1. Jyoti was taking care of a 2 year old with paraffin ingestion/poisoning. Now, neither of us had heard of paraffin before coming to this country, but given that it's a product that's found in diesel fuel, we figured it was not very good for this kiddo. My guess was a waxy petroleum substance (reminding me of "parafilm" that we use in the lab all the time); Jyoti's suggestion was that it was a liquid nonabsorbable nonpolar organic compound (given that she uses "tincture of paraffin" as a laxative for other patients...). Dr Google says...we're both right; it is the general name for any alkene hydrocarbon (the octane found in gasoline, and the kerosene that the baby most likely ODed on are both examples). Well, the kid looked ok, but yesterday Jyoti saw that he was in mild respiratory distress, and was tachycardic though had moist mucous membranes. Given that the team was electing to keep the baby NPO, and that the baby was trying to suck the moisture out of its own thumb, Jyoti ordered IV fluids. A specialist attending later decided to cancel that order, because the baby "looked well." Today as Jyoti prerounded with her medical student, the baby literally turned gray in front of their eyes, and stopped breathing and underwent cardiac arrest. Apparently he was really quite normal this morning before that. The team rushed in and resuscitation was begun. Despite intubation and fluid boluses and chest compressions, the baby expired after an hour.
2. As I walked into the ward from lunch, the intern quickly pointed me towards cubicle C, where a patient had just become unresponsive. The patient was a young female, 35 yo, with HIV not on HAART, who had come in with vague abdominal pain concerning for an acute abdomen. A surgery consult had just seen the patient a few hours earlier, and decided that there was nothing acute about her abdomen. But by the time I saw her, her abdomen was huge and tight and hyperresonant, almost certainly indicating an abdominal catastrophe. She had had fevers but no antibiosis was begun. As the senior medical person there, I was asked to run the code -- which is ridiculously different from running a code in the US. For one, there is no heart monitor, so at most we should really only be doing Basic Life Support, not Advanced, given that we have no idea whether the lack of pulse means VFib, VTach, asystole, or PEA. But apparently that's not how it's done here. I attempted to lead everyone in BLS, getting very effective chest compressions from an MO (whose patient this was) and good ambu bag breaths from the nurse/orderly. Given the lack of information about the electrical activity of the heart, I figured that epinephrine couldn't hurt, since it's common to almost every pathway. But my intern and MO kept trying to go through various algorithms, which didn't quite make sense to me given that we didn't really know what we were treating. So we ended up giving epi and atropine for a few rounds, while doing 15-2 chest compressions to rescue breaths. This was an interesting mix of BLS and ACLS...but I went with it, and tried to review all reversible causes with the team; my leading diagnosis was abdominal catastrophe and sepsis, which would only get better with fluids (which she was getting), aggressive antibiotics (which were out of stock today), pressors (which we don't have), mechanical ventilation (which we don't have), and surgery (once she was stable). But I figured it would be good teaching to review the 5Hs and Ts of PEA, which most people appreciated, and we did end up giving some bicarb as well. And to top it all off we finally got a defibrillator there, but there were no pads to read the rhythm (they had fallen off and were nowhere to be found). There were defibrillation handles, so we ended up shocking once as well, figuring it probably couldn't really hurt. I guess it was a reasonable learning opportunity for those involved, but I was pretty sure that as soon as we got there and I saw her belly, there was not much we were going to be able to do.
I wonder if Jyoti's patient could have been better managed prior to the code, or if something happened suddenly between 6 and 7 am to make him decompensate. I truly think it's the latter. I think the adult patient was really sick, and I'm not sure if the surgical team missed something this morning; then again, she was so sick that she may not have survived a major abdominal surgery. And given that our ICU is effectively closed to any sick HIV patients, I'm not sure there was much we were going to offer her. But after going through a resuscitation effort here in Botswana, I think there are a lot of things that could be improved. a) have pads on the defibrillator! b) have a mechanism in place to care for a patient after resuscitation has been achieved (or else it's futile!) c) house officers should review evidence based guidelines for resuscitation and apply them to what the hospital can offer. this should be a hospital wide policy, so that people don't just pick and choose some things from BLS and some things from ACLS...
No comments:
Post a Comment