Small miracles

So I have now been here for six weeks and I have experienced every possible emotion from fatigue and hopelessness to sheer joy and gratefulness.

So I have now been here for six weeks and I have experienced every possible emotion from fatigue and hopelessness to sheer joy and gratefulness.

In my position in the MSF hospital, I am the doctor for the pediatric intensive care unit (ICU), pediatric neonatal unit and the tetanus unit. We have one other doctor who is a general practitioner and she is responsible for the general pediatric floor. We are assisted by four local medical assistants, one for each unit. Our hospital has been over capacity since I arrived averaging 120-130 patients in pediatrics on a given day (I believe the beds are for 70-80 patients but we have twins in many beds and mattresses on the floor everywhere).

In my neonatal unit, I accept very low birth weight infants (1.25kg/2.75lbs and above) with gestational ages as early as six months. The tetanus room has had five to eight children at a time, mostly neonates as they get the infection from the umbilical cord once it’s cut. The Pediatric ICU is overflowing with malaria, malnutrition and respiratory illnesses.

The first weeks were extremely hard on me, I spent a lot of time and energy focusing on what I could not do, instead of acknowledging how much we were accomplishing. I was worried about gaps in my knowledge as I am a general pediatrician, not an ICU doctor (though I am so grateful for the ICU training I received in residency). I was draining myself emotionally and realized mentally I would not survive if I kept going this route.

Two small miracles happened for me right around the same time and it was the turning point I needed.

During my first week here, a mom brought in her two-week-old baby who had been born at home. The baby had stopped breast feeding and was having trouble breathing. We placed a pulse oximeter on the child and her level was really low (saturations were in the 50's). She had crackles in her lungs and a loud murmur. I knew she was in heart failure. I told the mom we would do what we could but the child may not survive the night.

We started oxygen, gave a small bolus for dehydration [a small volume of fluid], started antibiotics, some maintenance fluids as the child was too sick to breast feed and gave diuretics. I really did not think the child would make it through the night, but the next morning there she was breathing fast and retracting but still alive. She now had edema [swelling] and a liver edge (signs of worsening heart failure) so fluids were stopped and a nasogastric tube (NGT) was placed. Mom was taught how to express breast milk and how to place it in the tube for the child. 

The patient survived for days like this, her lungs were full of fluid, all I could hear were crackles on auscultation. She weighed less than 4 lbs and all her efforts went towards breathing (all we have is 5 liters of oxygen by nasal cannula to support breathing). I talked with mom daily and she knew I had a guarded prognosis, but I would continue to do what I could.

Then one morning, I did my exam and they were gone, the crackles were just gone. I heard clear breath sounds. I must of listened for what felt like ages but I couldn't believe what I was hearing, or wasn't hearing. Over the next 10 days, she continued to improve. She started breast feeding and the NGT was removed.

She came off oxygen. Finally, she gained weight and was able to come off diuretics. One month and one day later, I was sending her home. She still has a murmur and she may get sick again but for now she's thriving. I told mom she is my miracle child. (For the medical people my only explanation was persistent pulmonary hypertension that slowly improved with time.)

My second small miracle happened right around the same time. I have been struggling with malnutrition. The mortality rate is high when a malnourished child goes into shock and it has been extremely frustrating for me, especially since malnutrition is not something I see in the US.

A patient was transferred to me from the feeding center for decompensation - a sudden deterioration in condition - and by the time she arrived she was in shock; non responsive, cool extremities, and thready pulses. Again my hope for resuscitation was not great and the fluid balances in malnourished children can be tricky.

We gave a small bolus and started antibiotics. She responded a little to the fluid so we gave another small bolus and then placed a nasogastric tube to rehydrate. We gave ReSoMal (a rehydration solution for malnourished children) through the night. I said good night and gave strict instructions to the night staff. I didn't hear from them that night so I was not sure what to expect the next morning, but once again when I arrived there she was sitting up in bed drinking. I wanted to cry, I was so happy.

She was my first malnourished child in shock to recover. She continued to improve and started to gain weight and has now returned to the feeding center.

The days are still up and down and the bad days are still bad but I'm starting to see all the good we do here as well and I keep holding out for small miracles!