Monday, 21 October 2013
Haste does not make waste
Yesterday was rather depressing as my day at the hospital ended with another child's death. This time, of a two-year-old boy who likely had severe malaria and multiorgan failure. He came to us febrile, tachycardic (>200bpm!!), tachypnoeic (70-90/min), hypoxic and markedly jaundiced. Over the course of the afternoon, he became more and more obtunded and was anuric for the entire duration of his stay. It was such a frustrating day as there were a multitude of events that did not happen as (I thought) they should have. What with delays in getting the first dose of artesunate in, the NGT for rehydration (since no one could obtain IV access), the dextrose as he became severely hypoglycaemic (the glucometer reading dropped from 1.6mmol/L to "Lo" half an hour later) and finally, the decision to proceed to insert an intraosseous line. Was there a single person to blame? Would it have changed the outcome? No, but I feel that things could certainly have happened half an hour to an hour earlier at the least. Then, I can truly rest easy (or easier) that we had done everything that was possible within our limitations. As it is, it tears me inside that this sick, sick kid wasn't initially taken seriously enough and treated with the respect and urgency that the severity of his case demanded.
In contrast, another two-year-old boy today almost crashed as well but I'm hoping we caught it in time. This kiddo is one of the worst cases of malnutrition I've seen yet. He's two years and three months old but weighs just under six kilograms; yes, he's lighter than most infants! Poor boy's from a nearby camp for Congolese refugees (it still astonishes me that there are people who would seek refuge in South Sudan). He had a NGT inserted today as he was losing weight despite being on a therapeutic feeding regime; a few minutes into his second feed, he became acutely unwell with marked respiratory distress. I suspect he aspirated; as it is, we got him on oxygen and antibiotics pronto. At the moment, he still looks pretty terrible but thankfully, not as moribund as before.
Before I started serving here, I don't think I truly understood or grasped the concept of the so-called "golden hour", the hour in which one can potentially change the clinical outcome of a critically unwell patient (although I think the concept came out of trauma medicine). There are so many factors that affect how a resuscitation plays out, e.g. if the patient deteriorated around handover time, the proximity of the patient to vital equipment, the seniority of the staff on duty, if it was a normal working day or a weekend and in daylight hours as opposed to in the dark of night etc. I recall one of the codes I attended while on cover shift back home: a middle-aged man scheduled for elective cardiac bypass grafting had arrested on the ward the day before his operation and I was sent to get his ABG results. I was flabbergasted when first the ICU nurse then the ED nurse refused to let me process it in their respective wards. Seriously, this guy doesn't have a heartbeat and you're saying that I can't use your machine because the correct procedure is to bring it to the lab?!
This rather reminds me of Jesus' warning to His followers to discern the hour of His second coming.
"Now learn this parable from the fig tree: When its branch has already become tender and puts forth leaves, you know that summer is near. So you also, when you see all these things, know that it is near, at the very doors...But of that day and hour no one knows, no, not even the angels of heaven, but My Father only. But as the days of Noah were, so also will the coming of the Son of Man be...Watch therefore, for you do not know what hour your Lord is coming. But know this, that if the master of the house had known what hour the thief would come, he would have watched and not allowed his house to be broken into. Therefore you also be ready, for the Son of Man is coming at an hour when you do not expect Him." (Matthew 24:32-33,36-37,42-44)
Sometimes, we need to know when to hurry. It may well be that we still have time to eat, drink and be merry. But it might also be that this very night, our souls will be required of us (Luke 12:13-21). Before Whitney Houston, Michael Jackson, Heath Ledger and Cory Monteith closed their eyes for the last time, I doubt any of them imagined that they would end up six feet under shortly thereafter. Whether self-inflicted or not, death comes for us all. May we be found ready!
Addition: Sadly, the second boy passed away today afternoon (22 Oct); I was called to his bedside after he arrested but this time there were no warning signs or any preceding deterioration. It's a bit of a mystery but my money's on some electrolyte imbalance or overwhelming sepsis.