Our first code

The pace of clinic this afternoon followed Murphy's law - hardly anybody showed up for the first few hours, only to have several sick kids show up in the last hour of the day. Tammy and I worked on admitting an asthmatic, and I was feeling pretty proud that we'd learned how to navigate the system enough to work up and admit a child in this foreign setting all on our own.

As I walked back through the clinic to find a Sister to ask about sending the child to the floor, I found the medical officer quietly resuscitating a baby. She and the Sister were bagging the child while trying to gather together materials for intubation. Once we recovered from our surprise that nobody had called a "Code 22" or at the very least a "Peds 99," Tammy and I quickly got involved in the resuscitation - it was a 3-week old baby with meningitis.

I carried in the clinic's single pulse ox machine (from the opposite end of the clinic,) and our work began. We took turns bagging while everyone searched for the right equipment for intubation. First the ET tubes were all jumbled together. Then nobody could locate a stylet to aid in intubating. Then we noticed the stomach was becoming quite full of air, to the point that it was impeding our efforts at bagging. Guess what wasn't readily available. After several minutes of searching, someone finally did find an NG tube. After that the intubation blade wasn't the right size, and the right-sized one had a burnt out light. A lightbulb switch later, the medical officer was finally ready to intubate... until she took a look and asked for suction. The suction tubing was coiled all around the wall suction unit, and the Sister s l o w l y and carefully unwound it, finally passing it to one of us before turning on the vacuum... only to find it wasn't working!! (Remember, we're still bagging through all this.) Someone did bring out a backup suction machine, and finally, on the third attempt, the baby was intubated.

If the previous paragraph was painful to read, imagine standing there sorting through all of it while watching a pale lethargic baby repeatedly try to desaturate as you bag with a mask the size of the child's whole face.

Though we were glad the child was intubated and had a more stable heart rate, our work was not done. For the next hour or so Tammy and I took turns bagging the baby while the medical officer tried to sort out where we would send the child. Without x-ray to confirm placement, we used auscultation and palpation to determine that the tube was too deep. Those same skills also confirmed that we successfully repositioned it. Previous residents weren't kidding when they say that physical exam skills are incredibly valuable here.

The medical officer declared the situation "a disaster" because the child is HIV positive, and we are not supposed to resuscitate children with HIV. The position is that those children already have a shortened lifespan, so the very limited hospital resources should be reserved for those who are "salvageable." I don't even know how to begin expressing how strongly I disagree with this idea on so many levels. Can you imagine declaring a whole group of children unresuscitatable? I was so glad that we'd intubated this one before they discovered that. I can't imagine what would've happened otherwise, by which I mean I can imagine it and am unspeakably thankful that it didn't happen that way.

The medical officer then embarked on a series of phone calls to find an accepting unit for this child. The Prem unit didn't want him because he'd come in from home. Like our NICU, they prefer not to accept those children who have gone out into the world and gotten exposed to community-acquired infectious agents. The ICU didn't feel comfortable with a child as small as he was. By the time we finally went home they planned on sending the baby to Casualty (the ER) so they could sort out the patient's placement.

The discouraging part is knowing that the child will likely die, despite our best efforts. Kids die from meningitis in the USA too, but there I would've been able to honestly say "We did our best." I guess we did our best today too, given our limited resources. It was the best we could do, and our best was enough to get that baby a secure airway, good sats, and fair perfusion. ABCs, African style.