Pediatric Advanced Life Support, and Reporters: Just another day . . .

I am mentally exhausted this evening, but as I think back on the day, I realize it contains just the mix of raw life-and-death and bizarre circumstance that I appreciate about being a missionary.  The day dawned grey after all-night rain, so my new friend Dr. Emily and I grabbed umbrellas and made our way through the muddy streets towards Nyahuka.  I rarely walk:  my bike is my usual mode of motion, but that was not so fair to Emily.  And I enjoyed the slower pace, the greetings along the way, stopping in at CSB, hugs to Justine who has completely transformed the library (Annelise's vision realized at last), hearty palm-shifting hand-shakes with staff, enquiries about my family.  At last we reached the hospital.  In spite of earlier quiet, Asusi warned me the ward was filling up.  But with her and Balyejukia, and Nathan and Emily, we began to work our way through.  Nice to have another pediatrician to discuss cases with, a fresh young American academic perspective.  Asusi and Balyejukia also know what they are doing, a strong team, and I tried to keep affirming the excellent decisions they had made in my absence.  Dr. Emily has begun to research the diagnosis of TB in children, a subject dear to my heart, and we had a couple of perfect examples of the challenge of sorting out a malnourished child's root problem.  We were just deciding to put a 4.9 kg (10 pound) 3 year old twin with Sickle Cell anemia back on TB therapy (she had defaulted a year ago), when a family carried in their limp and unconscious infant.  Balyejukia quietly called me over, with the words "this is a hopeless case".

Well, as it turned out, he was right.  Let me begin by saying that 6-week old Tumwine did die at about noon today, probably because he had begun convulsing during the night and the flooded river made it impossible for his family to reach the hospital until mid morning.  But rather than feeling helpless and discouraged, I was left with a sense of marvel that our little primitive ward and team functioned so professionally.  Because I had just re-certified in PALS (Pediatric Advanced Life Support), it all seemed so familiar.  Bounding peripheral pulses with mottled skin and a 7 to 8 second capillary refill:  distributive shock, most likely septic.  Gasping respirations, cool, unconscious, critical.  We jumped into ICU mode, and my team was amazing.  I didn't even get to try one of my new spiff intraosseous needles because Balyejukia was so quick with the IV access.  Thanks to several lectures on septic shock I didn't hesitate to push hard on fluids.  We had ambu-bags from Heidi's nurse friends, and Emily assisted the child's breathing throughout the almost two hours of hard work.  Fluids, dextrose, antibiotics, oxygen, epinephrine, an ng tube, labs, and prayer.  Airway, breathing, circulation.  Whenever his heart rate dropped, and sometimes stopped, Emily and I would do CPR for a minute or less and he'd come back.  Asusi was ready with every medicine, and corrected one of my dosing orders, which I thanked her for (which is a nurse-doctor scene straight from the PALS text).  OK I did have to dig up money for fuel and oil to get the hospital generator started to hum the oxygen concentrator to life, but it DID hum to life.  Sadly, though the baby's circulation improved, he never woke up, and over the course of the second hour his pupils stopped responding to light, until they were fixed and dilated, a sign of irreversible brain damage.  At that point we had done cpr numerous times, and it was taking longer to get his heart back each time.  I decided to do a lumbar puncture, more to have a head start on anyone else who became ill in the family than to hope to save this baby.  The cerebrospinal fluid was grossly bloody.  A hemorrhagic infection, or trauma?  Either way not a problem we could cure.  I am thankful God provided Emily that day, as we had to make the hard decision eventually to let him go.  The next time his heart stopped, we continued oxygen and waited a minute.  Nothing.  His grandmother, resigned, accepted our condolences.  We removed the tubes and wrapped his little body.

And then walked out into a ward that was filled with reporters and cameras.  Yes, Nyahuka Health Center, in the news.  Tomorrow World Food Program is sponsoring the launch of a new educational push to draw attention and action towards the problem of chronic undernutrition in Bundibugyo.  I believe that this is a direct result of Stephanie Jilcott and Scott Ickes' advocacy and research.  Several teams of people from Kampala, UNICEF and WFP, have come out to investigate, to talk to us, to ponder the fact that 45% of kids in Bundibugyo are stunted in their growth because they suffer hunger.  Almost half.  The impact is devastating, but quiet, felt in poor school performance, in lethargy, in sorrow.  Ahead of tomorrow's major launching party to-do, WFP brought reporters.  And so we suddenly found ourselves answering questions for the New Vision, the Monitor, the Independent, while Uganda TV cameras rolled.  A bit flustering.  I tried to remember the important stuff, emphasize social issues, team work, multi-factorial causation necessitating creative holistic approaches, education for girls, etc . . . but who knows what I actually said and how it will come out.  Bewildered parents who agreed to talk had their photos snapped a dozen times or more, with their skinny scabby kids.  

Last patient of the day, patiently waiting until the ward quieted down mid-afternoon, an HIV-infected mom on anti-retroviral therapy,  with a not-yet-infected baby, deciding to wean.  Thanks to the conference I had good data for her on this issue, and a more scientific and reasonable assessment of her risks, which are GREATER for weaning (death of the child from infection and diarrhea and malnutrition) than for continuing to breast feed (death from AIDS).  She still wanted to wean, so we affirmed her choice.  And prayed for her, and talked about her life, too.

So, a crazy day, but not so unusual.  Families in crisis, looking for help.  Opportunities to pray, to offer advice, to teach, to advocate, to emphasize, to protect.  Individual tiny important lives, in the balance.  An entire society, also in the balance, pondering big cultural questions of family unity and responsibility and the impact of adult decisions on child survival.  Jesus reached people through their concern for their kids, children who convulsed, who had fevers, who died, whose parents came to him in their time of sorrow.  I'm glad to be a small part of a good team of Ugandans and missionaries doing the same.