Hospital

I started work in the hospital on Monday, and as expected, in the ward
round was tiring in the humidity, and was tough for me to get back
into thinking medicine. After so many weeks of real medicine, I'd
forgotten most of it!

Many things made it different from a ward round in the UK. Of course,
it's still the doctor trailing his team around the patients, checking
on their latest test results and routine examinations, but with
interpreters, and what I felt was a lack of a warm bed-side manner at
times – hard due to the language barrier and sheer number of patients
to get through. Because of that, I made an extra effort to smile at
the sometimes nervous, often scared-looking patients, and greet them
good morning.

There are 5 wards: paediatrics, obstetrics, men's medical, men's
surgical, women's, and there's an extra little Alpha Project room for
malnourished kids. There's one operating theatre, a lab that can do
quite a few tests, a non-functioning X-ray machine, and certainly no
canteen facilities (patients often go for days without food due to
lack of funds or family to help prepare it). No food = poor recovery.
This is something that is often forgotten by medics I think – basics.
At 5pm, after the outpatient clinic (which is like a GP surgery), the
doctor, the student Community Health Officer (Solomon), and I were
called to see a little baby boy, CJ, who was in acute respiratory
distress. He was gasping for air, not alert and quite limp. He was
previously admitted with a haemoglobin of 2.7g/dL. A kid of his age
would be classed as anaemic if his haemoglobin was below 9.5g/dL For
those who don't know, haemoglobin is what carried oxygen around inside
red blood cells. When you don't have enough haemoglobin, we call it
anaemic. 2.7g/dL was said to be "incompatible with life" according to
the doctor. We were not sure why he was struggling to breathe, we
thought it most likely mucous from a chest infection. His lungs
sounded like they were full of water.

A is for airway

I gave him a jaw thrust to open the airway as much as possible, to
make every gasp of air as worthwhile as possible. Surprisingly, some
staff hadn't heard of a jaw thrust before.

B is for breathing

Normally, he'd be given oxygen – a lot of it – but no oxygen is
available here. No oxygen concentrator, no oxygen tanks. Oxygen is the
first thing you think of in managing any patient. We took him for
nebulised bronchodilator therapy (vapourised medicine to open his air
tubes as much as possible). There's no electricity in the wards, so we
had to do this in the lab. His oxygen saturations (the proportion of
haemoglobin in your blood carrying oxygen) had gone from 80 to 97 from
this alone.

C is for circulation

He'd been transfused with donated blood already, but no test was
called for to have his haemoglobin checked again. Even if he had 100%
saturated haemoglobin, and he only had a quarter of the normal level
of haemoglobin, he may as well have bled ¾ of his blood away – there's
just not enough oxygen going around his exhausted body.
(His post-transfusion haemoglobin wasn't checked at all.)
DEFG is for don't ever forget glucose.

Well, we forgot glucose. Actually, I'm not sure if we did or not,
because I don't think we have the equipment to test for it.
I asked the ex-pat American nurses to do some physiotherapy to clear
some of what I thought to be mucous out of his lungs. Blood started
coming out of his nose instead, and we then thought he had pulmonary
oedema. Fluid from his blood leaking into his lungs causing him to
effectively drown. Some of the expert local nurses managed to
cannulate his hand (put a tiny tube into his vein) so we could give IV
furosemide (a medicine to make his kidneys drain fluid from his body).
He pissed pretty much straight away, and was saturating at 100%.
Breathing was laboured, but seemed much better.

I agreed to come back at 7pm to give him nubulised saline treatment,
to help him breathe better with humidified air, and again at 9pm,
whilst the generator was still on.

At 7, he did a lot better, and mum was OK.

At 8, doctor check on him, said he was doing good.

At 9, I came back to find him a lot worse, mum sobbing. As babies do,
they seem fine for ages, then they suddenly everything crashes. He was
breathing faster, shallower (probably extremely acidotic), cold hands
and feet. I called the doctor to bring the equipment to check his
saturations. I did a jaw thrust for a good while, then tried to help
clear fluid out of his lungs.

He went limp in my hands. I lay him on the bed, mother started
wailing. No pulse, called for the nurse, and I started CPR.
Before the doctor arrived, he was pronounced dead at 9.09pm.
I've never had to deal with death like this before, and never done CPR
on a baby before.

I comforted the mum, but nothing I said could help her now. The family
live far away, out of phone reception, so it maybe that the mother
will have to carry him back herself.

So much more could've been done. All those things that you learn about
in medical school… but a lot of those tools aren't available.