I dashed to ICU, snapped the photos I needed and headed back to the office to get to work. Nothing seemed out of place in the few minutes I was on the unit. I was able to complete the lecture and was back on the unit by 8 am. After setting up my trusty projector and computer I thought I'd check on the patient's while the nurses finished their morning tasks. I was immediately drawn to the incubator that was occupying Bed 2.
I have learned a lot about pediatrics in my time here, but still not enough to feel extremely confident. However, it didn't take me a minute to figure out the child was in distress. I asked the staff who was taking care of the baby. They hadn't decided yet. Glancing at the flowsheet there were no vitals beyond a heart rate that was way to fast and a temperature written down. The baby had pulled it's oxygen mask off and there was no saturation being picked up. His feet were cold. Again, I asked the staff who was the nurse assigned to the patient. After what seemed like hours of debate, which in reality was only a few seconds, one of the newest ICU nurses said he would take care of him. When he came over to the incubator I asked him, "Why am I concerned about this baby?" Fortunately, the nurse had been a good student and was able to rattle off some textbook answers about airway, breathing, and circulation that were pretty close to being accurate. I asked him to find our pediatric blood pressure cuff while I adjusted the oxygen mask and tried to get a saturation reading. No blood pressure cuff to be found. I finally called one of my pediatric colleagues and got a quick response of, "Can I call you back we're in morning report." The newest member of our team didn't know that if I'm calling you during morning report, it's not to chit chat. I explained that I really needed a BP cuff for a neonate and that I was extremely worried about the child. She promised that she would get back to me. I then texted my ICU Senior on that day, which was Claude. He came immediately to the bedside. The IV wasn't working so we started by trying to get a new one. With Claude handling the situation, I dashed off to pediatrics to get the precious BP cuff.
Use to dealing with adults and in an ICU, I like my numbers. In fact, I learned very quickly in Haiti that I'm too reliant on them when I looked above the cot and discovered there was no monitor there. Natural reaction to an ICU nurse to look for more numbers and data to give us more information. I was told by my colleagues that in a neonate the blood pressure was really the last thing I needed to be monitoring and to simply trend my other vital signs. I was pretty exasperated at this point. "I have a heart rate that is way too high, no saturation, the child is blue, and it's temp is almost 39." It was all I could do to keep the panic out of my voice. I didn't have much to trend, but what I did have I knew was bad. Thankfully, Veronica sensed my panic and came back to the ICU with me. She immediately was concerned too. I was glad I wasn't over exaggerating the situation.
The nurses had been unable to gain new IV access in my absence but they had finally checked a blood sugar and discovered it was dangerously low. At this point I wanted to throttle the night shift. They have heard me say a million times over, "You cannot document what you did not do" and "It is important to document all that you can to paint a clear picture of the patient" at least a thousand times. And overall they have improved dramatically in their documentation skills, but on this particular night with this particular patient... I was so upset that all my time and energy appeared to have been wasted.
Was this an overreaction I was having in my head? Probably. But at the end of the day, the baby died. He was five days old. And I know that he died because of poor care. A resident from the pediatric team or surgical team should have checked on him overnight. The ICU resident should have checked on him overnight. And the nurses should have known better. It is so difficult to be understanding here at times. Did I throttle a nurse? No. But I was so extremely upset at the situation. All it would have taken was for a nurse to notice the coloring was off, which would have been reflected in the poor or lack of a saturation reading. I don't know what happened, but it was too late by the time action occurred. I know we can't save them all and there are a lot of hopeless cases here. But this was one that should have survived and he didn't.
Then last week I received a phone call from Jeff, HRH Internal Medicine Physician, asking who was on for ICU because he was concerned about a patient. In the U.S. easily 75% of the patients in the Internal Medicine ward would be in an ICU. So if you think I have it rough, you should take my situations and multiply them by 20, and that's what Julie is working with. So needless to say, if one of the IM doctors is calling, they're really concerned about a patient. I gave him the information for his resident to contact the ICU General Practitioner but offered to come down to take a look and perhaps speed the process up. The patient in question didn't look that bad and I was happy because sometimes the ICU refuses patients because there simply isn't anything else to be done. But this woman looked as though she would pull through if we got her to ICU.
Jeff finished talking the Théogène who in turn agreed to accept the patient. Then of course, it was discovered that there was no portable oxygen. This isn't the first time (or the last) that this has happened. Jeff and I both made the call that we could rush her up to the ICU and she would be fine. She had been sitting in IM without her oxygen on for the 15-20 minutes I had been there anyway. Jeff went with the patient and grab the box of belongings and waited for the family so that they would know where we were going. By the time I got to the ICU, a full minute after Jeff and the patient, they were coding her. Jeff said that she just out of no where gasped about 100 yards from IM and stopped breathing. At the end of the code about 45 minutes later, after time of death had been declared, I told Jeff, "I was not anticipating that." He'd had it worse, apparently she was the eighth patient of his to die in two weeks. Neither one of us saw that happening. Her mother was so upset that she ran away from the staff because she didn't want to hear the bad news. I ended up slamming my office door I was so angry at the situation.
On Friday of last week I walked into the ICU and the staff told me they had coded our male patient at 5 AM. I took one look at him and knew he was going to die that day. Patients will do something that medical professionals call "guppie breathing." I have never had a patient guppie breathe that was still alive my next shift. What was worse is that we could not for the life of us get this man's oxygenation saturation above 85%. I texted Théogène... "I'm sure at this point he already has anoxic brain injury. How do you do this every day year on end?"
I knew what I was getting into when I came here. Théogène even warned me multiple times upon my arrival how depressing it can be. And I shrugged it off. I'm use to death in my job. It is my job. Sometimes the only thing keeping someone from completely dying are chest compressions being performed by me (because in reality, if I'm doing chest compressions, the patient is already dead). I've been at this for years... and yet it finally got to me. Sometimes these situations are just so beyond frustrating that I can't even describe them. I didn't wait around last Friday to watch him die, but rather went home and ended up spending the entire weekend in bed or on the couch sick.
I give the Rwandans so much credit. What they experience here is more than I ever have to experience back home. Most of the time it seems their efforts are fruitless so why even bother?
Lessons Learned:
1) Eventually, anger you didn't even realize was there will come creeping out. It may result in slamming of fists into doors, making loud noises with books or doors, and/or having extremely ill thoughts towards others.
2) What matters most though is how you handle this anger... All the above are not going to help the situation. Sometimes it's best to just pause, take a deep breath, repeat yourself a million and a half times more, and encourage the culture change as best as possible.
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