Where there is a will...

August 06, 2018

Where there is a will...

You’ll all be delighted to know that things get a little bit lighter in this post. Had to lay it on thick to get you all interested.

As always, the weekend flew in this week. Of note, I attended my first gospel church session. You can just imagine. I was in my element – people were dancing in the aisles, there was laughing and clapping. Communion takes the form of a shot of grape juice and the traditional wafer. Certainly makes a difference from the Irish Catholicism I know so well. When we arrived (I went with friends from work), we were greeted by the pastor’s wife who promptly gave us all a big kiss on the lips. Again, you can imagine. Then continued two hours of all singing, all dancing praise. I was quite far removed from my comfort zone, but in the best way. We marched out of church laughing and smiling – that’s the way it should be.

In the afternoon I was invited out to a friend of a friend’s farm for the afternoon. They live about ten minutes outside town on an amazing plot of land not far from the Lesotho border. We climbed a hill on their land and the view was spectacular, we even had a sherry at the top. I’ve attached some photos below. We then rewarded ourselves with wine, ribs, and a wee Drambuie for the road, sure, you know yourself.

Monday morning came round with a bang again – walked into labour ward and found a baby grunting with a wet sounding chest. Oh here we go again you are thinking – this story has a good ending, so bear with.

A girl this time, had been born with shoulder dystocia – it’s when the shoulders of the baby get stuck in in the mother’s pelvis. I’ll say no more than that for fear of someone collapsing. This wee one had a fairly traumatic delivery and now had developed severe respiratory distress syndrome after inhaling meconium. She also had evidence of an ischaemic brain injury – much like my wee friend from earlier entries who I have told you about.

She was saturating at 88% on 8 litres and I could see secretions in her nose. I disconnected her and sucked a load of old meconium out of her nose and mouth. I got a bit of a fright here because she quickly desatted down to 50%. We won’t be trying that again. The baby needed intubated and ventilated so I called the referral hospital – usually our conversations fill me with such joy and inspiration I could hardly contain myself. (Sarcasm is the lowest form of wit but it is crucial to who I am as a person). Not surprisingly, they weren’t interested. No beds they said – and then the kicker ‘if she has HIE (hypoxic ischaemic encephalopathy) there won’t be much point in ventilating’. I.E. She’s already going to have challenges – why waste a bed on her. You can’t get too carried away demonising the doctor here – there are babies queuing up all over the place for precious NICU beds, no one means to be so elitist – but I turned the air blue when I put the phone down.

The baby was grizzly all day and constantly fighting the oxygen mask – her requirement was too much for nasal prongs which are less annoying. I asked one of the other docs to come and have a look – there’s safety in numbers and I respect her opinion entirely. We made a few changes to her fluids and optimised her antibiotics. I started her on anti-seizure medication and we sat back to see if she improved. She was holding her own today with sats of 90% on 10L via face mask but if she tired, which she inevitably will – there won’t be anything else for us to. Sorry, not good enough – it’s too much to watch a baby die just because there aren’t enough beds. There’s a reason why I made it all the way here so I got my thinking cap on.

The baby needed more pressure to push air into her lungs – CPAP. Basically its higher pressure oxygen which forces air in to the lungs which are blocked with fluid or infection or underdeveloped. When I was in Ethiopia for elective in 2015, we faced a similar problem and one of the paediatricians who was visiting from Aberdeen teamed up with a visiting engineer (again from good ol Aberdeen) and they made bubble CPAP for the NICU. In simple terms, it’s a circuit made up of an oxygen source, connected via tubing to the baby, with more tubing connecting the baby to an under water seal. The further down you push the end of the tube under the water, the higher the pressure. Sounds great doesn’t it? I really wanted to give it a go. (I apologise for my painfully basic explanations but my grasp of physics is about as good as my long jump).

There is a way to approach such things in this setting. I wasn’t going to make any friends by marching in with all these great ideas poking holes in the way my colleagues have been managing sick babies for years with ten times as experience as me, and ten times less equipment. I floated the idea with one of the neonatal sisters, who was 100% on board from the start. Of course she was. The enthusiasm of the staff here to improve and make things better never fails to astound me. We set about hoking in cupboards trying to find the things we need, all the while watching videos on YouTube over and over again trying to set it up. (Goodbye data – Vodacom are making a fortune off me).

We were struggling in the meantime to keep Lil Miss settled. She was grizzly and had this horrendous high-pitched cry. When I did Neonates (very briefly and in a very protected cuddly fashion) in FY2 we used to give the babies dextrose syrup before bloods or cannulas – it has an opioid effect on them when they are neonates. I asked the nurses about it today and they laughed. Not to worry – we made our own by raiding the tea trolley and making a syrup. Ten minutes later our little friend was much more settled and licking her lips from the sugary treat. Another win.

By 1800, with the assistance of some distilled water from the operating theatre – a complete, leak – free CPAP circuit had been constructed. We connected Lil Miss up to it and her sats went from 88% on 10L to 95% on 5L. She had halved her 02 requirement and was much more comfortable with the prongs. She had less evidence of respiratory distress and things were looking up. At the same time – her teenage mother who had spent all day desperately trying to produce milk for her baby finally came up with the 20ml she needed for her two hourly feeds. There was whooping, and singing and hugging in the NNU tonight. (I have however written my details in the notes in capitals and underlined in red and want to be phoned overnight if any issues – because if you can’t be a control freak in this situation then when can you).

Not to make you all sick with happiness – but our other little man with HIE and respiratory distress made a miraculous recovery over the weekend and I reluctantly let him go home today – reluctantly, because looking at him and how much he has improved makes me feel like a total boss.

Some pics below of recent events, enjoy x