Sunday, Bloody Sunday

I went to the hospital today to check on a few patients. I was horrified at what I found.

I saw one patient who has one of the worst cases of cellulitis I have ever seen. In fact, I’m still wondering if she has osteomyelitis. I asked if she was still soaking her finger daily in hot, aseptic water as I had prescribed (I knew that two or three times per day was too much to ask for). It turns out that the surgical ward is closed on Sundays. And sterile gauze is not available on the medical floors. So she would have been unable to re-wrap her finger if she removed the dressing. She would have to wait until tomorrow.

I then checked on the child with hydronephrosis and pyelonephritis. His father complained that he was not getting any medicine. I checked with the nurse. For some reason the order I wrote to start antibiotics a week ago was never transcribed to the medication sheet. He was receiving the medication that had been written for the day after admission for worms in his stool, but had not received one single dose of antibiotics for his pyelonephritis. Because he had been improving daily since admission I had no reason to suspect he was not receiving the treatment I ordered (which just goes to show that we probably don’t need a good portion of the antibiotics prescribed). I was ready to pull my hair out, wondering what had prompted me to come in in the first place.

Before I left the ward I was asked to see a “critical patient” who was admitted yesterday. I found a 4-year-old boy who appeared pale, somewhat listless and in severe pain. When I examined him it seemed most likely that he had inguinal cellulitis with associated lymphadenitis and possibly osteomyelitis or septic arthritis. But his abdomen was distended, he had decreased bowel sounds and was complaining of abdominal pain. As unlikely as it was, I was concerned that he might have an incarcerated inguinal hernia. But because it was Sunday he could not get the x-ray of his hip that had been ordered the day before (and never done). I decided to contact the surgeon on call and to give the boy some pain medication. But guess what! Because it was Sunday the pharmacy was closed and I could not get anything besides Tylenol for him.

At this point I was completely fed up. This was absurd. What happened to patients who were in accidents and came into the emergency department from off the street? No one seemed to know. I decided to visit the emergency department and see for myself.

Sometimes an ineffective, unorganized system works to your advantage. While I was waiting for the emergency department doctor to show up I wandered into the trauma bay. All the medications were sitting in an un-locked cabinet just waiting to be liberated. And liberate I did. I helped myself to some morphine and a strong NSAID as well as a medication to reverse an opiate over-dose, just in case. Eventually the doctor showed up. I told him that I was a pediatrician from the United States and that I had a patient on the ward whose finger wound I had drained who was in need of some sterile dressing. I received a nice full bag of sterile gauze and a pair of sterile gloves with a smile. And I was on my way.

After returning to the ward I set up the girl with the finger cellulitis to soak her finger. And I gave the boy with abdominal pain some morphine. But while I was waiting for the surgeon to show up the doctor who was actually on call and supposed to be responsible for these patients told me that a baby was being admitted to the NICU. He asked if I would come help him out. The child we admitted seemed to be doing ok. His mother had been admitted to the hospital for an infection, presumed to be due to retained placenta. And because the infant was found to be febrile he was admitted for a sepsis rule-out. Except they weren’t planning on getting any cultures. How can you possibly rule something out if you don’t test for it?!?!

At any rate, I soon noticed that in the crib next to the infant we were admitting was a severely jaundiced child. I have never before seen a baby who is bright yellow all the way down to the toes the way this child was. I looked in the chart and noticed that he had been transfused for anemia, but it did not appear that any workup for the anemia had ever been done. And I found no record of a single bilirubin level. I could not contain myself. Of course the lab was closed, because it was Sunday. So I had no way of knowing what the actual bilirubin level was. And I certainly did not want to perform an exchange transfusion unless I was absolutely certain that it was necessary. So I had phototherapy started and ordered a bilirubin level for first thing in the morning. How depressing. Because today is Sunday this infant will likely end up with cerebral palsy and deafness from something completely preventable.

At least I was able to relieve one child of his pain and help heal another. But these are truly small comforts in the grand scheme of things.

I know that the Sabbath is supposed to be a day of rest. But I don't understand how you can rest comfortably knowing that so many children are suffering.