Trauma made easy/crappy

In an effort not to be Debbie Downer, I don’t share all of the tough cases that come along, so I’ve been sitting on this one for awhile. It happened the other night but since I’m trying to balance my “good outcomes” with my “not so good outcomes”….read ahead. It turns out ok.

I was working an evening shift. Since one of my co-workers was sick, I’d worked a double shift that day and was just dead tired. I was counting the minutes until 10pm so I could go crawl into bed. Fortunately it was raining pretty hard that day which is awesome for a couple reasons. First, I love rain. Always have. Second, people here do NOT love rain, so if it’s raining, they tend to stay in their houses…..and not come to the hospital. It had been really slow that day and evening.

At about 8pm I was in the peds ward checking on my kiddos when they told me there was a patient to be seen. When I walked down to our “ER” (the bench in front of the nurses station) I saw a kid about 4 or 5 years old that did NOT look good. When I asked what happened, they told me it had been a motorbike accident. Shoot. I’ve seen how these motorbike drivers drive! They. Are. Crazy. So right away I knew that most likely they had been traveling pretty fast and of course...... no helmet.

Right away I noticed a relatively big head laceration on his forehead. Rats. That means he probably hit his head when he fell off. The second indication that all was not right with this kid is that when I bent down to look at him, he reached for me. Kids almost NEVER reach for me here. He was hurt, and I’m a scary white person, so he should have been trying to hide from me. The fact that he reached for me was a big red flag. He was also mumbling incoherently (I couldn’t understand a word of it anyway, but clarified with his father that no, he was not making any sense).

So I was pretty sure he had a head trauma of some kind. Mild concussion or big brain bleed….who’s to know. As I started looking closer, I noticed that he was bleeding from his nose as well. He started coughing and coughed up some bright red blood. His lungs sounded horrible….probably full of blood after seeing what he coughed up. His abdomen was distended but was it distended because everyone here as worms and distended bellies or because he’d perforated some abdominal organ and was bleeding internally.

We have an OR team here. Some of them have been here forever. They’ve been trained by lots of different people so do a lot of different surgeries, skin grafts, etc. They’re very talented. If it wasn’t for the fact that if I had surgery here I would a) have to lay naked as a jay bird in front of all the people I work with. B) have my arms tied down like I’m being hung on a cross to keep from putting my hands where they shouldn’t go c) have to settle for Tylenol for any post-op pain and d) have a HUGE scar because laproscopes haven’t made it here yet…..I would totally let them operate on me.

Anyway, I digress. Since I am confident in our OR team, I called the CHO (community health officer) who works here to see what they would be able to do. The conversation went like this.

Me: Hey buddy. I have this kid here who flew off a motorbike, most likely has head trauma, is coughing up blood and may or may not have a lacerated spleen and/or liver. I’m wondering if it would be possible for the OR team to open up this kid, take a look at his liver and spleen, see if it’s bleeding at all, and put in a chest tube if necessary. I’m not sure if he needs all of that….I’m just wondering if they can do any of that.

Him: No. They don’t do any of that.

End of conversation. Ok. At home, this kid would have kept me running for a few hours…x-ray, CT, meds, consults. Here? I sutured up his head lac and admitted him for observation. I did call the lab man in to check his hemoglobin. At least we could give him blood if he needed it.

Honestly? My pediatric trauma assessment skills aren’t finely tuned, but I didn’t have a lot of confidence this kid would make it. I was most concerned that he had a big head bleed that was just going to continue to get worse. His mother came to see him and the wailing started. As I left to go home, I expected to be awakened by more wailing as he passed away.

BUT!!!!

It’s been 3 days now and the kiddo is doing great!! MUCH better than I hoped for! He’s started eating a little and today was walking all around. Not quite up to smiling yet but patiently stood still while I took a picture. :)

Note: I put 7 stitches in this kid’s head. It took me a painfully long time. Two guys were there to “help” me and I think by the end of it they were uber frustrated and just glad it was over. Apparently I need to keep practicing. :)

Thanking God for a great outcome in what seemed to be a hopeless situation!!

Bleh

Every morning I do rounds in the peds ward. Malaria season is upon us which means that the peds ward is SUPER busy! Last week we had a record (at least since I've been here) of 31 patients. There were mattresses everywhere and they were labeled things like P2/3 (the matress between bed 2 and 3) and Private Room 1A, 1B, 1C. And there is usually just one nursing assistant for the whole ward. B.U.S.Y.

Since I do rounds in the morning, I generally have a good idea who the semi sick patients are and who are the ones I need to keep an eye on. However, about 10am the admisisons start rolling in. Since they've already been seen by a provider and been given their blood and medicines, unless the nursing assistant or one of the parents comes to get me, I wait to see them on rounds the next morning.

However, since it's been SO crowded recently, I've started doing some more rounds in the afternoon. This set of rounds is abbreviated and just involves me going around the room, physically looking at the kiddo and giving the parents the opportunity to tell me if they've noticed something wrong. I especially like to do this after a child dies because all the other parents get really anxious and need some reassurance.

Today at about 1:30 pm. I was down in the OB ward when I heard the familiar wailing coming from the peds ward. Never a good sign. I went down to check it out. Sure enough, one of the kiddos had passed away. I did what I hate doing, which is listen for the respirations and heartbeat and then tell the mother or father "ee don go." (He's passed away.) When a person dies, they always pull the sheet up over the head but I haven't had the courage to do that yet. I just can't cover their precious little faces.

So after that kiddo died (he'd been a new admission so I hadn't seen him that morning), I started doing the rounds of the ward, reassuring parents and looking to see if there were other super sick kiddos. Ding...found one.

This kiddo had come in a little bit ago with a hemoglobin of 2.6. For those of you who aren't medically inclined.....it's low. Really low. Incompatible with life kind of low. He was getting blood, but he was getting it through his umbilicus. Also not a good sign. Anytime I get a kid who is getting blood through his umbilicus, it means that the OR guys had tried and tried but couldn't get an IV in the scalp. It also means that the blood is going into the abdomen which means it takes a lot longer to raise the hemoglobin level....like days instead of hours. Bad.

The child was not breathing well (not suprising with no oxygen due to no blood....think back to your high school biology lesson). As I stood there for a second, collecting my thoughts, he started seizing on and off. I asked the mother if the child had been breastfeeding well and she said he had been until today. I checked the blood sugar- 46. Really low. Incompatible with life, low.

D50 is a medicine (dextrose- 50%) that we give to patients with low blood sugar. It brings the blood sugar back up really fast. I knew we had had one vial of this but also knew that last time I'd seen it, it was really low. I ran down to the OR to see if it was there. Didn't see it anywhere. I called my boss to see if we had any more. Nope. Then I called another co-worker to see if he knew of any secret D50 storage places. Negative. The only option I have is to give this child D5 (dextrose 5%...clearly not as strong as 50%) which we usually give as IV fluid so the it comes in 500ml. However, I only have on "IV" line...and that's not even going into a vein! He desperately needs blood, and desperately needs sugar.

I knew the OR team had tried multiple multiple times to get an IV in the scalp because it's the only reason they ever put one in the umbilicus, but sometimes they don't try the arms. IV catheters are precious here so they are kept under lock and key. I ran down to the storage to grab a cannula. I wanted to see if I could get an IV in the arm. Maybe they hadn't tried there.

I looked...and looked...and looked. This kid literally had no blood. I think I poked that kid 25 times. I poked him so many times that the needle became so dull it would barely puncture the skin. As I was poking him (he was essentially unconscious at this time so he didn't cry or pull away) his breathing started becoming easier. I also realized, as I was trying again on his other arm, that my elbow was now sitting in a puddle of his urine.....he'd become incontinent. This commonly occurs right before death. I knew as I sat there poking this kiddo that he was not going to make it. But I couldn't seem to stop. I couldn't just sit there and watch this child die. I'm not sure why. I've done it before. For some reason, this time I knew I would keep trying until he took his last breath. I wanted his family to know that we had done everything....tried everything. In a last ditch effort, I grabbed a bottle of D5, the biggest syringe I had (which was 5 ml) and put some sugar water into his peritoneal "IV." As I pushed it in, he took his last breath.

His mother had already left the room to begin grieving outside. The crowd that had gathered began to disperse. The show was over. We'd given it our best shot.....but we'd lost. "ee don go." Malaria wins again. Bleh.

"Young Life"

When I was in the States I was involved in a ministry called Young Life. I loved it because I pretty much hung out with high school kids all the time. Well, they don't have Young Life in my village, but I decided I could still hang out with high school kids. This is "Fatu." She goes to the same church that I do and I enlisted her to teach me to cook. (I don't have a great desire to eat African food because it sets my mouth on fire, but I want to be able to cook for guests I have over and I don't think they will appreciate my peanut butter and jelly sandwiches as much as I do). I've learned that people here don't seem to know how to cook for less than 10 people so this was the huge pot of rice that we cooked.

GIANT pot of rice. It started overflowing!
I have a bunch of boys that live nearby so I called them to come help us eat it. After dinner I taught them to play "slap jack" which was hilarious to watch. However, I discovered that these kiddos are the biggest cheaters I have ever seen!!! Every time we slapped the cards they would all try to sneak some into their hand. Stinkers!

Although they liked "Slap jack," Jenga is really their game. We have a piece of paper on my wall that is keeping track of who loses each time. (Note: I'm the only one who hasn't lost so they were all trying to "set a trap" so that I would lose). Not going to happen......steady as a rock.

Since we have no lights, we play by candlelight. I have a cinnamon candle that my sister and brother-in-law gave me before I left. I love it because it reminds me of home. One of the boys wanted to drink it. Ouch.

Fatu and I representing the girls in the Jenga game

The next morning my neighbor commented on the loud noise coming from my house. When I told her about the kids that were over she said, "well, it wasn't really them that I heard the most...it was you." Oops! Quietness has never been my forte. And during a high stakes game of Jenga and Slap Jack how are you supposed to keep from screaming??? Impossible.

Let the good times roll......

Needles Anyone??

After a few days in Freetown doing some administrative stuff for WMT, I'm back in my little village town. Honestly, I was so drained....emotionally and physically when I left last week that I wasn't sure if I'd want to come back. But as soon as I walked into the little Peds ward I realized how much I'd missed my little kiddos and was glad to be back!

I've learned something about doing rounds on the ward. The first thing I look at is the kid....do they look sick or not? The second thing I look at is the date of admission. I've found that our routine kids with malaria associated anemia can usually be in and out in about 3 days. So if the date of admission is more than 3 days, I know I'm going to have to think harder about what's going on. There were 22 kids in the ward and my first 8 or so were easy! Mostly new admissions who had received blood and were waiting for their post transfusion hemoglobin to be drawn that morning. Then I got to P9. Admitted July 29. Rats. I looked at the girl and she looked sick. She's older than most of our kids-probably around 7 or so. And she was skin and bones--clearly malnourished. Mom's complaint was that she didn't want to eat and that she was still vomiting up everything she ate. She'd been diagnosed with malaria, transfused and her post-hemoglobin was 8.....which is pretty good for these kids. Her malaria medicine was finished but since she'd been vomiting, I decided to give her something for nausea, start her on a different malaria medicine, and recheck her hemoglobin.

I got the results a couple hours later and her hemoglobin had dropped from 8 to 6. I kind of hate it when kids have a hemoglobin in the 6's because it's kind of boarderline as to whether or not we should transfuse. Since I have now seen one adult and one kiddo who did NOT do well after a transfusion, I am always a little nervous. But with this kid, it was an obvious choice because she looked sick and since she was so malnourished she was going to need all the help she could get. I sent her down to the lab to get her blood.

No donor. The kiddo was A+ and mom was B+. This happens sometimes and we may have a small supply in stock but we transfused so many kids today that we didn't have any extra blood. Never fear! I am A+. Woo hoo! I've been trying to donate since I got here but they kept telling me to keep it and they'll call me when they need it. Score!
I haven't been able to donate blood in America for years because I've been coming to Sierra Leone every year. Because it is endemic with malaria, they make you wait a year after you're back before they'll let you give. I remember the time I found that out. I'd been waiting for an hour or so and had filled out the questionnaire when they sent me back to the lady who checks your iron and clarifies any of the "bad" answers on the questionnaire. It's all sectioned off so it's very confidential. When she saw that I'd been to Sierra Leone she told me that I couldn't give. I had to do the walk of shame back to the door without giving and wanted to shout to the waiting room "Just in case any of you are curious, NO! I did not use IV drugs or trade sex for money! It's just......Africa!!!" But I didn't. Social filter. I'm learning.

Anyway, I digress! Again. I told them that I wanted to give some blood for this kiddo. It's not good enough in America but in Africa I think it's prime real estate because it's malaria free!! We don't check for malaria so I know sometimes we infuse kids with blood that has even more malaria. You win some.....

I went to the lab and told them I wanted to give this kid some blood. Lab Man said we should go to the OR. That's weird. They always do it in the lab. I always get nervous when I have to poke someone I know so I thought, maybe he's just a little nervous and wants to make sure he gets it right in. I'm ok with that! I've been told I don't have great veins but I've never been stuck more than once so....shouldn't be a problem. Well, small problem. Fourth time was the charm. At one point I was feeling around myself and felt what I thought was a pretty decent one. I tried to think if there was any way I could poke myself. That would have been tricky.
As soon as he got it in I started worrying. They always do a screening for HIV, hepatitis and maybe a couple other things. They hadn't done that with me. As far as I know I don't have any of those diseases but I've stuck myself with dirty needles a couple times and I'm always playing in blood over here so....well, you never know. I definitely didn't want this kiddo getting sick but felt kind of weird saying "Hey, by the way....can you check me for HIV?" But that's pretty much what I did. No problem, they checked me when they checked my blood type. Good.

After I was finished I called the little girl into the OR room to start her IV and give her....my blood. I've been giving blood for years and it was kind of weird to see the blood hanging up, knowing that 5 minutes earlier it had been in my body.....pumping through my heart, lungs, etc. Weird.

After she went back to the ward I looked outside and had a line of kiddos waiting to get blood. The IV's are usually put in by the OR staff but Wed. and Sat's are half days so they leave at 12. It was just me and a couple other nursing assistants who don't put IV's in very often. Crap. It wouldn't be a big deal if I could use catheters and put them in the arms....but those are in such short supply that I knew I needed to at least try the scalp first. Dangit. I hate those things. And I really stink at putting them in. 0 for 5 so far. I can always hit the vein but then I blow them. BUT!!! Today was my lucky day!! I put in my first successful scalp IV!!! And may or may not have done a little dance in the OR. I've been trying for weeks!!! It's the little things, you know?

So all in all, it was a good day! Got to give blood, got to successfully put a needle into a child's head........I was made for this! :)