Baby Z

Baby Z is one month old and was on the operating table for routine 
hernia repair. Just prior to incision I heard the nurse anesthesist, 
we have no MD anesthesist, rustling about. I asked if everything was 
ok and he said no doctor. I immediately tore down the sterile drapes 
to find the infant without an endotracheal tube blue and pulseless.

I began chest compressions immediately, the child could not be bagged 
masked so I reintubated him and continued with advanced cardiac life 
support as in the USA, giving epinephrine, atropine etc...

The child's pulse came back and he took some breaths on his own but 
not enough steady respirations to sustain his life. He was also 
hypoxic for some time so I had no idea what to make of his neurological 
status.

We have no ventilators here so I moved him to the ward with his 
endotracheal tube in place, connected him to a saturation monitor, an 
oxygen concentrator, taped my stethoscope to his chest and my ears and 
kept bagging everytime his stauration fell below 90 percent. My back 
up was to have another concentrator should this one quit, which it did 
needing to be restarted every 3 minutes! I also had people set up as 
"runners" should the power go out, which it did, to run immediately to 
the generators to make sure they would be turned on.

I was very suspicious that he had flash pulmonary edema, I've 
experienced this a few time post-op back home. So, I started lasix and 
kept bagging, oh how nice it would be to have a portable Chest Xray if 
only to make a diagnosis. As a new attending surgeon, no one can 
understand the relief that comes with a correct diagnosis.

This went on for nearly ten hours. After ten hours little Z was 
maintaining his own respirations and saturations. At this time I 
decided to pull out the endotracheal tube put him on face mask oxygen 
and pray. God willing the child struggled a few hours and by evening 
was suckling looking about and neurologically intact. He has had an 
episode of seizure but seems to be doing well. He will now have to 
battle the anticipated pneumonia from the intubation and probable 
aspiration when he seized.

Oh and the mother asked today if I will take him back to fix the 
hernia...uhm...not today!

The Textbook Says It Should Work

This week held an interesting patient, Brunhilda. Brunhilda presented in clinical stage four HIV, or AIDS. In addition to her admitting diagnosis and being treated for thrush, HIV gastroenteritis, cachexia and having a hemoglobin of 3 (normal is above 12) and platelets of 40  (normal is above 120) she decided to have a sigmoid volvulus. Now the initial treatment, assuming there is no dead bowel is to try to reduce this with a colonoscope.  After explaining what I needed to a nurse it was decided there was one of these "strange instruments" in a closet but unfortunately no one had a key! Seriously! They wouldn't let me practice my Tai-Kwon-Do skills and break the door so patiently, three hours later, the key was found. 

Now, I have done many colonoscopes but I have never had to attempt to pass a scope through a volvulus without isuflation, a monitor, or electricity. It was the only hope that could be done as there was no way this woman could go "under the knife". So the textbook says it should work...  and let me tell you the relief I got when after passing the scope I got the biggest shot of stool in the face! Thank you God and Thank you to the gastroenterologist who left a closet of dysfunctional yet life-saving scopes!! 

Brunhilda  started tolerating clear liquids today and maybe just maybe if her HIV gets in check she can have definitive surgery for her sigmoid volvulus  before I depart.