Thursday 2 February 2012

Jazz Thursday

    Before I get into the details of today, I wanted to mention two stories that the medical people reading this might enjoy. The first is fresh in my mind since it happened just this morning. As you recall, I was on-call for the ICU last night. Well, you may remember that Joe and I each intubated a patient before coming home to finish the blog (patients in ICU beds 1 and 2). I laid down to get some rest, and slept pretty well until my pager went off at 4am. "302" read the notice (a standard non-urgent ICU page). "I shouldn't have to run in for this," I thought as I made my way to the phone. The phone conversation went something like this:

bring bring
ICU Nurse: "Hello, this Kijabe ICU."
Me: "Hey, this is Brett."
ICU Nurse: "Yes Dr. Campbell, I calling because of patient in bed 1 has low saturations."
Me: "Okay, how low are they?"
ICU Nurse: "Yes, they are 88 now."
Me: "What's the ventilator FiO2 set on?"
ICU Nurse: "Yes, The patient is on 10 liters"
Me: "Okay, I... wait, they are on what?"
ICU Nurse: "Yes, 10 liters facemask"
Me: "Why are they on a facemask if they're intubated?"
ICU Nurse: "So, the patient pull the tube earlier."
Me: "Oh, the patient self-extubated earlier tonight and they are desaturating now?"
ICU Nurse: "Yes."
Me: "Okay, I'll come in and put the tube back in."
ICU Nurse: "Okay"

    Awesome. Apparently, self-extubation in an unstable patient isn't a warning flag for them. I got involved in a few other ICU issues in addition to the reintubation when I went in, and didn't get back to bed at home till 5:30am (then woke up an hour later for work). But before I get into today, the SECOND fun story:

    So you will recall our patient from two days ago that we decided to electively intubate in the ICU after putting a PIV in per the request of the medicine team. You will also recall that this elective intubation resulted in non-elective hypoxic bradycardia, CPR, and death a day later. Well sometimes the strangest, almost hilarious things happen in those terrible situations. In this case, we had a bunch of people around us when we were preparing to intubate her. Everything was laid out in proper fashion, there were multiple levels of back-up plans, and the only confounding thing about the pre-intubation checklist was the fact that the pulse-ox did not work (not unheard of in Kijabe). Moments before we induced, Joe noticed a lab tech trying to draw admission labs from her arm. Recognizing that Airway comes before Labs, he kindly asked the tech to step aside until we could secure the airway, which the tech then did. The airway, of course, devolved into chaos with two people struggling to intubate, and bradycardia followed. The student nurse anesthetists finally succeeded in intubation, but we recognized pulseless electrical activity with a heart rate in the low 30s, and began chest compressions. Joe took the first shift, and I took over when I had gloves on. Joe was calling for resuscitation meds while I scanned around the area to make sure my compressions were adequate. First, my eyes settled on the student anesthetist who had struggled to intubate. As is often the case, he was giving big breaths 30-35 times per minute (way to fast for CPR). I told him that he needed to only give 6-8 breaths every minute as having the lungs inflated would hurt my ability to compress the heart. He complied. Next, my eyes settled on the pulse-ox, which was now working and showing a sat of 98%. "This indicated distal perfusion, which means that I'm doing good chest compressions." I pointed out to the group in attendance (there's never a bad time to educate). Finally, my eyes came to rest on the patient's right arm (which was kind of under me, so I hadn't noticed it before). On that arm was a tourniquet. Distal to that tourniquet was a tech, furiously trying to get labs from a patient during CPR. I guess he had taken us seriously when we told him to get labs after we had secured the airway... We quickly dismissed him again.

    Ok, so a little less sleep than I expected, but we gave a second lecture to the ICU nurses this morning about mechanical ventilation. It went as well as could be expected, though they still seem very intimidated by us (perhaps if Joe would stop brandishing his Maasai spear during the talk?). We finished the talk and went to close out our accounts from our time here. While in the Director's Office, Steve Letchford (the main guy here at Kijabe Hospital so much as told us that we should become long-term missionaries because we have done such a good job. I took a picture of Joe waiting in line to pay, and promptly got reprimanded by a hospital guard (apparently he doesn't know just how many pictures I've taken here so far).

"Corporate Accounts Payable. Nina speaking... Just a moment."

    We celebrated our new-found liberation from our money with, you guessed it... Mandazi.

Calm down, dopaminergic pathways... you'll be sated in a few seconds.

I took this picture in the cafeteria... Sound advice.

    We did a handful of blocks in the OR today before getting tangled up in other things (Joe in an airway for another organophospate poisoning in Casualty, and I in a pre-op for a sick liver patient). We got Joe's patient settled in the unit before returning to the OR where we BOTH got tangled up in a bad cranial tumor case. Dr. Albright said it was the first time in this long career that he had ever seen a middle cerebral artery burst upon opening the dura. Believe it or not, we extubated the patient in the ICU, but he won't do well tonight (we were just trying to give him a chance to say goodbye to his family). We finished the day in the OR with Joe doing evaluation feedback for the remainder of the student anesthetists, and I (somehow) doing a case independently (I thought I had attending status here). We came home to Rob and Jonathon preparing for a meal with Susan and Nora to celebrate Rob's journey back to Nashville tomorrow.

The aftermath of Rob's fruit-cutting

...Which I guess makes this the math of Rob's fruit-cutting.
He's a man possessed.

    We walked over to Dr. Newton's house, and he drove us up to RVA so Joe could play piano with the Jazz Band for the campus. It turned into an all-out schooling, as Joe proceeded to create looks of amazement on every face in the house. He even got a casual job offer from the band director (who seemed to know less than Joe about jazz (not surprisingly). Be sure to ask to see the video I took when I get back.

Joe: "That's cute, but no, I don't think you will ever be quite as good"

One of Dr. Newton's kids watching from the balcony. 
Seriously, Joe had these kids excited about Jazz. It was fun to watch.

    We came back home and ate with the ladies, and are leaving a huge pile of dishes for the cleaning personnel tomorrow. No, I don't feel guilty. I do, however, feel bad about breaking a chair that I leaned to far back on...

There's the chair in the immediate foreground...
Oh Tobias the chair, if only I could have saved you...

   Before I go to bed, I also wanted to mention that this morning when I went back in to intubate, I ran into Moses from the last post (of course) on my way. Sadly, instead of just a friendly hello, he told me how he has decided that Joe and I were sent to him by God to help support his family financially because his house had burned down 5 years ago. Why does everyone here think that I should be the bread-winner for their family?

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