On Call: Ups and downs

Switched call with Susan - she took yesterday and I took today - so that I could go to the sing-sing practice yesterday.  She got a car accident and didn't get home until 9 pm.  So far I've been rocked gently from highs to lows.

The very smallest baby in the NICU - 775 grams the last weighing - has a bilirubin of nearly 30.  We tried a bili light, but it's not a very good bili light, and the numbers climbed again today, so we decided to go for an exchange transfusion.  (For the non-medically inclined, this means I draw off 10 mL of baby's blood and then put in 10 mL of donor blood; repeat until we've exchanged the estimated volume of blood in baby's body - hopefully replacing the bad blood with good.)  It would have been much easier if the umbilical line hadn't stopped working this afternoon, so I did my best to do an exchange transfusion through a peripheral IV in the lower leg - the only IV we could start.  Baby's not really stable enough to attempt a cutdown.  We exchanged about 10% of the target volume before I could no longer draw blood off the IVsite, and then we gave up.  There was really nothing else to do.  So now we wait, and we check it again in the morning.  Things don't look good for her.

This morning I did a D&C for an incomplete abortion, and hopefully I got everything out.  There's always a crowd of nursing students around me so I try to teach them what I'm doing.  They seem to be listening.  With Susan's help (we spent a lot of time together today) I set a broken arm and casted it.  Very exciting.

There's a little boy named Junior on A ward who fell into the fish pond today;  he was breathing when they pulled him out, but nobody knows how long he was in there.  He's pulling with every breath, lying quietly with eyes closed, and 89% on room air.  We don't have a ventilator.  I did a chest X-ray and he was already developing a little pneumonia.   What he needs is a ventilator and blood gases and big gun medications.  What he's getting is 1L by nasal cannula, a CBC, and chloramphenicol with flucloxacillin - and I prayed over him with the woman who brought him in, and told her to call his mother and have her come stay with her son.  I'm very worried about him.

ER asked me to see a patient with acute abdominal pain; I laid hands on her and called backup Bill.  "I think she has appendicitis."  He came up and examined her as well, and nodded.  We had Surgery in the room and getting her ready for the OR when the WBC came back at 26,000 (more than twice normal).  Jim whistled.  "That's a lot."  It was quite satisfying to feel like I knew what I was doing - even if my first reflex was to send her to CT scan.
He just called: her appendix was gangrenous but not ruptured.  "Perfect timing."  What a relief.

I was about to leave when I got a call from A ward.  "Baby arrested."  And he had; a little asthmatic 6-month-old who'd been wheezing and gasping in the ER, was on theophylline and salbutamol nebulized treatments and steroids, who we'd considered giving magnesium to if he didn't improve soon, had just gotten to the ward when he stopped breathing.  By the time I got there there was nothing to be done: pulseless and apneic, with his mother softly wailing over him.  So I prayed with them, and she thanked me.  I almost wish she hadn't; it just underscored how completely helpless we are here sometimes, without all our machines and our technology.  

A generation goes, and a generation comes,
   but the earth remains for ever.
⁵The sun rises and the sun goes down,
   and hurries to the place where it rises.
⁶The wind blows to the south,
   and goes round to the north;
round and round goes the wind,
   and on its circuits the wind returns.

Ecclesiastes 1:4-6

Walked home from the ER tonight and saw a beautiful sunset.    Had dinner, took a deep breath, and then went back in to see a patient who might or might not be in labor.  She's having "small pains", second baby, previous C-section.  She doesn't know why she had the section and she doesn't know why her baby died.  It was all done in Hagen, though, so I asked her where she was from.  Longwe - not from Jiwaka - and the OB ward has full beds.  We talked.  I told her she could pay extra money (longwe is 75 kina instead of 55 for a week of bed space, plus 185 kina instead of 110 for a C-section - for a total of about $60 for Jiwaka or $95 for longwe - imagine that as your hospital bill) and sleep on the floor, but that the best thing to do was for her to go to Mount Hagen to get her care.  She took this quite well, and ultimately I gave her a shot of salbutamol and told her to go to Hagen if her pains recurred. 
Driving back down to the house, the strangeness of the situation struck me.  It's like telling a patient "You're not from this county, so we're going to charge you 50% more and also, since this isn't emergent, I think you should go back home, maybe in the morning."  And (a) I just gave tocolytics to a patient at term in early labor and (b) I told her to go home and go somewhere else to get her surgery done, because we were full.  I'm sure there's some kind of law in the States about doing that, but here it means that we don't have more patients than we can take care of with our limited resources.

There's another 10 hours left of call.  I'm afraid of what more it may bring.