pecc doings, part two

As a warning, this is a fairly heavy post, but it’s what I’ve found myself pondering the last several days, and it’s also important to me to be able to share even the hard parts of what I see and do. But it may not be for everyone. 

I’m back in Boston. I managed to sit in a pollen-covered chair on my porch about five minutes after arriving home, which made the hour afterward a little miserable. But a double dose of Zyrtec and half a dozen spritzes of nasal steroid later I seem to be returning to baseline…

Interestingly, the thing that may have made the biggest impression on me over the last two weeks at KNH was an exposure to the paediatric wards that I haven’t had before. What I realized was that as sad and challenging as the PICU can be, I have been – in some ways – very sheltered within its walls. I see the patients in front of me. It can feel bleak when it’s clear a child has a terrible prognosis, but the PICU has ventilators, and it has pressors, and we can do the Critical Care Things, mostly. But out on the wards – at least in the acute rooms, where the team gets called to do PICU reviews – all they can do is put a child on oxygen, keep giving them medications, and hope for the best. And kids die. Some of them would eventually, even in a PICU, but some are dying simply because there’s no room in the inn. 

Heading in for a PICU review

Each day after PICU rounds are complete, we walk the wards and see any children who have been requested for PICU review. On Thursday, I was standing at the bedside of an infant while the ward resident told us about her, and as I was unwrapping layers of the baby’s clothing, I watched as she began breathing irregularly and then began to gasp. What then? I knew there were no PICU beds, and what I had heard of the story hadn’t given me much reason for hope. But we did some ventilation with a bag and mask and gave a dose of epi for weak pulses, and the resident spoke to the parents before we talked ourselves into stopping. We walked away with her pulse fading as a nurse was pushing a bolus of fluid into her IV. When did she die? I don’t know. I’m not sure anyone actually did, and somehow that feels even sadder.

Diarrhea, septic shock, acute kidney injury, acidosis, respiratory failure: it’s the terminal spiral of too many infants on the KNH wards. Far too many simply present much later than they should. An infant we heard about on Friday in ward 3A had been at home without passing urine for a week before being brought to a district hospital. There she spent another week without any urine before being transferred to KNH for the only remaining option, peritoneal dialysis. She was still breathing, but hypoxic and clearly uremic, and I could only hope that the plan to get the PD catheter in urgently that day was executed in time.

But the baby that really broke my heart was a beautiful three-week-old who had presented with a mild version of the usual story, until the night before we saw her when she had suddenly developed respiratory distress, needing a lot of oxygen. Did she aspirate? Maybe. She was certainly uremic and could have. But I think she wasn’t beyond hope. We didn’t have any PICU beds, so we had them call around. Main ICU? Full. NICU? Full. Could the newborn unit at least do CPAP? Full. Was there a CPAP machine somewhere, anywhere, that we could hook up and attach to the baby? Maybe. They’d work on it. Her mother was quietly wiping tears from her eyes as we talked about options, and I suggested they put the baby on a cannula and turn the flow up as high as they could in the meantime, just in case it effected some positive pressure, but the next day the ICU residents told me that she had died while they were trying to organize the CPAP.

In my US life, I hear a lot about hospital capacity alerts and lack of ICU beds, but in contrast to KNH, it feels like a joke. Here we always, as a matter of protocol, have a bed reserved for emergencies. There are three other PICUs within five miles of my hospital. I can only guess that a large number of the children admitted to the KNH wards – there are four, and they are not small – would make floor nurses at my hospital absolutely faint. And yet the KNH ward nurses and residents keep going. How? Whatever the answer is, it inspires me to engage the difficult consults and to try to teach however I can, even in the absence of any good answer for the child in front of us.

How do you tell these stories? I often pass myself off as a regular old pediatrician during casual interactions in my everyday life because the idea of critically ill children, even in a highly controlled environment, is a lot for some people to contemplate. But even my colleagues’ eyes widen when I talk about some of the children I’ve met and cared for in Kenya... 

More medical resources and better infrastructure are one answer to the challenges that places like KNH face. But I believe that smart, well-trained health care providers who are able to think critically and make hard decisions well are ultimately just as important. I don’t claim to be the smartest doctor (goodness knows) or the best teacher (hardly), but God has wired me to be resilient (usually) and continues to grow the place in my heart that loves trainees and being a part of their training, especially in challenging places like KNH. Even at the end of sad and exhausting days, I’m grateful for that.