Last weekend I had a meeting with my medical referent because he knows I have been very stressed by the work load lately. His question to me was, "how can I support you better?" The reality is he cannot. Everyone here already gives 110%, the system is just too overwhelmed.
Most days there are more patients than beds. We have many nights when a child and parent have to sleep on a blanket on concrete floor. I have had up to 13 preterm infants in a room with beds for nine. At home when the hospital service is full, we find another hospital to admit the patient, but here we are the only hospital and turning away a sick child is not an option. With so many children it is difficult on everyone.
There are more medications for nursing to give, more vitals to check, more infants, children and parents to feed, more blood sugars to monitor, more feeding tubes and IV cannulas to place. When it is busy it becomes easier for things to accidentally get overlooked.
We don't have a 1:2 or even 1:4 nurse to patient ratios in our ICUs like we do in the United States. We have one nurse and one nurse assistant for however many patients get placed in their ward. And it seems like the days when the wards are the most crowded, are the days the children are the sickest. Two Fridays ago, was one of those days!
I have a MSF nurse assigned to help me in the ICU wards. He is basically my right hand and there are days I would be lost without him. I give him the checklist of all the things that need to be done on patients from enemas, to weaning oxygen, to placing IVs, to feeding tubes, to wound dressing changes, to medications, most days he probably feels like my list never ends. He then trains the local staff on how to do all these things and follows up to make sure they are done.
Last Friday, however, both him and I had a much more pressing job. Ventilating children.
The morning started with the admission of twins born at home, one who was doing ok and one was struggling to breathe and had poor feeding.
Shortly after admission the child stopped breathing altogether.
We grabbed the Ambu bag and oxygen and started ventilating the child. While my nurse bagged, I ran my differential diagnosis of apnoea [temporary cessation of breathing] in a newborn. Blood sugar and hemoglobin were ok, antibiotics were started for infection, a bolus was given for probable dehydration (infant had poor feeding and poor urine output). Phenobarbital was given for possible seizure. Then there is the list of things I cannot test for or treat; head bleeds, metabolic disorders, electrolyte disturbances to name a few.
A translator was called and the situation was explained to the family. After 30 minutes of treating and ventilating we needed to stop and see what the child could do. The child was placed on oxygen and it felt like an eternity but the child started to take some breaths. The child was placed with the family and we would wait and see.
Shortly after this admission we were called from the newborn ward to the pediatric ICU. A previously healthy two–month-old (also a twin) was being admitted with increased work of breathing and had also developed apnea. My differential diagnosis in this child was a little shorter as he was older and previously healthy. Again my nurse started to bag as the child stopped breathing and the heart rate was dropping. The heart rate came up immediately with ventilation and after a few short minutes, the child was breathing again.
He was given fluids and antibiotics, including treatment for pertussis [whooping cough] as we have had quite a few cases of "whooping" children and in young infants they can have apnea instead of the classic whooping cough.
Over the next hour or so the patient had several rounds of apnea all which responded to ventilation. I left my nurse there for hours just monitoring and ventilating the child as I was called for an infant with neonatal tetanus who had stopped breathing.
Neonatal tetanus is tricky. We treat it with high doses of diazepam to try and stop the spasms but this medication can reduce respiratory drive and the spasms themselves cause paralysis of the respiratory tract which also leads to respiratory failure. So it’s been a difficult balance for me. This time it was a bad spasm and the child responded to ventilation until the spasm subsided.
The last child of the day was the one I wrote about in my last blog. My nurse and I left that day emotionally and physically exhausted. The hardest part is that some of this illness is completely preventable with vaccines. If mom was vaccinated the infant would be protected from neonatal tetanus.
I woke up the next morning with anxiety over what I might find once I got to the hospital. We lost the one child overnight (the child from my last blog) but the other three children were alive and stable. Over the next days and weeks I watched each of these children get better.
As each one was sent home (and all three have now gone home) I reminded my nurse that he helped to save each of their lives!