Ishmael

The hospital work has been anything but dull....
I forgot to mention that on Easter, we were called out of Church to run across to the hospital because a 19 year old boy had just drunk a bottle of Clorox bleach and was obtunded. We rushed across the road, Jenna calling poison control as we ran. Luckily, besides being an irritant and possibly leaving a severe burn in the patient's mouth, esophagus, and stomach, Clorox is not supposed to be deadly. When we arrived, the mother had already forced her son to vomit and he was lying still on the bed, eyes rolled back in his head. We quickly assessed vitals and response to pain. As the nurse placed an IV, we held his head up and poured water into his mouth. Luckily, he could still swallow. We were able to get a couple of bottles of water and milk down him and he started to come around. He was arousable to his name, although he could not say much. We left him to recover and by the next day, he was sitting up in bed eating breakfast when we arrived at the hospital.
But yesterday was the real challenge...this is when we met Ishmael.
After seeing about 15 patients in the morning, things running smoothly and patients seeming satisfied, a distressed mother came into the room holding her baby. One look and I realized something wasn't right. The babies' head was very out of porportion to his size, and although only 6 months old, his sutures appeared extremely wide...the front suture was about 1.5 inches apart. "What's going on" I asked the mother, through the translator. Mother tells me that her 6 month old son had been sick since Saturday, vomiting, diarrhea, fever, and his head was getting bigger acutely since Saturday. I called over to Jenna who was seeing a patient on the other side of the room...."I think this child has meningitis, and hydrocephalus, and I don't know what to do!" We both agreed to try and call a doctor at SLU or Cardinal Glennon and seek help, as we knew we were in over our heads. After many transfers, I was finally place on the line with Dr Warren. He walked me through the treatment of meningitis, the IV fluid boluses we needed to give the infant, and the way to administer the fluid if we couldn't get an IV line due to severe dehydration. I relayed this all to the nurse, aquired the anitbiotics to be administered, and cleaned a crib for the baby to stay in. The nurse took the supplies and I reluctantly went back to my other patients. About an hour later, between patients, I went to check on the baby. I had not heard anything from the nurses, so I assumed everything was going okay. Unfortunately, my assumption was completely incorrrect. I walked up to the nurses sitting around the infant, dumbfounded, trying to pour Pedialyte into his mouth. There was no IV in place, and the infant was no longer moving...he was completely floppy, being held by his mother, his eyes rolled back in his head. I looked at the nurses, shocked, scared, amazed. It was translated to me that they could not get an IV started due to his severe dehydration. I was angry that no one had come to tell me, but it was not an appropriate time for anger.
I yelled for Jenna to come and help me and rushed off to the storage room where I had seen an NG tube the day before. I searched for veins to start an IV, but to no avail. With Jenna talking me through it, I inserted the NG tube and quickly hooked it up to Lactated Ringers. Then I grabbed the antibiotics and administered them IM. After the infant was stable, I went back outside and called Dr Warren back. After describing Ishmael's breathing, his pinpoint pupils, and his obtunded state, Dr Warren said that it sounded like he was beginning the stages of brain herniation. I choked back tears, 'please...no...I can't let him die....' I was thinking, but trying to push back my emotion and listen carefully to Dr Warren's descriptions on how to intubate him, to hyperventilate him and vasoconstrict the vessels in his brain to decrease the pressure. He also explained how to insert an intra-osseous line into the baby's tibia to administer fluids, as the NG tube is suboptimal for absorbing the fluids in the way that this baby needed.
I got off the phone and the baby appeared as if he was improving slightly...he was crying! Oh how good that cry sounded to my ears! I got a 16 gauge needle and inserted it into the baby's tiny leg, feeling the bone crack beneath my needle and drawing back bone marrow. I was in!! My very first intra-osseous line, and I got it first time! We hooked it up to the IV fluids.
In the meantime, we were working on getting the infant transportation to an Emergency Room in town. Finally, 6 hours after the baby had arrived and we had put the car search in action, a vehile arrived. I jumped into the car, infant in my arms. Jenna sat in back and held the baby's IV fluids and IO line. And we rushed to town. The man who drove us, charged us $10 US, a ridiculous amount in this country to drive 20 minutes. And then he insisted on stopping along the way to talk to some friends because he was supposed to have a meeting!! He left us sitting in the car in the sun, I sat their sheilding his eyes from the sun and listening carefully for breath sounds to make sure he was still alive as he had become obtunded again. I could not believe our driver!! I wanted to yell and scream, but instead I fought back tears and prayed that this baby did not die in my arms. We stopped again once more to get gas before finally arriving at the hospital. I ran into the back entrance and told the gaurd to quickly get a doctor. Within seconds, a Cuban doctor came down the hallway and ushered us into a room. I quickly told him the baby's history and what has transpired throughout the day. Without hesitation he ushered us into a clean, white washed room with monitors!! And runnning water!! And hospital beds! I was amazed and shocked by the high standard of this ICU! Within 2 minutes the doctor and nurse had placed a central line and were pumping fluids into the infant. I exhaled...
I could breath for the first time that day. Finally, the baby was in good hands! I could not even express my gratitude to the Cuban doctors. Thank you for being in this country! Thank you for being here! Thank you thank you thank you!!
As I walked out of the hospital after exchanging numbers with the doctor and a promise that he would call with any news, I was blind sided by two arms around me in a huge embrace. I turned and looked...it was Ishmael's mother, arms wrapped around me. "Thank you..." she said in broken English. Then hugged Jenna and disappeared into the hospital. I was so happy, but still nervous.
Today I went back to the Cuban hospital. There was Ishmael, awake and crying in his bed! We did an ultrasound of his brain and the hydrocephalus was not at a level that the physician was worried. He said they would keep Ishmael in the hospital for 3 more days to administer IV antibiotics and fluids and then they would discharge him with close follow up to monitor the size of his head and ensure he is not building up fluid. I know he is in good hands now, and he will be okay. I think I felt, for the first time, the most terrifying feeling of almost having a baby die in my hands, with no higher authority to turn to, and the incredible bond I felt to Ishmael after feeling that I helped in saving his life. I will be forever changed by this experience.