My Last Day On Ward D

Today was my last day on Ward D. I will use the next couple of days to get some work done and to relax a little before I return to my 80-hour-work-week back in the states.

This morning my favorite doctor and I started rounding in our usual fashion at one end of the long hallway that comprises Ward D. It was straightforward enough – the child with diabetes whose blood sugar has been extremely difficult to control; the child with septic arthritis, responding well to antibiotics; the girl with an avulsion fracture of her elbow, still awaiting surgery after more than a week; and a child with HIV experiencing various side effects from his antiretroviral medication.

The next two children we round on are in beds in the hallway. They sit outside a room that is locked and never opened. It contains various supplies, including a half a dozen brand new tricycles. Why someone does not clean this room out, make use of the tricylces and put patient beds inside is beyond me.

The first of these two patients is a girl who was admitted over the weekend with a large swelling in her cheek. On first glance I think maybe she has mumps, or some other infectious parotitis. But on further inspection the origin of the swelling seems to be more consistent with a dental abscess. After getting the history that this has been going on for several months and inspecting the inside of the child’s mouth – which shows displacement of a molar forward at an odd angle by a firm mass protruding from the maxilla/buccal mucosa – it becomes clearer that this is likely a malignancy. My colleague suspects Burkitt’s lymphoma. A full physical exam reveals no further abnormalities, other than a nodule protruding from the scalp, concerning for a possible metastasis? At this point there is not much we can do. The CT scanner is finally up and running again after being broken for several weeks. So hopefully we can get a CT of the head and neck. And we will send her to the maxillofacial clinic for consultation regarding possible surgical removal. But without chemotherapy her prognosis is poor.

The next child is one who was admitted about a week ago with severe malnutrition. He has evidence of both marasmus and kwashiorkor. In fact, I believe he has Bitot’s spots on his sclera, a physical exam finding suggesting vitamin A deficiency that I have never seen before. Unfortunately his workup has been negative so far. While his nutritional history certainly is inadequate, it is not poor enough to account for the severity of his malnutrition. The rapid HIV test was non-reactive. But I’m wondering if it is a false negative. And his chest x-ray shows no evidence of TB, although this by no means excludes this diagnosis. So we will continue him on nutritional supplementation, start vitamin A and a multivitamin, and treat empirically for TB. He should also be receiving copper, zinc and folic acid supplements (as I have learned during my time here these comprise an important part of the malnutrition treatment regimen), but in this developing country where malnutrition is a major cause of childhood morbidity and mortality – these supplements are currently unavailable.

The next room seems to be doing well. The girl with a history of congenital heart disease who is in need of repeat surgery is doing much better and ready for discharge (with the anticipation that she will receive her surgery in the next couple of months). The boy with hemorrhagic cystitis is still having a significant urine output, although now it is no longer grossly bloody. The urine output was measured at 2.5 liters in one day (well above the usual 500mL – 1 liter usual for an adult), but unfortunately his intake was not measured at the same time. So the volume of his output is difficult to evaluate. We cannot test his urine electrolytes, making the workup even more challenging. At the very least he is improving. The boy with scrofula (who is being treated with an appropriate anti-TB regimen despite the fact that the medical director never showed up to approve of my dosing) is also doing better. My friend with the finger cellulitis has been discharged over the weekend, as has the girl with newly diagnosed diabetes.

Instead I find a child with an enlarged liver, an enlarged spleen, fevers and pancytopenia. I am concerned about leukemia and lymphoma. While I am examining him he starts having a seizure. Fortunately it stops on its own. I immediately consider the necessary workup. I have no way of measuring his oxygen saturation, but I have no reason to believe hypoxemia to be the cause. I can get an immediate blood glucose level – 115 – certainly not the cause of his seizure. I ask my colleague if there is any chance of getting serum electrolyte results within an hour. He reassures me that it’s possible. In the mean time I decide to perform a lumbar puncture and start treatment for meningitis. It is highly unusual for me to stop rounds in order to do a procedure. But given his neutropenia and the paucity of antibiotics I have to choose from, I don’t want to delay treatment.

We finally move on to the other end of the hallway. In the last room at the end are the three children being treated for active pulmonary TB. It is less than ideal to have them all in one room together, but better than having each of them in a room with other susceptible children.

Unfortunately, over the weekend the ward ran out of beds and a couple more patients were added to this room. One girl appears to have a dental abscess. The other, severe cellulitis. The infection looks like it started on her knee and has spread up and down the leg from there. There is something about this one that I find unsettling. Maybe it is the nature of the skin discoloration or the severity of her pain, but I am worried that the antibiotics we have might not be enough. I ask about a surgical consult and am told that tomorrow morning is a possibility. I don’t want to wait that long and am told that potentially this afternoon we can get someone to come by and take a look at her. I draw a line around the area of erythema, sigh, and move on.

At this point we are given the results of the serum electrolytes I ordered on the child who seized!!! Hallelujah! It truly feels like a miracle. I ordered STAT labs and was actually able to get them STAT. But I do not have much time to rejoice. The boy’s potassium is low. Not low enough to cause a cardiac arrhythmia (and certainly not the cause of the seizures), but low enough that I want to start supplementation right away. The other abnormality is the boy’s calcium. At 6.8 (corrected to 5.9 once his albumin level was available) it is certainly low enough to have been the cause of his seizure. We need to get some calcium into him right away.

When I ask about my options for electrolyte supplementation no one is certain of what is available. After a few minutes of hemming and hawing I decide to go to the pharmacy myself. When I show up and explain briefly why I am there I am told to have the charge nurse call instead. I repeat that a child has just had a seizure on the ward from a low calcium level and I need to get some calcium into him urgently. Can I please find out what is available? The woman initially shows me potassium chloride?!?! While this is something I need, it is not calcium. After a brief argument about whether KCl is potassium or calcium, I notice a box labeled “calcium gluconate” on the shelf. Aha! I ask if there is any other calcium supplement available – like an oral form. She insists that there is not. While I hate giving calcium through a peripheral IV due to the nasty burns it causes if the IV infiltrates, I am satisfied that at least I can treat the cause of the boy’s seizures. With five vials in hand I head back to the ward.

Unfortunately the charge nurse is both wary of IV calcium (as he should be) and busy recording all the orders written on the patients on one end of the hallway. Can we discuss this later?, he asks. I try to explain again that this child had a seizure a little while ago because his calcium level was too low. This is not something that can wait until “later.” (Why do I continually have to explain the urgency of this?) He is not happy about it, but I think in order to get me out of his hair, he brings me to another nurse and tells her to follow my orders.

Right after the nurse changes the IV site, before we can do anything else, the child seizes again. Again the seizure stops spontaneously after less than 90 seconds. We then start giving the calcium. I try to tell the nurse that it needs to be very slow. And she acts like she understands me. But she pushes the first portion in faster than I would like.

At this point I’m a little freaked out. At home one of the charge nurses won’t even let me give pharmacy-approved IV calcium supplementation to children on monitors on her floor. She insists on sending them up to a higher level of care first. And here I am without any monitors, let alone any means of correcting a problem were I to detect one, with a nurse who is pushing a calcium bolus faster than I’m comfortable with. I don’t even know if the fluid is supposed to be diluted first.

I take a deep breath and watch as the nurse delivers the rest of prescribed dose. I try to tell her to go more slowly, but it doesn’t take. At this point all I can do is keep my every sense focused on this child, watching him breath, feeling his heart beat, tuning in to his every movement, and pray that nothing bad happens. He seems to get through the whole bolus alive. The nurse draws the rest of the labs I’ve ordered since finding out the electrolyte results and sets up the child’s IV fluid with potassium in it. I really wish I could give him an oral supplementation to help increase the level faster, safely. But I try to be thankful for the few options I do have.

At this point the surgeon walks in. My colleague had actually gone and found him and told him to come to the ward now. When we find the patient with the bad leg infection I notice that it has already spread beyond the borders I drew maybe half an hour earlier. Unfortunately the surgeon does not find this fact nearly as alarming as I do. He does not feel any fluctuance and reassures himself that her distal pulses are strong. He decides she does not need surgery.

I think back to accounts I have read about patients with necrotizing fasciitis written by a surgeon in the U.S. I remember him stating that sometimes there was nothing specific on the patient’s exam to tip a surgeon off to the disastrous nature of the infection he or she was harboring; that sometimes a doctor had to rely on intuition to make the correct diagnosis. I want to mention this to the surgeon and tell him that my intuition is screaming at me that this child’s leg isn’t right. But I have learned enough in my time here to know that would be useless. I wish I could get an MRI of the leg to be more certain. Instead I accept his advice to continue the current antibiotic regimen (which does not include my top two choices in such a situation), to start anti-inflammatory medication and order splinting of the leg and elevation of the foot. I add in a few blood tests as well.

I wish I could say that the fun ended here.

Instead, after lunch I decide to check on the medication record for the patient who seized earlier in the morning. I don’t usually do this, but for some reason I want to make sure the calcium supplementation was recorded correctly. Thank goodness I checked! The nurse had transcribed the order as 5mL of potassium boluses every 6 hours (not the calcium I had ordered) – easily enough potassium to cause a fatal cardiac arrhythmia in no time.

Unfortunately this is not the only mistake I find. I notice that the volume of potassium I had written for to be added to the maintenance IV fluid was incorrect. I wrote the dose correctly, but when I converted it to volume I totally screwed up. While a nurse in the US would have caught my error immediately (and if she didn’t certainly someone in the pharmacy would have), the nurses here are not in the practice of re-calculating medication doses (or thinking about what they are for that matter – IV potassium boluses every six hours!?! Ack!) Both mistakes are corrected and I heave a small sigh of relief.

The rest of the afternoon is relatively uneventful. We admit another girl with a finger cellulitis (related to the traditional henna tattooing, I think) after draining the abscess and sending it for culture. I prescribe finger soaks and IV antibiotics again, hoping that this will become routine treatment.

At this point I am glad the day is over.

It is a good thing that today was my last day. I don’t think my blood pressure could handle one more. I only hope that when the residency program starts in October that more changes will be made. And that somehow the children will survive in the mean time.