Sunday, July 3, 2011

One of those days. Sorry, it's really long......

Today was one of those days. Since I need to process today for myself and don’t think I have the energy to write it in my journal and here, this will serve as my journal for today. Welcome to my inner thoughts. :)

Today was supposed to be my day off. However, when I looked at the schedule, I noticed that the guys who was supposed to work today was going to have to work two weeks in a row without a day off. Since I’d just come from having 10 days away from the hospital in Freetown and he’d had to pick up the slack with some crazy busy days, I offered to work in the morning for him so he could go to church.

Since it was a Sunday and weekends tend to be low key (in America at least) I took my IPOD and a book, planning on listening to a sermon when I had time. I arrived to the hospital at 8am and all was quiet. They’d had a pretty quiet night with only a couple of admissions. They had one guy who came in vomiting blood and with diarrhea with blood clots in it. Ok, I thought. He’s definitely sick. His hemoglobin was 8 when he came in last evening so I went and asked the lab man if he could draw another hemoglobin this morning since he was still having bloody diarrhea. (Sorry if that’s too graphic….I tried to warn you…these are my inner thoughts!)

While I waited for the lab to come back I went to check on him and checked his blood pressure. It was 70/50. Low. Very low. He had some fluids running but I knew what he was really going to need was blood! Since we don’t have a way to give packed red blood cells but give whole blood here, it’s a lot of volume that we give. I didn’t want to overload him so decided that when that fluid finished I would wait to give him the blood. So I started to wait.

At 8:30 they started coming. The outpatient department (kind of like the ER or Urgent Care) isn’t open on Sundays so all the patients that come to the hospital are seen by the senior person (in this case me). Praise the Lord we had the lab open today so as the sick kiddos started coming, I took the history (almost always the same….fever, vomiting, with maybe diarrhea or a cough) and sent them down to have their blood checked for malaria and hemoglobin. After the first two cases we ran out of malaria tests so I just started treating for malaria (since 98% of them are positive). Two out of the first 4 had a low hemoglobin so they needed blood. No problem. I sent them down to the OR and one of the nursing assistants (there were two of them and I to cover the hospital today) put the IV in and started the blood.

An odd phenomenon kept happening though. Even though I kept seeing patients, the line of patients waiting to be seen kept getting longer, not shorter. In addition to seeing the outpatients, I still needed to do rounds on the inpatients. While I try to round on everyone, I could see after 2 ½ hours of seeing outpatients that today only the “critical” patients were going to get seen. This included new admissions from last night and patients with fevers. At about 10:00am the peds nursing assistant started coming and asking me to go to the Peds ward and see some patients. Some wanted to go home and some needed to be seen. I still had a line of patients waiting to be seen. Whenever I start to get a little overwhelmed I have a thing that I do. I literally stop whatever I’m doing and I think about what’s the most important thing I need to do. Seeing the sick peds was pretty high on the list. So was my guy who needed blood. I looked at the outpatient and the cases that were there didn’t look emergent so I decided they could wait. I went to check on my guy who needed blood (M2). They had found a donor for him and were looking for the adult blood bags. We didn’t have any. We only had pediatric blood bags. This meant that the donor would have to get poked twice to fill up two pediatric bags. She did not want to do that. Are you kidding me? You’re not going to donate because it means you have to get poked twice?? Now, maybe I’m being judgmental because while I don’t enjoy getting poked, I am not deathly afraid of it. Maybe she was. Well, I had to be frank with her and tell her that if she didn’t donate, her uncle would probably die. She went back to the lab.

Next, I went to round on the kids. There were about 5 who had high fevers. Most of them had come in last night and started the malaria treatment. I wasn’t too concerned because the medicine hadn’t really had time to work yet and they all looked stable. There were two kids that still had fevers but their parents were requesting to go. They both looked sick. One of them had started the treatment for malaria yesterday but hadn’t started to perk up yet. I wanted to keep her but her mother was adamant to go. I knew that if I kept her here when she didn’t want to be here, she would either A) leave in the middle of the night and not take any of her medicine with her and/or B) not come to the hospital next time her child was sick. So I sent her home with some malaria treatment and Tylenol. The second kid that wanted to go home had come in 2 days ago super super sick. He was really febrile, seizing, very sick. Well, He had started to turn around and was looking better but the family was tired of waiting and wanted to leave to go try herbal medicine. Ill admit this frustrates me a little. Sometimes I feel like people expect miracles here and if their kids aren’t better in a day, then they give up and want to go. This kid was almost dead! It’s going to take more than 2 days of medicine for this kid to perk up! Frustrating! Fortunately she still had some money on her bill and they won’t let her go until her bill is paid. Since they kid now had bad sounds in his lungs, I started him on an antibiotic and asked them to please wait. They were kind of held captive.

I went back to my little bench where I see patients and started seeing patients again. A kid came in with a crush injury to his hand from his hand getting caught in a rice machine. The OR guy was still around so he took him to the OR to do what he could to patch him up. Then a super sick kid came in. I could tell right away that she needed to be part of the critical patient protocol so before I sent her to the lab I gave her two shots of Quinine to treat malaria and sent her to the lab to have her blood drawn. I went to get all of the supplies I was going to need as soon as she got checked so I could start her IV and give her the antibiotic that’s part of the protocol while we waited for her family to donate the blood. While I was waiting on her, I went to see if M2 had his blood hanging yet. He didn’t. I hurryidly told the outpatients waiting that I’d be back and went down to the lab to find out what was going on. When I got down there they told me that the girl was still afraid to donate but they had some 0+ blood in the refrigerator. We would give this guy that blood and his niece would come back the next day and replace it when we had the adult blood bags again. Fine. Awesome. I grabbed the blood and ran down to the mens ward. He actually wasn’t looking too bad. He was talking to me and asking questions. I paused to wonder if I really should give him this blood. Because we can’t screen the blood as well as they do back home, I only give blood here if I think the patient will die without it because a reaction could kill him. He looked pretty good. But when I asked him if he was still having diarrhea he said he was and that there was blood in it. So I decided to go ahead with the blood. His pressure was still in the tank and blood would really help. I started it slowly and was going to come back and check in a few minutes.

I went back out to my outpatient bench and saw another patient. After about 10 minutes the wife of M2 came to get me. He was not looking good. He started breathing rapidly and with difficulty. Crap. This looks like a reaction. Crap. I immediately stopped the blood. When I went to give him some IV fluids his IV had infiltrated. And we have no more IV canulas. At this moment my critical peds patient who I had sent to the lab came back. I ran to get some steroids from the cabinet to give to M2 while the nursing assistant worked on starting an IV using a blood collection device. I told him to keep working on that while I ran down to the OR to put an IV in this kid to get his blood going. As we were going down to the OR I looked down at the blood result. His hemoglobin was 2.6. I’ve never seen that compatible with life. Shoot. I started to run. We got him down to the OR and I spiked the blood bag and got ready to start the IV. As I did that his mother told me to look at him. He was gone. Died on the OR table.

I wanted to be compassionate and caring. I told them I was very sorry. They started wailing. I wanted to stay in the room with them for awhile, but I knew that I had the guy in M2 who was NOT doing well. So I left them in their grief and ran down to M2. (They technically needed to pay their bill because I’d given some medicine and they’d had labs etc. but I just didn’t have the heart to make them pay before they took the body. I can settle up with the hospital later if I need to). M2 was still not doing well, but he was looking a little better. Please GOD let him live! Abraham (the nursing assistant) wasn’t having any luck getting the IV in. Dangit we needed an IV catheter. This way just wasn’t working. I had been trying not to bug the guy who I was working for and was expecting him at any time but so far he hadn’t come. He’s the one with the keys to get things like IV caths so I finally decided I had to call him. As I stepped out of the ward to call him I saw an unconscious woman being carried down the hall. They went to stop at the OPD bench but I just waved them down further down the hall towards the womens ward. They were going to need a bed anyways so might as well see them there instead of on a bench. I called my friend as I followed this patient down the hall and told him that now we were really desperate for IV catheters. He told me he was coming. When I asked the nursing assistant to check a blood pressure, she said it was 40 and that she needed fluid. 40? Either it was REALLY low and/or she wasn’t really sure what it was. Either way I knew it was low and she needed fluid so I took of to get the stuff we’d need. Her family said she’d started having diarrhea and vomiting the night before (time is very relative here) so I knew she was probably super dehydrated. Just then my friend arrived so I gave him the low down on this new patient while I grabbed a couple IV catheters and ran towards M2. Sorry OPD patients. You’re going to have to wait a bit longer.

I tried multiple multiple times to get an IV in this guy but just could not do it. I’m not a horrible stick so I wasn’t sure what my deal was, but I finally went down to get my friend and have him try. Neither the nursing assistant or I could get it. After a couple tries, my friend got the IV in and we started his fluids. There was really nothing else we could do (at least that I know of and that they usually do here) but wait and see.

I went out to see some more outpatients and was seeing my first one when M2’s family came and got me to go check M2. He was gone. I don’t even know what to say. In hindsight, I wouldn’t have given the blood. I think I might have killed him. But with what I knew at the time, I don’t think I necessarily made the wrong decision, but now knowing what happened, I would have made a different one. I still feel like I killed a patient. It sucks. I’ve never heard so much wailing as I watched his wife and especially his daughter in their pain. Their daughter was probably about 16. What would I have done if I’d lost my father at 16? It really stinks.

Things settled down a little after that. The evening shift started arriving so we had a little more help in terms of staff. I went down to check on the woman we’d admitted and she was coming around while she was getting her second liter of fluid. I think she might be ok….hopefully! I went to tie up some loose ends, gave report to the nurse coming on and headed home.

I’m not a drinker. Today I was glad because I think it was the kind of day that might have driven me to the bottle. But since I can’t stand the taste and don’t think that would have been the best idea anyway, I went home and made up a big ole’ thing of Raspberry Crystal Light and drank a quart of it. (I forgot to drink anything all day so I figured I could handle it). Then I grabbed my Bible, my computer, my journal and my keys and hit the road. I didn’t really know where to go, but I just needed to get away. My days at this point consist of going to the hospital and then going home. And repeat. I needed a change of scenery so I took my car and went for a little drive…..up the road. Right now I’m parked on the side of a deserted jungle road putting all my thoughts on a computer.

So that was my day. Sorry it was so long and jumbled. I know some days are just like this. I had rough days at work in America and I have them here. The one downside here is that in America God blessed me HUGELY with awesome roommates who would listen to my rants, nod encouragingly and help me process things. Here, death is just such a part of things that when I try to talk to Sierra Leoneans about days like this I get “well, yeah, they died. We did everything we could. That’s all.” Not quite what I’m looking for. J I had too many counseling majors as roommates….I got spoiled!

But praise God for today huh? It was hard, but He was there. And I know He won’t give me more than I can handle!

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