "You Intubate her!". Me "err, no! But I can certainly bag her whilst you decide with the family if they can afford for her to be transferred to a neurosurgical ICU in Phnom Penh or Vietnam?"
Then he went up to the mother - red-blotchy faced from 4 months of worry and distress - and told her that her daughter was a lost cause and she should take her home to die as there was nothing he would do for her here.
The family's neighbour (a midwife) followed him into the staff room, imploring him to keep her there, to give her antibiotics to see if she would respond to treatment. He refused her request. I explained that the least we could do was give her IV antibiotics for her shunt infection - the same response.
I went to talk to the family, the patient's mother grabbed my hands and thanked me in Khmer for trying to help her daughter, she was sobbing and raw and at this point I could have joined her.
Often on the ward I will suggest something and it is rejected but if I go back a few hours later it has been done - it is all about saving face. So when I went back after lunchtime I was fully hoping to see a bag of Ceftriaxone dripping into her and a chance for the diazepam to be metabolized given.
Not so, her bed was empty. The only nurse I could find (asleep in the staff room) informed me "p'tair" - she had been taken home.
I can't even begin to describe how impotent and frustrated and angry and guilty and sick to the very pit of my stomach I feel about this whole episode.
A patient had laid on a bed in the corridor for 6 hours without a 'plan', I had tried to advocate for a 'plan' that was within the limits of the resource poor setting we were in, and it feels to me that because I thought it was inappropriate to intubate her she was then sent home with one 'plan' - to die without even being given some paracetamol for her fever.
oh esther. Know that you are making a difference just by being there. Stay strong.
ReplyDeleteWhat an awful story. Glad you tried though. You're clearly making some kind of a difference and that's better than nothing. By the time you leave there'll be a bunch of people who are still breathing because you went.
ReplyDelete