During my medical training, I revered (and was taught to do so) the learned academic doctors. Those well-known doctors in high powered medical centers where research was abundant and sacred. Those who could easily drop the reference to any piece of medical information and casually throw out sentences like “we really only need to give him a single dose of IM dexamethasone as shown Slawoski et al, NEJM, may 15 1998”. Perhaps it was all a show, as I never checked on those to make sure they weren’t just blowing wind. Regardless, these were the best docs. These were the ones who knew the latest research and standard of care. They were powerhouses of information, and we didn’t understand why patients didn’t lie agape in their presence, feeling fortunate to be under their care.
I now know better. The really impressive doctors aren’t the ones walking casually through the halls of the tertiary university hospitals, surrounded by every sub-specialist, the latest equipment, and all the tests at their disposal. The real heroes are the country docs, the pit docs in the small hospitals, the solitary souls who have to make the tough calls alone in the middle of the night. ‘Cause you know what, THAT’S scary! It’s one thing to do it for one night, or even a couple of months as part of some idealistic volunteering sabbatical. But to do it for a career, day after day, solitary night after solitary night- that takes cajones.
We’ve had a couple of cases recently which has made me appreciate this all the more:
About 2 weeks ago, I had just left the clinic and was preparing the dinner. Rainy season had begun, and this was a particularly stormy night. Thunder, lightning, torrential downpour, and the obligatory subsequent power outage. We were in candlelight when my phone rang. It was one of the nurses. “We have an emergency, a sick kid”. I was a bit surprised, as the doc on call was a fellow ER doc, prepared for anything, though it was his first call. His first hour of call, actually.
I walked in to find him bagging a 12 year old intubated kid. Apparently, he had been diagnosed with asthma ~5years ago and given an albuterol inhaler, which he would just buy more of from local pharmacies where you don’t need prescriptions. Used it throughout the day, every day. Never saw a doc. Now with a severe asthma attack. He had been carried in by his dad, blue, and literally took his last two breaths in the ER, one in the doorway, and one in the guerney, before he lost his pulse. CPR was started, given epinephrine, fluids and intubated and regained his pulse. This is the point where I walked in. We gave him everything we could think of (magnesium, steroids, terbutaline) and even some in line albuterol nebs, though we didn’t have the equipment for this (some fancy McGuiver action on our part with some tape and tubes fixed this somewhat). It was soon clear, though, that we would need to transfer him. No ventilator in our hospital. The nearest big hospital with fancy things like a ventilator is in Guatemala city, 3 hours away.
So we loaded him into the ambulance and took off. I could have asked one of the other docs to go with him, but it was really my responsibility and, in reality, I was probably best trained to handle any problems on the way (the other ED doc had to stay in the ER). Plus, there was no way I was going to miss that adventure! Now let me paint the picture a bit more clearly. This was an old 1970s ambulance with suspension that left you in just that. There was no electricity in the back, so we had no suction. No Pulse oximetry. No nebulizer. I was seated to the patients side, hand bagging and watching his chest rise and fall. His dad was to my right, holding the oxygen tank ever-so-loosely attached to the wall of the bouncing ambulance. To my left was a nurse, holding the IV bag so it wouldn’t bounce into my face and looking a bit worried, and to her left, on the floor, the uncle. Still pouring rain, muddy, wet and slippery windy mountain roads. One 8x10 inch window to the side. I don’t normally get that car sick. As we had no official ambulance medical kit, I had thrown together all things I thought I might need in terms of medications and equipment into some black plastic shopping bags. We had a monitor/defibrillator to check his heart rate, but I didn’t know how long the battery would last, so I would only turn it on occasionally. I figured if his saturation were to drop, his heart rate would rise.
About an hour and a half out, I realized I forgot to bring the mask part of the ambu bag, so if he lost his tube, I would have to rely on my dry Swedish lips. Throughout all this, I was bagging slowly, watching the chest rise and fall. I've never felt so incredibly responsible for someone's life before. Each breath was literally in my hands. I wasn't thinking this in a ohmigod whatamidoinghere panic. Nor was it a egotistic life-saving hero way. It was just a focused realization. I remember thinking that this was it- all the years of training and work had led to this, and I had to carefully plot a backup plan for each potential disaster.
Soon thereafter, he started to produce copious froth in his tube. No suction. I turned him on his side and tried to waggle the tube a bit, to no success. Heart rate slowly rising. 130 bpms. Do I stop and put a new tube in on the side of a dark country road or keep going? Keep going. Finally get to the hospital. Heart rate 145. Huge, ugly hospital that makes SF General seem like a pristine movie set. Now this is in the midst of the Pig Flu scare, so all the patients in the hallways have masks on. You could almost see the viruses floating in the air. I hand over the care of my patient to some residents who didn’t exactly exude cutting edge medical care. I had to tell them to please not bag him at 30 breaths a minute to allow some CO2 to make it’s way out once in a while.
Then back to Santiago on another 3 hour bumpy ride. Last I heard he was still alive, but in a coma. Hoping to hear better news sometime, but not too optimistic.
A couple of nights later, it was my turn to be on call. Just as everyone else was going home, a mother came in carrying her 7 month old with trouble breathing. He the worst stridor I ever heard (i.e. upper airway obstruction). Chest caving deeply inward with each breath, retractions so deep I could almost see the heart border. Oxygen saturation 85%, but up to 95% with some oxygen. Likely croup. I started some nebulized epinephrine (no racemic down here) and a shot of dexamethasone. He was clammy and sick looking so we tried getting an IV multiple times without success. Finally, I had to put in an IO. This means an Intraosseous needle, a big, thick needle that you have to insert using all your force right into his leg bone, pushing deep until you feel the pop of the bone give way. His dad just about passed out watching this. This is one of those things that is so natural to answer on a test question. You know it’s the right answer, but actually doing it reality is a bit unreal. He finally got some fluids and became a bit better. He had not had any vaccinations, so epiglottitis was still a possibility. This is a very serious infection of the area by the vocal cords where it can quickly swell and cut off the entire airway. The textbook teaching is to never look at the vocal cords (as it can cause it to spasm shut) unless you are in a controlled setting, such as an operating room, with an ENT specialist doing the looking. Another dark, rainy, rural Guatemalan night by myself wasn’t entirely “controlled”, but it was what it was. I finally managed a quick peek at his cords with the laryngoscope (holding a couple of sizes of endotracheal tubes in my hand, just in case), and thankfully it looked OK.
So do you send him to the big hospital 3 hours away as he is, still gasping away? Do you intubate first, hoping the bouncing of the ambulance doesn’t make you lose your small, uncuffed 3-0 tube? Or do you keep working away, hoping for small, miraculous improvements where you are? The dad was asking if he could bring him home yet. I told him no. I chose to keep him, and he actually did improve, very slowly, and as his breathing slowly improved, so did mine. And he did go home the next day.
And last night, during my call, the rain and thunder came again, like the ominous and foreboding soundtrack that it was. The ambulance came in with a 20 year old girl. Apparently, she had had a cough and fever for the past 2 nights. Showed up in a clinic in town in the evening where she passed out and found to have a low blood pressure and look sick. When she arrived in my ER, she had a blood pressure of 50/40 (that’s low), a hear rate of 135 (double normal), a respiratory rate of 36 (high), and a pulse oxigenation of 82%. This went to 87% on 100% oxygen.
She was clearly sick, with pneumonia and sepsis. I felt quite proud that we were able to get 2 large IVs in and get 4 liters of IV fluid in her (as well as the obligatory antibiotics, but no cultures, because we don’t have them- how do you like them apples, JCAHO?). She just got worse. Her saturation kept dropping into the 60s, so I finally intubated her. Still couldn’t get her above 70%. At this point 2 more patients came in, one pregnant and thinking she was about to deliver. My sphincter firmly in spasm, I did what any any self respecting doctor would do- called for help.
While our obstetrician (Kaiser's own Sara Johnson) was caring for the pregnant patient, our internist and visiting nurse helped with my 20 year old. She just wouldn’t get better, whatever we did. She had acute respiratory distress syndrome (ARDS), fluid in her lungs, edema in her body, bilateral pneumonias. Ugh.
We sent her with the internist and nurse to Guatemala city. She made it there alive, but died a couple of hours later.
If we had had the latest equipment (CVP monitor, ABGs, etc), it’s possible things might have been different. I’ve beat myself up thinking I gave her too much fluid, but know that, faced with the same situation, other ER docs would have done the same. Could we have saved her if we had done anything different? I don’t know, and don’t want to keep asking myself that. People get sick. People die. And in between we do the best that we can.
Perhaps my academic residency professors would point to a study showing benefit from something or other. Perhaps a career rural solitary doc would have some insight. I’d like to hear from both, but mostly the latter. He’s been there before. I’m not that hero. I can’t wait to get back to the safety and shelter of my fully staffed, modern, specialist laden, efficient and professional ER. But it sure alters your perspective.
Like everything else on this trip. Hope you're all well.