Priorities

So, it’s been an incredibly busy and challenging week. One of the things I’ve struggled with this week is how people prioritize who will get their limited time and attention.

For instance, this evening a 1 month old baby came into the hospital very badly dehydrated and possibly septic (systemic infection – very serious.) Her mother has abandoned her, and the grandparents have been feeding her soup for the past 20 days. She looked very close to dying.

I began working on her admission right away, and asked a nurse to get an IV started immediately so we could give fluids and antibiotics. She rolled her eyes but started the IV – not an easy task in such a dehydrated baby. Even though the nurses here are great at starting IVs, it took her many tries, and several minutes. I thanked her and asked if we could get the antibiotics for this patient before she began administering the evening medications for the other (more stable) patients in the unit. She said yes, but then turned around and began stacking up some charts so she could begin giving out those medications. I began to give the baby a fluid bolus to help resuscitate her, but her IV stopped working very shortly after I began. When I let the nurse know, she just waved me off, saying “Tale, tale.” “Soon, soon.” That is the standard “I’ll get to it later” reply here.

I spent the next hour and a half working with E, my translator, and A, a physician/housemate who had stopped by the unit to see if I was ready to leave. A wound up being of great assistance, but she was really taken aback by the craziness of the situation. We did our best to get the IV working (unsuccessful), established an IO (interosseous) using an 18-gauge needle but it too stopped working after a few minutes (and the needle bent when I tried to re-establish it), then A inserted a femoral line (central line inserted in the groin) which worked great until we tried to tape it in place. The tape we had wasn’t very sticky, and the line fell out nearly as soon as we were done securing it.

All that is to say that after all of our many attempts to get fluids into this dehydrated baby who didn’t have a functioning IV or any medication, the nurse was still calmly administering medications to some of the least sick patients in the pediatrics unit. I finally sent A to ask for the antibiotics so I could give them IM (intra-muscularly – directly into the thigh muscle in this case) myself. The nurse who’d been waving us off finally brought the medications over, handed them to me, and watched me administer them. Unimpressed, she immediately turned and went back to her work, continuing to ignore my sick patient’s IV trouble. We reminded her one last time that the patient needed an IV, then had to leave for the day. (Transportation sometimes dictates when we stay/go a bit more than I’d like, but I’d been at the hospital for ~11 hours – an eternity in Haiti time.)

It’s not that the nurse didn’t care about my patient, she just had other priorities. Her goal was to get through administering all of the medications that she had to administer. She couldn’t take a step back and see that there was something more important to do in that moment – a sicker patient who needed her attention just then. I’ve run up against that way of thinking many times this week. We can be actively resuscitating a patient, but the nurses may just decide they’re too busy to help out.

I don’t want to sound like I’m picking on the nurses – it’s not just them. We have a new Family Practice residency program starting here, and the residents started working in the hospital this week. One of them was helping resuscitate a baby yesterday (a full code – chest compressions, bagging the baby, etc.) and his phone started ringing as he was gathering the materials to aid in the resuscitation. He stopped, answered it, and was having a nice chat until I waved my arms at him, reminding him that we were trying to save a baby’s life!

V, the other pediatrician here, is also similarly casual about urgent situations – he walked casually into one of the rooms on Monday and said to me “We have a baby with a temperature of zero in room G!” I asked what he meant, and he kind of laughed and shrugged, saying one of the babies was apneic. I took off for the next room, where E and L helped me resuscitate the baby. V did come to the bedside eventually, helped for a minute or two, then wandered off to see some outpatients. (That baby recovered fully after a brief but full resuscitation. Can’t have only depressing patient tales here.)

I just don’t understand how someone can see a baby stop breathing and not have the urgent “Call a code!” response that’s been drilled into us in my training in the US. One of my goals for my time here is to work on a system for “calling a code” to alert people to an emergent situation and to raise awareness re: what the appropriate response to an emergency might be. I imagine that folks here might see me as too fixated on babies who are “clearly” beyond the point of rescue, but then there are the kids like the one I mentioned in the previous paragraph – they do recover, and they do fine. I think every kid deserves a shot at that, no matter how “inconvenient” their crisis.

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3 Comments

  1. Sara,
    I can’t imagine how terrible life is for your patients and staff. Your positive attitude and willingness to incourage the staff to treat a life as the number one priority, has got to rub off on some of them. God Bless, we’re so proud of you and your work.

    Uncle Dick

    Reply
  2. Mom

     /  February 3, 2012

    Sara
    I continue to be amazed at your insight into the difficult situation there. You have the ability to assess the crisis & not reinvent the wheel, but rather remove the bumps on it. A reflection of years of good training. I hope that the staff there will be receptive to your ideas and implement some of them.
    Dad & I are so so proud of you for all that you are accomplishing. Be safe!
    Love, Mom

    Reply
  3. Thank you both! It is nice to be able to make a follow up post today which reflects some of that change I wrote of hoping for in this post. It gives me hope for my time here.

    Reply

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