We get back to the call room around 3am. I am aware that if I fall asleep immediately, I can get almost 2 hours of sleep, barring any problems, until I need to do my next round. Of course, I cannot fall asleep. I have been up since 9am, and have been at work since 2pm. And I won't leave work until sometime past 6pm. I guestimate that I am somewhere at the half-way mark of of my shift. Aside from trying to figure out how many hours of work I have left, I am making a mental note of things I need to look into. Why is our 35 year old male who his HIV+, with a low CD4 count, and who has Guillian Barre syndrome having high potassium levels? Why is our 20 year old female who delivered a term baby boy a few days ago having severe pulmonary hypertension.
The night has been a doozy. We are short one resident/registrar. I am covering the pediatric ICU patients , and the medical ICU patients, and the other resident is covering the surgical ICU and the step down ICU patients. Needless to say, we are taking a moderate beating.
And then the phone rings. My thoughts grind to a halt.
"ICU"
"Eh, Dokotela, um, there is a pediatric admission here."
"What?"
"We didn't know about a pediatric admission."
"Neither did I!"
Since we are short-staffed, of doctors, and barely hanging on, we are actually trying to not take admissions tonight. We're evaluating potential admission on a case-by-case basis. I have been on the phone with the trauma surgery resident on-call and have helped them manage a patient who may need ICU in the morning, and I have been on the phone with the obstetrics residents helping them manage a patient a well, but technically we have not accepted any patients for admission. However, there was one sick kiddo in the pediatric admission ward, but he sounded ok earlier on, and we hadn't agreed to accept any kids.
"Eh dokotela, can you come quick."
"Sure."
I grab my stethoscope and glasses off the desk, and the other resident and I head into the ICU. It takes a minute for the scene to register in my brain. On opening the doors to the ICU, I see across the ICU, one of the pediatric residents that I know, doing CPR on a child--on a child, on a gurney in the middle of the ICU. I am a little perplexed. Well, more than a little. Quite frankly, I can't figure out what the fuck is going on. I quickly look to my three kids in the ICU, who are all asleep in their beds. I get to the gurney, and it is a newborn size baby being resuscitated. My brain goes into resuscitation mode. The details which lead to this point are completely irrelevant. I want to know those details, but I'll get them later.
The child is intubated. I relieve the pediatric resident from doing CPR as I slip my two hands around the child, and use my thumbs to and fingers to compress the thorax, hoping to generate enough blood flow to perfuse the vital organs.
"He came in tonight."
I'm compressing, seeing the heart rate on the monitor. The heart rate that is being generated by my hands. "Epi please." She calls out the dose of adrenaline. I'm using North American terminology. She is translating, and giving the doses.
"2 weeks old. Took some muti [traditional medicines]. Very sick on admissions."
He's easy to do CPR on. The nurses and I are synced. He's not trying to give the baby a breath while I am compressing the chest. "Labs."
"Severely hypernatremic [sodium too high] and shocked. We're worried about Congenital Adrenal Hyperplasia."
"He's the right age. How much fluids? Can we give bicarb please. Has he had steroids?" She tells me how much fluids he has had. I'm going to give him more. This is a gorgeous infant. It sucks he is going to die. He has this adorable curly black hair.
"How much?"
"40 per kilo."
She and I review. We give calcium to try and correct for high potassium. Sugars were fine. I stop doing my chest compressions There is no longer a rhythm when I stop. 20 minutes ago, when we started, there were some heart beats, but now they are gone. I look at this child. His skin is mottled.
And I realize, that I have to make the call.
"Does anybody else have any suggestions?" I look to all of the nurses present. I look to the pediatric resident. I look to my co-resident in the ICU.
This is one of the first lessons I ever learned in medicine. And it took me a while to understand this lesson. It was February 1994. I was doing my first Emergency Department clinical as an EMT student. One of my friends and I had signed up for a Sunday night shift. And it was off to a painfully slow start. And then the ambulance phone rang, and the report was a cardiac arrest coming in, due to arrive in a few minutes. This is what you wanted as an EMT student, to see some "action" on the clinical. We stood outside the room as they wheeled the guy into the ER resuscitation room and tried to revive this man. And then the firefighter doing CPR had pointed to me and told me it was my turn to do CPR, I froze. This didn't seem like the time to learn how to do CPR on a real person. The guy was sick, and needed somebody who actually knew how do to CPR.
After what felt like an eternity of doing CPR, I remember the ER attending doctor saying she thought we'd done all that we could, and then she asked "does anybody else have any suggestions."
And I'm sure my eyes nearly popped out of my socket. For, at the time, I remember thinking that she was the "doctor" and should very well know what the hell to do. And in time, I realized that it was a courtesy measure to see if the entire team was in agreement that an adequate resuscitation attempt had been done.
So, I asked the team in the ICU for other suggestions But I balked at the responsibility of actually making the decision to stop the resuscitation efforts. I knew that nothing would bring this child back to life; but only doing resuscitation for 20 minutes seemed pathetically short. A 2 week old child, who was alive shortly ago was now going to be declared medically deceased, and was I willing to decide this after 20 minutes in our ICU. I asked the reg who her consultant was. Turns out she is on my old ward, and I knew the consultant would feel we had done an proper resuscitation given the circumstances, of which she'd been informed earlier when this child first showed up for admission. So the resident called the attending who was updated on the events, and the course of our resuscitation attempts, and she was in agreement that the resuscitation attempts should be stopped.
"Can we please stop." And a silence fell over the unit. Alarms beeped in the background, but silence fell as there was a collective sense of loss. I thanked the team for their help in the resuscitation (another lesson I learned that February night). I examined the child from head to toe. "Sorry nana."
I would have never thought that, 15 years ago, on that February night, that I would someday find myself in Soweto, resuscitating a 2 week old newborn male, having a flashback to Dr S and the first resuscitation I had ever seen...
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