Day 3 has continued along the same vein as days 1 & 2. I spent most of the day (sans VA) doing an audit of the death cases for ICU medicine, which is always guaranteed to whip me up into a state somewhere between agitation & despair. I was just about to call it a day & go to the office of the NGO that funds my placement to speak to the director when R got a call about a child on the paediatric ward.
As we walked over to assist, R somberly told me that in Buddhism we have to accept when someone dies, as this is their designated time. I responded that as a non-Buddhist, emergency physician, from the west my philosophy was to fight against this fatalism - especially in children, oh the hubris....
The 3 month old boy had been sick for 3 days with fever, runny nose, cough & difficulty breathing. When the parents had taken him to the local health centre he wasn't breathing - they were sent up to the big hospital. When the child arrived C - who works for an NGO hospital - started to resuscitate with CPR & ventilations. He gave him a bolus of IV fluids & after some oxygen & ventilations with a bag valve mask the baby had a pulse. After an hour of resuscitation he still wasn't breathing so C called R to give him a hand. I just happened to be with R when he got the call. Obviously as a paediatric emergency doctor I am not an appropriate person to call when a child needs resuscitating.
The student nurses in attendance (no doctor) were not giving effective ventilations so I proceeded to show them how to maintain an airway in a 3 month old & improve their ventilations. We also aspirated all the air that had been bagged into his stomach. We did this for a long time. The baby remained lifeless, pupils fixed & delated, cold peripheries. Things weren't looking good but he had a good pulse so following my medical culture we shouldn't give up.
C asked if I would intubate him - I, of course, said I would & wanted to know what the staff's plan was if we did this (they don't manage ventilated patients here). The parents were resigned to the fact that their only son was dead, they had no money to go to Siem Reap where the 2 nearest hospitals that can manage a ventilated child are & the staff said they had no one that could go with the baby on transfer. They couldn't find an appropriate size tube to intubate the child nor a laryngoscope. My Buddhist fatalism started to creep in.
We kept bagging the baby, the pulse remained strong.
CP - the paediatric 'all-star' showed up, came in to the paediatric ER, told me the baby was brain dead & walked out again.
A long series of conversations followed. I spoke with Dr P at an NGO hospital - because of the Dengue epidemic they had no ICU beds or ventilators, neither did the other hospital in Siem Reap. Was it really worth intubating the child & transferring him to Siem Reap only for all treatment to be withdrawn once he got there because there were no beds/ventilators/staff to treat? The parents did not even want him to be transferred but it was difficult with the language barrier to know whether this was solely based on financial concerns. CP clearly thought we should withdraw treatment but he wasn't the doctor on duty & he wanted the duty doctor to make that decision. C - paediatric nurse with NGO who had been there from the start of the resuscitation thought we should stop, he was confident that the child's down time would mean he would have significant hypoxic brain injury. V - trained nurse from BTB looking after the patient agreed. I am a westerner with western sensibilities & we don't give up on a child with a pulse - I was grappling with the medical culture gap. But as an advisor it wasn't (thankfully) my decision to make and I was beginning to understand the sense of hopelessness you often encounter when talking about seriously ill patients with Cambodian health workers.
They stopped ventilating the baby & he started making gasps. J wanted the mother to hold her child but CP was more concerned about emptying the baby's bladder by pressing on it. I left.
I went to sit outside on a bench & ask myself what was the right thing to do? Or WWJD?
J answered the second question by shooing away the gathering crowd of rubber neckers from the window of the ER. CP had moved his attentions away from bladder evacuations & gave the baby vitamin B1. Then the baby was wrapped up & given to his mother to hold.
J, R, C & I left the ward.
Reflecting on the whole 2 hours we had spent on the ward I came up with some positives. We had capacity built student nurses' airway skills, we had taught about the importance of NG tubes in sick children to decompress stomachs & improve ventilation. We had role modeled compassion & caring. I had convinced myself & everyone there that I can still to manage a paediatric airway.
I was still feeling pretty shit about the whole experience despite my attempts at positive thinking.
I broke my self enforced sobriety after my little knock to the head & went for a beer. There were no other doctors or nurses around so I couldn't debrief, instead I just sat pensively looking into my 50 cents glass of beer. And the refrain is - what is the right thing to do here?
Then my phone rang - it was CP, he called to let me know that the baby was breathing a little better. It was 6 30 pm. I don't know how long the baby went without oxygen, I don't know what degree of hypoxic brain injury there will be, he may not even survive the night but CP had called me to tell me about his condition.
That means something, I'm still trying to work out what exactly.
As we walked over to assist, R somberly told me that in Buddhism we have to accept when someone dies, as this is their designated time. I responded that as a non-Buddhist, emergency physician, from the west my philosophy was to fight against this fatalism - especially in children, oh the hubris....
The 3 month old boy had been sick for 3 days with fever, runny nose, cough & difficulty breathing. When the parents had taken him to the local health centre he wasn't breathing - they were sent up to the big hospital. When the child arrived C - who works for an NGO hospital - started to resuscitate with CPR & ventilations. He gave him a bolus of IV fluids & after some oxygen & ventilations with a bag valve mask the baby had a pulse. After an hour of resuscitation he still wasn't breathing so C called R to give him a hand. I just happened to be with R when he got the call. Obviously as a paediatric emergency doctor I am not an appropriate person to call when a child needs resuscitating.
The student nurses in attendance (no doctor) were not giving effective ventilations so I proceeded to show them how to maintain an airway in a 3 month old & improve their ventilations. We also aspirated all the air that had been bagged into his stomach. We did this for a long time. The baby remained lifeless, pupils fixed & delated, cold peripheries. Things weren't looking good but he had a good pulse so following my medical culture we shouldn't give up.
C asked if I would intubate him - I, of course, said I would & wanted to know what the staff's plan was if we did this (they don't manage ventilated patients here). The parents were resigned to the fact that their only son was dead, they had no money to go to Siem Reap where the 2 nearest hospitals that can manage a ventilated child are & the staff said they had no one that could go with the baby on transfer. They couldn't find an appropriate size tube to intubate the child nor a laryngoscope. My Buddhist fatalism started to creep in.
We kept bagging the baby, the pulse remained strong.
CP - the paediatric 'all-star' showed up, came in to the paediatric ER, told me the baby was brain dead & walked out again.
A long series of conversations followed. I spoke with Dr P at an NGO hospital - because of the Dengue epidemic they had no ICU beds or ventilators, neither did the other hospital in Siem Reap. Was it really worth intubating the child & transferring him to Siem Reap only for all treatment to be withdrawn once he got there because there were no beds/ventilators/staff to treat? The parents did not even want him to be transferred but it was difficult with the language barrier to know whether this was solely based on financial concerns. CP clearly thought we should withdraw treatment but he wasn't the doctor on duty & he wanted the duty doctor to make that decision. C - paediatric nurse with NGO who had been there from the start of the resuscitation thought we should stop, he was confident that the child's down time would mean he would have significant hypoxic brain injury. V - trained nurse from BTB looking after the patient agreed. I am a westerner with western sensibilities & we don't give up on a child with a pulse - I was grappling with the medical culture gap. But as an advisor it wasn't (thankfully) my decision to make and I was beginning to understand the sense of hopelessness you often encounter when talking about seriously ill patients with Cambodian health workers.
They stopped ventilating the baby & he started making gasps. J wanted the mother to hold her child but CP was more concerned about emptying the baby's bladder by pressing on it. I left.
I went to sit outside on a bench & ask myself what was the right thing to do? Or WWJD?
J answered the second question by shooing away the gathering crowd of rubber neckers from the window of the ER. CP had moved his attentions away from bladder evacuations & gave the baby vitamin B1. Then the baby was wrapped up & given to his mother to hold.
J, R, C & I left the ward.
Reflecting on the whole 2 hours we had spent on the ward I came up with some positives. We had capacity built student nurses' airway skills, we had taught about the importance of NG tubes in sick children to decompress stomachs & improve ventilation. We had role modeled compassion & caring. I had convinced myself & everyone there that I can still to manage a paediatric airway.
I was still feeling pretty shit about the whole experience despite my attempts at positive thinking.
I broke my self enforced sobriety after my little knock to the head & went for a beer. There were no other doctors or nurses around so I couldn't debrief, instead I just sat pensively looking into my 50 cents glass of beer. And the refrain is - what is the right thing to do here?
Then my phone rang - it was CP, he called to let me know that the baby was breathing a little better. It was 6 30 pm. I don't know how long the baby went without oxygen, I don't know what degree of hypoxic brain injury there will be, he may not even survive the night but CP had called me to tell me about his condition.
That means something, I'm still trying to work out what exactly.
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