Day 17: Needles and Cuts

After so many days on pediatrics, I am starting to see a theme. The big three disease here are HIV, TB and malaria. Additionally, lots of patients come in dehydrated, in shock and/or convulsing. We followed up with some of the same patients today. Trying to keep all of the different types of fluid resuscitation straight because it is different if the kid is malnourished, HIV positive, in shock, or if they have all three.

One patient was noticed to have extremely cold hands and feet (was in shock), and needed fluids. The registrar (aka resident) couldn't get access via the hands/arms or feet, so the attending did a line in the right femoral vein (groin). One hr later, the line had moved. After trying her left femoral vein and missing, then trying her scalp, they finally did a jugular (in the neck). During this time the patient was not focusing her eyes. She was 5+ for malaria and having total body convulsions any time she was stimulated. She got transferred to the malaria ward.

In the afternoon, I saw 3 LPs (lumbar punctures). They don't numb them here before putting the needle in the back and sterility is minimal (note: LPs are used to diagnose meningitis). The 3rd LP was a young 3 year-old who was thrashing around so much that the registrar and I could not hold him down. Another registrar came over, waved us aside, and got up on the table. She put the kid's legs between hers and hugged him while laying on top of him to hold him still.

It was procedure day because I also was able to see them do a pleural tap (in the chest to drain fluid from around the lungs). The patient had consolidation in her entire left chest, so they stuck a needle and tube to drain the pus. Then they converted the tube into a chest tube and made their own drainage system with a plastic bottle. They use what they have available here.

When I got home, more stories were told. One girl had seen them do a breech delivery where they had to break the baby's humerus (arm bone) to get him out. She also saw a baby born blue and floppy and was able to stimulate (rub hard and shake) him back into life.

Another group member had an injury while playing basketball, when an opponent's chin landed into his head, leaving a large cut. The group gave him whiskey, put ice on it and stapled it back together with surgical staples back at the house. Never a dull moment in a house full of med students.

Day 18: Rough day

Still on PSCW. In the morning, we heard a wail and turned to see that one of the ICU patients had passed away. The child had severe hydrocephalus (lots of fluid in brain) which a shunt had previously been placed. The shunt had become clogged, which was why he had been admitted.

During this time, another mom waved me over and I grabbed a Chichewa-speaking medical student and headed over. Mom was requesting for the NG tube to be removed (NG is a nagogastric tube that goes through the nose and into the esophagus to feed a patient). Her son had been admitted for vomiting and diarrhea, but she said he had stopped and was eating on his own. She wanted the tube to be removed because he had difficulty breathing. The med student explained that the DIB was likely due to his distended abdomen and that an NG tube doesn't cause difficulty breathing because it doesn't enter the trachea. We looked the child over, told the registrar and then went to grab a quick lunch before lecture.

At the lecture, one of the other Malawian med students told me that the child had been found dead 10 minutes after we had seen him. I was shocked, and so was the registrar when I told him later on at movie night (Thurs nights are movie nights at our house). We still do not know how or why the child passed away. Both of us still feel guilty/responsible in some way and were surprised by the the lack of a reaction from the natives.

When a child dies, it is even more difficult than an adult's death. I've come to realize that part of my coping mechanism or way of reaching an okay place is if I know how/why the child died. I guess it is because I think that what I learn from that death may help prevent other's. So when I don't know what/if something went wrong, it makes it all the more difficult to come to terms with the situation. All I can do is keep learning and seeing patients and hope that one day I'll be a better pediatrician for it.