Stormy Weather

1/19/2010
Day 14

Half the sky right now is clear and sunny and the other half is dark and threatening. It feels appropriate. Another sleepless night left me a little cranky this morning. This turned into a lot cranky when I hit the wards to find the nurses hadn’t done a number of things that were ordered yesterday on our 8 month old heart failure kid. The nurse kept repeating that she did not understand the indication for placing a feeding tube (this baffles me, since the kid was clearly too sick to eat, hadn’t fed in 48 hours, and can’t get IV fluids since he is overloaded). I repeated multiple times why the tube is necessary and also reiterated that the order came from the consultant and it isn’t appropriate to simply not do it. I’m convinced they just plain didn’t feel like it. As a result the kid went another 12 hours without feeds. I think I had smoke coming out of my ears as we started rounds.

A storm also hit our service last night. We got 4 more new patients during the night:
A 16 yr old boy with upper GI bleed (but stable), getting scoped today, a 1 month old girl with respiratory distress (I did her LP), a 6 week old boy with respiratory distress, and a 4 year old (who weighs only 8 kg!!) with cough, fever, abdominal distension, hypoxia. This child is one of the most disturbing children I’ve seen. Every week I say that about someone. She is shockingly wasted and chronically ill appearing. She probably has pulmonary TB with liver involvement (has a number of small masses in her liver on ultrasound), or has pulmonary TB in addition to something strange in the liver. Once again, it is hard to unify the patients with one diagnosis when they come in so ill. Her grandmother who cares for her is apparently being treated for TB as well. I’ve actually never seen anyone in a respiratory isolation room (not a negative pressure room, mind you) until now (which means it’s serious). Few people wear masks here (oh, but I did! But I’ve probably already converted my PPD at this point. I feel the respiratory droplets hanging in the air all over the hospital…).

And then there’s Jane. Jane continues to do poorly. Her renal function is terrible again, and she is still requiring a lot of oxygen. Her temperature this morning as I examined her was 41.5 degrees C. That’s 106.7! It honestly nearly burned my hand to touch her. Today I wrote in my note that I thought prolonging her care was futile and unnecessary suffering for the patient and her mother. I recommended withdrawing care today. It is the first time with Jane that I took a stand. Phil, the ICU resident, and I were discussing our disappointment that no one acted on this yesterday. ICU rounds have been disjointed, with too many opinions being thrown around. It seems like the loudest voice wins each day, and it is not always the same person from day to day, making for an incoherent care plan. Meanwhile, Jane continues to look terrible, increasingly edematous each day, struggling with the vent (inadequate sedation at times), and desaturating with any slight manipulation (turning her, dressing her, feeding her). Her mother continues to pray at the bedside and to wander the pediatric halls (the mothers of ICU patients get beds on the peds wards to sleep in).

Just as I wrote that the sky opened up and it is now pouring. I do have to admit that this place is full of spiritual happenings. With that, I better return to the hospital to check on all these complicated patients. As I do so, I will try to keep my face toward the sun that is still shining through all this rain.