My new VA (#4) started work today, I was a little apprehensive about going to the wards after last week but braced myself, warning her it may not be pretty, then dived in regardless.
ICU medicine - the doctors were still only requesting white blood counts despite the introduction of a new form with a box for a full blood count. I was informed you don't need haemoglobin & platelets on a septic patient. However the same patient had been given 3 litres of IV fluid. Last week Dr ON was talking about shock index, this week Dr V, who was also at the American organised emergency care conference in Battambang last month, was treating patients with correct fluid management. I couldn't feel more ineffective if I had tried but as long as they begin to give appropriate fluids I genuinely don't care who persuades them - it just leaves me wondering what the hell am I doing here then?
Paediatrics - surprisingly, the 28 weeker who I thought wouldn't survive the weekend had survived. Mum was managing to express some milk for NG tube feeding, he was a little less jaundiced & the breathing was about the same - the breathing would have been a lot better I discovered if the doctor hadn't ordered the oxygen to be switched off. Apparently, the father relayed to me, the doctor told him that the baby would be able to suck if the oxygen was switched off, as it would make him stronger. I tried to explain that maybe he would have less work of breathing & apnoeas if he wasn't hypoxic but the father earnestly told me that he was going to follow what the doctor said - why not? No one else listens to me - I'm even beginning to doubt what I think myself!
Surgery - not so good. There was huge crowd of people - you could call it a mob - stood outside the OPD/emergency room. At a glance I could see a boy laid out on the floor being bagged - it wasn't looking good. My VA looked horrified, she's an english literature student & dead children wasn't in the job description.
Then something very strange happened - one of the surgeons saw me & said "Esther - please help us", I actually got asked for help, which of course I did because its my job & I don't need to be asked (although its also nice to know that its been requested & not begrudgingly forced upon the helpee).
So what started as a uncoordinated resuscitation of a drowned child on the tiled floor in a pool of river water vomit ended up 30 minutes later as an intubated child on a bed having good quality chest compressions, NG tube inserted, IV access obtained & adrenaline given every 4 minutes. There was even a cylinder of oxygen wheeled into the room so that we weren't ventilating with air. The nurse who handed me the syringe of adrenaline was visibly upset, the doctor that had asked me to help was sweating from the exertion of CPR & I had the detached calmness I only ever feel during a well run resuscitation. Things were quiet, there was an absence of chaos.
I called R to help as my new VA was startled & not medical. When he arrived he wasn't really sure why I had called him, the nurse anaesthetist had secured the airway, my tutorial on correct chest compressions had paid off & my VA, on my instruction, was getting a history from the mother.
I then began the unenviable task of discussing stopping resuscitation with the Mother & the surgeon, in a second language - walking the surgeon through what I would say & then him translating it in Khmer to the Mother who after much insistence from me had been allowed in the same room as her son & to touch him. It is hard enough stopping resuscitation in front of parents but when there are 20 plus rubber neckers it is even worse. I am finding hugging bereaved mothers increasingly more difficult as the paediatric death count increases. The under 5 years mortality rate in Cambodia in 2010 was 51 out of 1000 children, currently I feel like I am seeing every one of them.
I told the nurse anaesthetist & head of the OR, respectively, that their airway management & chest compression were great, then I went to debrief with R & my VA over coffee. I've accepted that I may not ever get to work in the new ER but by God I will drink coffee in the new canteen.
R & I discussed compression to ventilation ratios, warming techniques, use of drugs other than adrenaline in cardiac arrest, the benefit of having oxygen & an emergency trolley in an emergency area....
My new VA's feedback was that the boy's Mother had told her she was grateful for my kindness & compassion and felt that everything that could be done, had been, to try & save her son.
I tried to reassure my VA that this was as bad as it got here & it wasn't the best start for her but it was at least a realistic one. Thankfully she only works mornings so wasn't with me for the second paediatric death of the day, this afternoon.
It remains to be seen if she will show up tomorrow morning for day 2. I have a feeling she is more resilient than me, so will be still here, fighting poverty & injustice, long after I have bailed out.
ICU medicine - the doctors were still only requesting white blood counts despite the introduction of a new form with a box for a full blood count. I was informed you don't need haemoglobin & platelets on a septic patient. However the same patient had been given 3 litres of IV fluid. Last week Dr ON was talking about shock index, this week Dr V, who was also at the American organised emergency care conference in Battambang last month, was treating patients with correct fluid management. I couldn't feel more ineffective if I had tried but as long as they begin to give appropriate fluids I genuinely don't care who persuades them - it just leaves me wondering what the hell am I doing here then?
Paediatrics - surprisingly, the 28 weeker who I thought wouldn't survive the weekend had survived. Mum was managing to express some milk for NG tube feeding, he was a little less jaundiced & the breathing was about the same - the breathing would have been a lot better I discovered if the doctor hadn't ordered the oxygen to be switched off. Apparently, the father relayed to me, the doctor told him that the baby would be able to suck if the oxygen was switched off, as it would make him stronger. I tried to explain that maybe he would have less work of breathing & apnoeas if he wasn't hypoxic but the father earnestly told me that he was going to follow what the doctor said - why not? No one else listens to me - I'm even beginning to doubt what I think myself!
Surgery - not so good. There was huge crowd of people - you could call it a mob - stood outside the OPD/emergency room. At a glance I could see a boy laid out on the floor being bagged - it wasn't looking good. My VA looked horrified, she's an english literature student & dead children wasn't in the job description.
Then something very strange happened - one of the surgeons saw me & said "Esther - please help us", I actually got asked for help, which of course I did because its my job & I don't need to be asked (although its also nice to know that its been requested & not begrudgingly forced upon the helpee).
So what started as a uncoordinated resuscitation of a drowned child on the tiled floor in a pool of river water vomit ended up 30 minutes later as an intubated child on a bed having good quality chest compressions, NG tube inserted, IV access obtained & adrenaline given every 4 minutes. There was even a cylinder of oxygen wheeled into the room so that we weren't ventilating with air. The nurse who handed me the syringe of adrenaline was visibly upset, the doctor that had asked me to help was sweating from the exertion of CPR & I had the detached calmness I only ever feel during a well run resuscitation. Things were quiet, there was an absence of chaos.
I called R to help as my new VA was startled & not medical. When he arrived he wasn't really sure why I had called him, the nurse anaesthetist had secured the airway, my tutorial on correct chest compressions had paid off & my VA, on my instruction, was getting a history from the mother.
I then began the unenviable task of discussing stopping resuscitation with the Mother & the surgeon, in a second language - walking the surgeon through what I would say & then him translating it in Khmer to the Mother who after much insistence from me had been allowed in the same room as her son & to touch him. It is hard enough stopping resuscitation in front of parents but when there are 20 plus rubber neckers it is even worse. I am finding hugging bereaved mothers increasingly more difficult as the paediatric death count increases. The under 5 years mortality rate in Cambodia in 2010 was 51 out of 1000 children, currently I feel like I am seeing every one of them.
I told the nurse anaesthetist & head of the OR, respectively, that their airway management & chest compression were great, then I went to debrief with R & my VA over coffee. I've accepted that I may not ever get to work in the new ER but by God I will drink coffee in the new canteen.
R & I discussed compression to ventilation ratios, warming techniques, use of drugs other than adrenaline in cardiac arrest, the benefit of having oxygen & an emergency trolley in an emergency area....
My new VA's feedback was that the boy's Mother had told her she was grateful for my kindness & compassion and felt that everything that could be done, had been, to try & save her son.
I tried to reassure my VA that this was as bad as it got here & it wasn't the best start for her but it was at least a realistic one. Thankfully she only works mornings so wasn't with me for the second paediatric death of the day, this afternoon.
It remains to be seen if she will show up tomorrow morning for day 2. I have a feeling she is more resilient than me, so will be still here, fighting poverty & injustice, long after I have bailed out.
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