Just another day in casualty

I’ve said before that no two days in the ER or in casualty are the same…it’s one of the things that I love about my job. This past week added two more very memorable and unique days to my ever growing list.

Wednesday started like many other days. The morning was a bit on the slow side and coming back from lunch I expected to see things picking up (that’s usually when our day becomes busy). As I walked in, all the beds were full and we had a couple patients in chairs between the beds (not an uncommon scene at all). My focus quickly turned to three new patients along the same wall. One was a small child (9 months) who was a little small for his age. He appeared lethargic and had a concerning respiratory pattern. Next to him was a boy around 4-5 years old who was in status epilepticus (continuous seizures). A nurse was busy trying to get IV access to provide medications (some had already been given rectally but the seizures had not broken). Next to him was a woman in her 40s who appeared ill. My clinical officer informed me that she had fevers, headache and neck stiffness so he was preparing to perform an LP (spinal tap).

Since the woman appeared the least acute, I left my CO to deal with her. The seizing child was being cared for and hopefully would soon have IV access so I moved to the other boy. As I examined him in more detail, I found out that he had been vomiting and had diarrhea for the past couple days and then was reported to have had a seizure several hours ago. He hadn’t fully woken up since then. As I watched, I noticed that he was having periods of apnea (stopped breathing) for up to 10 seconds. His oxygen saturation was subsequently much lower than what is normal. I made some phone calls as we prepared to intubate. As our respiratory therapist (RT) began to bag, his sats improved but he remained minimally responsive. Next to him, nurses continued to struggle obtaining IV access so we paged for the pediatrician to come to casualty and lend a hand.

That’s when I heard my RT yelling for me that there was a problem with the woman who had the headache. The LP attempt was unsuccessful and as my CO was preparing supplies to try again, she went into fulminant pulmonary edema. I’ll spare you the details but those who have seen it know how dramatic it can be and this was one of the worst I have seen. At that point, we called for the other casualty physician to return (he had also been at lunch). When we lost pulses, we initiated CPR. I’m guessing that other calls may have been made because soon we had interns from peds and medicine services along with a medical consultant and our third casualty physician reporting. As we coded this woman, who only minutes ago had been talking with us, we had one of the most frustrating experiences I have had yet in casualty. She was in a shockable rhythm so we charged the defribrillator and as I hit the shock button….nothing. Repeated attempts…nothing. I still am not sure what the problem was but it soon became clear that this machine was not going to do what we needed it to. Thankfully, only a couple weeks prior, we had received a donation of AEDs (automated external defibrillator)…the type you see in malls and other public places throughout the U.S. A nursing student sprinted to the nearest location where we had placed one and a few minutes later we were able to deliver the shocks the other machine had failed to give. Sadly, despite our efforts, we were unable to successfully resuscitate her. Later we found out that she was the mama of five children and a relative of one of the men who help to run a local orphanage.

Upon returning to the 9 month old boy, I found that he still was having episodes of apnea so we attempted intubation. As soon as I placed the laryngoscope blade in his mouth, his eyes shot open and he began breathing with more regularity. We decided to watch him and see if he would still require intubation. (He never did and I’m told his condition has since improved.) As our resuscitation efforts were proceeding, the peds team was able to secure a line, give appropriate medications and break the seizures.

On Thursday, we were able to convene the disaster preparedness committee (due to other commitments, it had been months since our last meeting). Our primary focus was finalizing Tenwek’s MCI (mass casualty incident) response plan. A two hour discussion resulted in an almost completed document and clear direction for us over the next several months as we prepare for the next MCI incident at Tenwek. Little did we know we would get a chance to work through parts of the plan in only a few hours.

As we were preparing to have our chai break, our head nurse notified me of two potential MCIs close to Tenwek. One was a car accident with 7 victims (unknown ages/conditions). The other was the collapse of a tunnel where 4-5 workers were buried. Immediately we began clearing out casualty, notifying appropriate individuals and preparing supplies not knowing how many patients we would receive or the conditions they would be in. (I know with my EMS training I may be a bit biased but I sure do miss my prehospital colleagues!!) As time passed and little additional information was coming in, we continued seeing other patients while trying to keep ourselves ready for a potential influx of patients.

Later we found out that a young man we had been caring for throughout the morning was actually one the the victims from the accident (we thought he was from an unrelated accident). He came from another nearby hospital with a report of abdominal trauma and a positive DPL (a study checking for internal abdominal injury). I performed a FAST exam which showed that he had a large volume of fluid in his abdomen (after an accident, you have to assume that it’s blood). His blood pressure was trending down slowly but other than a complaint of mild abdominal discomfort, he appeared pretty good. Long story short, when my surgical colleague took him to theatre, he found injury to his mesentery along with 2 liters of blood in his abdomen. I’m still not sure how he looked so good with that volume of blood outside of his vasculature.

As our day continued, those on the scene of the tunnel collapse requested supplies and personnel from Tenwek. Again, I really miss my first responders. While my hospital staff and those on scene did their best, lack of supplies, equipment and training makes these scenes difficult to manage effectively. After a couple of hours, they were able to free one of the victims. Thankfully other than hypothermia, superficial injuries and psychological trauma, he was fine. Sadly the same cannot be said for the rest of those involved. By the end of the day, two bodies were recovered but an additional four remained buried. This morning in church we were told that efforts are still continuing to find the remaining victims.

By the end of the day, Tenwek only received two out of the potential 12+ victims. But it gave us a chance to implement our plan and I have to say that I’m proud of the team here and how everyone worked together to prepare for what could have been.

As I mentioned, during our preparations, we continued seeing other patients. One was another victim of a motorbike accident. He had an impressive dislocation of his right foot/ankle. (I’ve attached a picture at the end of the post. If you have a weak stomach, you may not want to look at it.) Surprisingly his pulses were intact, he still had sensation in his foot/toes and he retained some motor function. After a quick reduction, he was taken to theatre for wash out and fixation.

Another patient presented to outpatient and was found to have a skull fracture with pneumocephalus (air in his skull). He was been seen at another facility the day before when he was assaulted and struck in the head. His laceration was repaired and he was sent home. Today he presented because he had lost the ability to speak. His CT was pretty impressive showing a 2 cm depressed skull fracture.

 

 

 

 

Thank you for your prayers during our interviews for new interns. Hours of traveling, several days away and many interviews later, we are hopeful that we have chosen a good class of CO and MO interns for next year. Now we are praying that government postings go smoothly and there will be no issues with receiving those we have chosen.

 

Quick update on the home front.  (Steph’s last blog was pretty complete.)  The boys continue to grow up way too fast.  They thoroughly enjoy “working out” with daddy.  Pretty sure they are more of a distraction than anything but it’s great!

 

 

 

 

 

 

 

 

 

As Steph mentioned, candy and costumes abounded on Friday here as we had Tenwek’s Halloween celebration.  Noah insisted that I shave his head again so I could then paint him so he looked like Darth Vader even under his mask.  (On a side note, he has an impressive reverse tan where the scalp tattoo was from the last time.)  All of the kids had a blast as did the adults.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

And I have to post my DYI home improvement project.  I really miss having a Lowe’s nearby and I REALLY miss my tool bag.  DYI is exceedingly difficult without either of these.  Thankfully a friend (who Steph met online) recently came to Kenya on a mission trip and brought a lot of supplies and goodies for us.  Included was a shower head that we ordered.  Not surprisingly, it didn’t fit correctly.  Thankfully the saw on my leatherman came to the rescue and we now have a new shower head.  Still learning to be thankful for the little things!

 

Prayer requests:
1. Please pray for the prison ministry here. Church today focused on this vital outreach. Pray that those involved in this ministry will be strengthened and that their ministry will bear much fruit. Pray for us as we seek guidance on how to support, become involved with this ministry.

2. Another cardiac team has arrived and will begin operating soon. They are currently going over ~100 pediatric patient files trying to determine which ones (only about 12-15) will be chosen for operative repair. Pray for wisdom in their decisions and endurance during the long hours ahead of them. Pray also that through this time that the children and their relatives will clearly see the gospel in action.

3. Pray the for victims of the tunnel collapse and for their families. Pray also for the community as this has understandably been a devastating event.

4. Continue praying for us as the holidays approach. I know that the past couple weeks have been difficult for me. While I absolutely love “guy time” with my boys (wrestling, superheros and Legos), I have really been missing cuddles, tea time and dancing with my little girl. I’m sure that this will continue to be an area I struggle with.

 

 

 

Below is the picture I mentioned.  Again, consider yourself warned.