Is it March already?

"Double Bubble" sign

Our little baby with jejunal/duodenal atresia is going to the OR today. We had another baby come in with bloody stools and an oblong hard mass in the LLQ. Ultrasound showed some ascites and didn’t comment on the mass. Intussusception? I’ve read about the “sausage mass” and bloody stools but I have never seen or felt it before. Surgeons are going to take the baby to the OR and find out. With limited imaging, it’s kind of how things go here. All I know is that I’ve not felt something like that before, but if they find intussusception then I guess medical school multiple choice questions are valuable after all.

Achu's X-Ray

Unfortunately the little boy (his name was Achu) who came in with what looked like acute liver failure and sepsis/ARDS died last night. He was so so sick. I can’t believe he walked into clinic the other day, let me look into his ears, pick him up onto the exam table, palpate his belly. Just hours away from rapid decompensation. He looked so horrible. I keep wondering if there was anything else I could’ve done. With an albumin of 1, he was third spacing all of his fluids. Would dopamine have helped or just prolonged the inevitable? Would Lasix have made his death more comfortable? Mollie says she sees this type of picture on the adult side all the time—usually the patients come in with acute liver failure from toxins, etc and are dead by the morning. Even in the U.S. I guess I’m just not used to seeing kids decompensate so quickly, it’s hard to believe that there was nothing I could do.

But overall, a lot of the kids are doing better. The 1yo boy previously in a coma is starting to eat by mouth and will likely go home tomorrow. The two with cerebral malaria are acting more and more like themselves. The baby with HIV has finally broke her fevers and is looking better every day. I’m a little nervous that I won’t be on the wards this week. I’m sure everything will be fine, but sometimes it is difficult to remember that children are not just little adults. After all, this is an internal medicine residency, they just happen to have a children’s ward. It is very scary to think that at some points there are no pediatricians or family medicine doctors here. These kids are very VERY sick. Even at the peak of my pediatric residency training- chock full of inpatient and intensive care exposure- it is very difficult to manage these kids in their end-stage conditions. I certainly have learned more in a couple weeks being here than many months of residency training. My physical exam skills are the best that they’ve ever been- often it is all I have to rely one. I’ve been able to consult cardiology, general, derm, radiology, PICU, NICU, heme/onc, infectious disease via email, and it has been life-saving. It’s surprising how much you are able to do when you have no choice but to do it. And people are happy to help.

Reminds me of one of my most traumatic experiences of residency (up until now), which occurred my intern year. A 9yo child with trisomy 21 was admitted to the floor NPO and on fluids for possible SBO. She was up and talking upon admission, between vomiting episodes. Alone and tired at 3am, I did a routine (and easy) admission, and prepared for the next admission. Nurse calls and says her IV came out, so I begrudgingly head to her room with supplies. But upon entering the room, her eyes are rolling back in her head and she is not responding. I put oxygen on her face, as the intern from the other floor arrives to help with the IV. I listen to her chest and I hear complete silence. We immediately launch into full CPR. Malodorous vomit spews towards my face with every chest compression. Long and horrible story short, we coded her for close to an hour and she never regains a pulse and never has a shockable rhythm. Diagnosis was likely cardiac arrest from disseminated clostridium perfringens seeded throughout her young body. A freak diagnosis. A hypothesis, really. The date was March 26^th of my intern year and I will never forget the feeling of placing my stethoscope on a dead body. The point of the story, however, is that we have an inner instinct to do what we need to do in situations that we need to do it. I would not consider myself one of those people who gets huge adrenaline rushes in the face of acute situations. I hate mock codes, I get nervous for PALS training. But at that moment, I snapped into CPR gear before my mind could even process the situation. It was an instinct. That is what happened then, and that is what is happening now. Any one of my co-residents placed in this situation would do the same here as I am doing. They probably would be better at reading EKGs and placing IVs. This is what our training is for, this is what our 30 hour calls are for, this is what our sleepless nights are for. We have the ability to do so much more than we think we do, especially when we have no other choice. We have our training, our faith, our vulnerability, our good intentions. And sometimes, god-willing, we hear a heartbeat after an hour of chest compressions.  

Tomorrow Rudolf will likely go home, will likely WALK out of the hospital. I asked him if I could take a picture to show my friends and he acted as if I had just donned him a celebrity. His mother straightened out his shirt and scolded him to sit up straight. This is a great success story. He will play soccer, he will have a future, he will live beyond his childhood.

Sitting up and smiling, ready to go home tomorrow.

Spent the afternoon at a tea plantation yesterday, was good to escape the hospital for a while. Took a couple hours to get there and involved pushing the car uphill under the hot African sun, but was so worth it...