Another 48 hours

4-21-08; Whew… just finished 48 hours of call over the weekend covering ICU/Nursery (NICU)/L&D. Finally I’ve got some time to Blog. Now, where to begin?

Friday night had dinner with Dr Doug and Noel Walsh (he is a family Doc out here for 2-3 years, they have three boys) and Dr Robert and Ginger Nagy (he is an ENT, retired Navy, they have a daughter who is a nurse in the Navy). It was nice to share war and mission hospital stories.

Saturday morning took report from Dr Lean Finke (medicine side of a matrimonial Med-Peds team, husband Gary is a pediatrician) in regards to the ICU patients.

ICU – 4 patients:
#1- Zacharia, 40 years old male with tetanus, trach’d and stable on a vent (only adult vent available), utilizing magnesium sulfate for his muscle spasms (more on this later).
#2 – Helen, 24 years old male, organophosphate overdose (mode of choice in the developing world for suicide attempts). A few days ago when everyone thought she would die she had amazed everyone by coming a rudimentary pressure support adapter and commencing to breath on her own. She is now talking (though hallucinating, not sure if this is due to here anoxic brain injury, atropine or her baseline state, and may have been the cause of here suicide attempt) and eating.
#3 – James, 68 years old male remotely status-post hip surgery who subsequently experienced a bowel obstruction, underwent an ex lap and cecostomy placement. Stable for now.
#4 – Beth, 70 years old female with diabetes and hypertension who is 3 days out from AAA repair. Stable for now.

So, now over to the ward to round on my medicine patients:
Mohommed is a 68 years old male, from Somalia with hepatitis (probably hepatitis A), ascites and jaundiced. He has been sick now for almost two to three months and appears to be one of the rare ones who is having a hard time recovering (most recover completely from Hep A). He is developing hepatic encephalopathy and the hospital is now out of lactulose. I talk with the family about his prognosis.

The rest of my patients are fairly straightforward:
Aggrey, 38 years old male with TB meningitis, AIDS who surprisingly appears to be getting better. Having now had seven patients pass away in these two weeks, I don’t get my hopes up.
Zippy, 23 years old female with leokocytoclastic vasculitis and coalescing ulcers covering both lower extremities, rudimentary evaluation for precipitating cause is unrewarding.
Jane, 68 years old female with hypertension and diabetes now a week s/p Whipple for a pancreatic head mass.
A few more of this and a few more of that…and rounds are over.

Go home (50 yards away) to have a late lunch.

Pager goes off, Grace is here, term pregnancy, prior c/s, in labor desires repeat c/s…off to the theatre c/s performed.

Home again, trying to have late lunch…

Pager goes off, James is becoming hypotensive…back to ICU, bolus, bolus, bolus…still hypotensive. He needs pressors (MAP below 60mmhg), I place a central line and start dopamine, his pressures rebound and we've bought some time.

Home, now for dinner (still no lunch)…

Pager goes off, infant in nursery, born at 34 weeks, with h/o jejuna atresia, s/p reanastomosis has lost her IV access, no one has been able to replace PIV. Back to nursery, all extremities and scalp appear like a pin cushion, there are no peripheral sites to attempt, I place a PIV in her left femoral vein and hope it will last through the weekend.

Home, this time able to have dinner…

Pager goes off, Pauline a primip who is at term is experiencing fetal tachycardia and is remote from delivery. Back to the theatre primary c/s…

Home, it’s late, trying to get some sleep…

Pager goes off, ICU, Helen is starting to require more supplemental oxygen and having more labored breathing. Order a CXR and return to ICU to review. Appears as if ARDS (not uncommon in organophosphate OD). Attempt CPAP (no ventilator available) she does not tolerate it.

Back home to bed…alarm goes off 24 hours down 24 to go…

Having a cup of coffee…pager goes off…

Faith a 24 years old primip at 34 and 4/7 weeks, who has been admitted with mild preeclampsia is starting to have headaches, she is edematous, has 3+ urine protein and BP’s 180/110. She now has severe preeclampsia, fortunately LFT’s and platelets are normal. Give hydralazine IM to bring down her BP’s and bolus her with MagSO4. Fortunately she received steroids one week prior when she was first admitted. Cervix is long and closed; I receive word from pharmacy that the hospital is out of Magnesium (remember Zacharia in the ICU, he’s sucked up all the MagSO4), the option of attempting cervical ripening followed by induction of labor is out. I advise her that she will require a c/s. She accepts, she is in no condition to do otherwise. While back home at Swedish Hospital in Seattle these decisions are made without a second thought as we have outstanding NICU support, this decision weighs heavily on me as the hospital only has one dose of surfactant (to promote fetal lung compliance should the lungs not be prepared for this world) which would cost the family approximately $1,000 US (about twice the annual average income). I take Faith to the theatre and she undergoes a c/s, it’s a boy…my heart sinks a little…boys always struggle more than girls. Fortunately he is doing well as is mom, though I certainly would like to continue her on magnesium.

Round in the ICU, Beth’s abdomen is distended and painful (she is s/p AAA repair), vitals stable, pulses present. Order hemoglobin and abdominal films.

Go to male ward to visit Mohammed, he’s had a bad night, his creatinine is up, he is incoherent, long talk with the family, they understand there is nothing we can do he appears to be in hepatorenal syndrome. They desire to take him home where they would feel more comfortable practicing their Muslim customs. It is now that I find out that it is absolutely impossible to discharge on a Sunday. Explain to the family, they are gracious and understand he will have to spend one more night in the hospital.

Back to the ICU, hemoglobin stable, films show some air fluid levels but no dilated loops of bowel…back off on feeds.

I go home for a break…

Pager goes off… Esther is a term pregnancy with non-reassuring fetal status, back to the theatre for a c/s…

Back home for dinner…

Pager goes off… Helen is getting worse, I go to discuss her status with the family, I’m really tired of telling family members that there is nothing I can do…

Labor ward pages…Mary is a primip at 26 weeks who is in preterm labor… 4cm dilated… no Mag Sulfate for tocolysis, start her on steroids for fetal lung maturity, antibiotics for GBS prophylaxis (which were never given), Nifed and Ibuprofen for tocolysis.

Back home it’s late… can’t sleep…know the pager will go off any minute. Did I tell you that we also have a primip at 30 weeks gestation with a complete placenta previa and history of prior c/s. This greatly increases the likelihood of some form of placental invasion into the uterus and therefore drastically increases the risk of requiring large amounts of blood and subsequent hysterectomy.

Barely asleep and the pager goes off, 1230 am, 302 999 is the return page, this means don’t call, just run to the ICU. I arrive and the nurses are performing CPR on Helen, I don’t know why, there is no vent, I pronounce her and have a long talk with the family.

Back home… 2 am, pager goes off, Mary is delivering. Back to L&D, deliver what appears to be a 30 week infant (and yes, performed delayed cord clamping, even in Kijabe, Kenya). Kid is grunting but breathing on his own. Call in Gary Finke (pediatric half of med-peds duo), he is gracious to assist, infant Ballards out to approx 31 weeks and weighs 1400gm…he has a chance to make it. Youngest infant to survive here was born at 28 weeks.

0430 am back home and in bed…collapse, exhausted.