Only God Knows

I've just started rounds on surgery. The young girl operated on for perforated bowel secondary to Typhoid Fever is doing much better. She still has a drain in and we're doing dressing changes on the open wound on her skin incision but she's eating, drinking, walking, pooping and peeing so we are otherwise happy. Suddenly, Carson comes in and in his slow drawl tells me they need me to help find an IV on a kid...it's kind of urgent.

I walk through the open screen door, across the porch covered with convalescing patients and family members lying on colorful mats, across the well-swept courtyard and over to the sidewalk where a small crowd has gathered around a mother with a brightly colored head wrap holding a limp child sitting on a wooden chair facing away from me and towards the white coated nurse bent closely over the child trying to start an IV. It's the new nurse, Tchiptchang. Standing to the side, muscles bulging out of his scrubs, Abel holds a bottle of 5% glucose attached to an IV line waiting for the chance to attach it to a venous access.

I'm quickly filled in as I stride up.

"Really low blood sugar. Sick for a week. Treated at home with market meds and who knows what else. Just came in. Unconscious. We can't get an IV."

The kid's eyes are rolled back in his head. His hands and face are pale. His body is like a rag doll. I listen and he has a faint heart beat. He's barely breathing.

"Let's get him to the OR!"

We rush off around the corner and into the brightly lit OR prep room. We place the child on a gurney and I start doing chest compressions. Abel and Tchiptchang are trying to find a scalp vein. Carson is holding the IV which we have placed subcutaneously on his abdomen which is swelling up. He remains unconscious. I suggest they try and external jugular vein on his neck. Augustin arrives and tries as well. No success. I try a femoral vein on both sides while Abel and Carson take turns doing CPR. I fail on both sides.

The nurses keep trying on the scalp and neck. No luck. I call for another hemoglobin as I can't believe the first one is really 10. He looks too pale. His heart is still beating, though barely. We keep on CPR. He's about 2 1/2 years old. His mom stands in the background, a helpless and hopeless expression on her face. She's probably thinking of all the other small boys she's seen buried in her life and thinking about probably burying hers today.

I'm thinking back to the 4 year old I was just doing similar, unsuccessful, resuscitation efforts on last week. I'm about ready to stop. The hemoglobin comes back 8. We keep on CPR. The nurses keep trying to find an IV. I finally try the right femoral vein again.

I stretch out the skin on his inner thigh. I feel for a pulse but find nothing. I poke blindly with a 22G IV catheter attached to a syringe I aspirate from. I get some dark blood back. I can't really thread the catheter. I take out the needle. No blood. I slowly pull it back until the blood starts to ooze out. I call for the IV tubing and attach the 5% glucose solution and hold the IV to let it run in fast. We tape it down but someone has to hold it just so in order for it to work. Within 30 seconds, the boy's eyes open. A few seconds later he's looking around and starting to move his limbs. He has a strong heart beat and is breathing!

We give him some oral sugar water and show the mom how to keep giving him that all day long.

We let the glucose run in. The nurses finally find a real IV and we start treatment for malaria. Why do some make it and some don't? Only God knows.

James