Prior to leaving for church, however, I was paged to Casualty (the ER) to admit a baby with a temp of 42 degrees Celsius. If you are like me, you don't know exactly how high that is, but you know it is higher than it should be. I pulled out the trusty Blackberry and discovered that 42 degrees Celsius is equivalent to 107.6 degrees Fahrenheit. (!!!!!) I rushed down the hill to Casualty with only a nod toward the security guards instead of the usual brief conversation that Kenyan courtesy dictates. I arrive in Casualty to find one of the new ER docs already working on getting blood, urine, and spinal fluid, leaving me to obtain the history from the parents and get admission orders and notes done. Being just a few days old, the baby would be admitted to the nursery for further management after the labs were obtained. Unfortunately, by the time this was all done, it was too late to make it to church, so Amy and the kids went on their own (which left Amy to give the greeting).
Upon my arrival to the nursery, I found that one of the babies we had previously intubated and ventilated was having difficulty again. He had been doing well with CPAP since he was extubated the last time. We had been working on gradually increasing his feed volume and he apparently had another aspiration event, which resulted in respiratory distress. He had deep subcostal and intercostal retractions despite a CPAP of 5 cm H20. I REALLY did not want to intubate him again and put him back on the ventilator. I decided to check his venous carbon dioxide level to confirm respiratory failure (blood gases are not available at Kijabe). The level was quite elevated, supporting my assessment. I decided to reintubate him, and he proved to be even more difficult to intubate this time. Fortunately, the ER doc had decided to come by the nursery to help with the intubation and we finally succeeded in intubating this baby for the second time in this admission.
In a previous post, I mentioned that this was a 28 week infant who had made it through his first 10 weeks or so without any surfactant, intubation, or ventilation. This was now my second intubation of him in my 3 weeks at Kijabe. I resolved that I would not extubate him before I left Kijabe in a couple of days; I was not going to intubate him a third time. After intubation, we decided to carry the baby to the ICU while bagging him, rather than try to maneuver an incubator through the halls and bagging at the same time. We set the baby up on the ventilator and he remained quite stable the rest of the time I was there (but I did NOT take him off the ventilator before leaving). HIs mother, the one who had said "please help my baby" before the first intubation, was understandably quite upset by the need for reintubation. I attempted to comfort her and assured her that I would be praying for her baby.
Much of the rest of my day and night were spent managing blood sugars on the diabetic child. There was a little disagreement between the surgery resident and the intern on pediatrics about whether the child with the huge encephalocele was septic or not and I was paged that night to try to settle the dispute. The pediatric opinion was that the child was not septic, but that the only way the erosions on her encephalocele would resolve would be for the surgeons to remove the whole thing. The pediatric intern proved to be correct, but the surgical resident was nowhere to be found to inform of this, so my involvement in the dispute was unnecessary. I will confess that I was thankful that I was not on call Monday night, so that I could finally have some uninterrupted sleep.
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