one day (part II)

I slept in the doctor’s lounge.  I got a call at 1 a.m. that a 30-year-old woman came in with shortness of breath.  She had developed heart failure during a recent pregnancy, and her heart was only 1/3 as effective as it should be.  Because of that, fluid was backing up into her lungs and into her legs, and she was suffocating. She was sitting on the edge of the bed leaning forward with her weight on her arms, which were outstretched in front of her, gripping the edge of the bed.  It’s a position a position called “tripoding,” and it means a person is in severe respiratory distress.

The nurses had already hooked her up to a monitor, and I saw that her heart rate was fast, and her oxygen saturation was 85%.  Her blood pressure was through the roof.

I ordered oxygen, an IV, two different blood pressure medicines, a diuretic to get the fluid out of her lungs, and morphine for her chest pain.

Her oxygen saturation came up a little bit with the oxygen.

Her blood pressure didn’t budge.

We went up on the doses, still no effect.

I ordered two more different blood pressure medicines.

I sat at her bedside for more than an hour with her nurse, trying to give her enough blood pressure medicine to bring her pressure down without giving her too much.  If her blood pressure dropped too low too fast, she could have a stroke from lack of blood flow to her brain.

Finally, we got her stabilized.  Her lungs were almost clear, her blood pressure was in a normal range, and we were able to give her a lower dose of oxygen because her breathing was so much better.

She fell asleep, and I went back to the doctor’s lounge so I could try to get some sleep, too.  It was now 2 in the morning.

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At 3 a.m., the charge nurse called me to tell me that a 2 year old girl in pediatrics with cerebral malaria was having another seizure.

The pediatrician diagnosed the girl with DIC (Disseminated Intravascular Coagulation) as well — the malaria had caused her to have a disorder where her blood wasn’t clotting as it should, so she was bleeding into her lungs and into her brain.

Between the malaria and the brain bleed, she kept having seizures — in spite of all the anti-seizure medicines we’d given her.  When she was seizing, she would also stop breathing, and her oxygen would drop.

I ran to pediatrics to find the little girl having a seizure, her eyes rolling back to her head.  “Give her five migs per kig of Phenobarb,” I told the nurse.  “And get me the Ambu bag.”

I breathed for the little girl while the nurse pushed the medicine into her I.V.

Five minutes later, the seizure had stopped, and she was breathing on her own again.

I turned to find that her father, who had been sleeping on the floor next to her bed, was standing behind me, watching us care for his daughter.

“The seizure stopped. She’s breathing better,” I said.

He nodded.

But just as the nurse and I started to walk away, the monitor started alarming and we turned around to find that the girl was seizing again.

Again, the nurse pushed Phenobarb into the I.V. while I bagged the girl.

A few minutes later, she started seizing again.

This happened over and over again for two hours.  We gave her as much Phenobarb as we could, then switched to a different anti-seizure medicine.  It didn’t matter. She seized anyway.   Blood from her lungs started coming out of her nose, and pooling in the back of her throat. We suctioned it out, and kept going.  Finally, the seizures stopped.

On my way back to the doctor’s lounge, I stopped and checked on ISO 3.  Her oxygen saturation was down to 75%, but she was resting comfortably.  Her husband had pulled up a chair next to her bed and was sleeping with his head resting on her stomach, his hand holding hers.

I fell into a deep sleep on the futon in the doctor’s lounge.  I was awakened by the phone next to my head.  I answered to hear the charge nurse’s voice, sounding distant, telling me that the girl in pediatrics was seizing again.  And the girl in ISO 3 was taking her last breaths.

I realized as I turned on the light that I’d been holding the receiver upside down. No wonder her voice sounded so far away.

It was 4 a.m.  I was choosing between two dying patients.  I chose the child — because there was a chance she could make it, and there was still something I could do to help her.  There was nothing I could do for the woman dying of tuberculosis.

I spent an hour at the bedside of the seizing child.  Between seizures, I warned her father, and her mother — who had joined the bedside vigil at that point — that it didn’t look good, that their daughter was getting worse instead of better, and if she kept bleeding into her lungs and her brain, her lungs and heart would give out, and there was nothing we could do to bring her back.

They nodded that they understood.

As I was bagging the girl again for the tenth time that night, the charge nurse came over.  “ISO 3 just died,” she said.  “Can you come declare her when you get a chance?”

I had to declare her dead and fill out the death certificate so her family could take her home and bury her.

Declaring someone dead — I knew how to do it but I’d never done it before.   You can listen for heart sounds with your stethoscope, or feel the neck for a carotid pulse, or check for a corneal reflex — which is the last reflex to go.

It took another hour to get the girl to stop seizing.   I walked over to ISO 3’s room.  Her husband and parents were sitting on a bench outside the room.

I walked in to find a tiny body wrapped in a large piece of fabric - her mom had removed one of her long wrap skirts and used it as a shroud for her girl.

I removed the fabric from her face, and found her vacant, still-jauniced eyes looking blankly at the wall.  Her mouth was slightly open.  I tried to close it, but found that rigor mortis had already set in.  It made declaring her dead both simple — and macabre.

I covered her again, walked out of the room, and gently closed the door.

Her mother looked up at me.  I put my hand on her shoulder.  She jumped off the bench and motioned for me to sit down.

“No, no, please,” I said.  A mother who had just lost her daughter was offering me her seat because she thought I was tired and needed a place to sit down.

She sat back down.  I knelt in front of her and put my hand on her knee.   Her husband and their son-in-law had gone to pay the hospital bill so they could take her body home.

“I’m sorry,” I told her.

She clasped their hands in front of her and bowed, a gesture of goodwill and gratitude.

I stood up and bowed to her, and then hurried away.

Because the child in pediatrics was seizing again.