Never work with children or animals...

I found this saved on my desktop from a few weeks ago which i forgot to post! Enjoy! 

Wow this may be the fifth time I’ve sat down to try and write a blog entry in the past few weeks! Hopefully this one makes it online.

December and January have been crazy busy! I’m writing to you now from somewhere above northern Iraq – I’m flying back from the UK after a very brief visit for interviews for ‘after Africa’ whatever that may entail. More on that later.

So much has happened as usual since my last entry, I feel guilty for not writing sooner as everything gets jumbled up in the frenzy of caesareans, amputations and hectic on call shifts.

I’ll try and go as chronologically as I can through my adventures in December and January – the main theme sticking out seems to be that things just got busier and busier until we might explode – and then I had a week of leave to look forward to . Seven flights in seven days – I may be more tired than I was before I left?! Thanks to omnipresent Whatsapp, turns out the hospital was out of sight, but not out of mind. Cries of ‘need assistance in casualty please’ will be haunting me in my sleep for the foreseeable future, it seems as if there would be no relent to the battering we took from the influx of relatives coming back for the festive season. Echoes of NHS bed pressures came back with at one point us having a backlog of patients in A+E waiting on beds – I have to admit that the absence of any murderous patient flow co-ordinators clutching clipboards was welcomed.

We plowed on through December with the promise of some relief over the festive season, but the eventual appearance of the rota meant that the on call assault continued. I was on call Christmas and New Year and every other day in between. I counselled myself that this is why we’re here – to work and learn but come on what happened to the unspoken British curtesy of doing one and not the other?! (Christmas OR NY, not both!) Now a few weeks the other side of said rota, reflecting back I had a blast – we’ve amped up our ballsy approach to trauma and resus x 1000, but I’ll get to that in a bit.

My lovely little paediatric ward was not so lovely at all during December. It became jam packed with patients, each morning I found another more sick patient to make me forget about the previous day’s disaster. Long gone were weekends heading to the coast – the reality of the out of hours shifts in this hospital mean that inpatients are left to fend for themselves – so alas, Saturday mornings became more damage control for me, despite technically being off (wow – when did I become such a martyr!).

My main project in December was a little munchkin who was 8 months old and admitted with malnutrition. In total, she spent four weeks on the ward, and two of weeks that entailed thrice daily reviews with me basically stalking the paediatricians in the referral hospital for help. I cried twice down the phone (NOONE TELL SURGICAL RECRUITMENT – I’ll deny it all) and still she wasn’t accepted for transfer. To read the progression of my despair in the medical notes was particularly unsettling. Malnutrition in this country is truly horrific. The combination of infectious diseases, poverty and poor education of mothers about infant feeding means that we had 8 children within 4 weeks admitted with complications of malnutrition. Two have died. Two have new diagnoses of tuberculosis. One has been put into foster care after neglect. Meanwhile, I spend my afternoons counselling Diabetics and Hypertesive adults about obesity. It’s is staggering that within the same post code, indeed the same village that a toddler can die of not having enough to eat, whilst adults are dying of having too much.

Anyway back to my little one who is definitely the cause of the two grey hairs I’ve discovered this week. Her main issue was fluid balance. Children and babies with malnutrition have reduced body water through dehydration and their sodium rises, Okay so give them water you say. These children are acutely sensitive to fluids, and so for three days we had the white knuckle ride of flipflopping between hypovolaemic shock and fluid overload, despite the fluid boluses being less than 60ml each.

I could see her getting weaker and weaker, and the blood tests were becoming more and more deranged. Then her skin started to break down. We were following the protocol but she wasn’t getting better. No matter my best sales techniques, the referral hospital weren’t biting. I came as close to unprofessional as it comes on the phone to one of the consultants when I accused her of negligence – the baby was dying in front of me and all I was getting from my seniors in the referral hospital was ‘we have no ICU beds’ – the alternative to that is not district hospital! I spent days agonising over her, I counselled her Mum daily about what was going on and lo and behold eventually I got the sodium to turn around, the highest she reached was 188 (normal is 135-145). By the grace of god finally after four weeks of admission she was declared by the most senior nurse on the ward to be ‘haibo this one is fine!’ Sometimes I think these kids will have me in a straight jacket, but the sight of her plodding off into the veld on her mother’s back with her whole life ahead of her made me so very proud of how far we had come. I’ll see her again in two weeks to check things are still progressing well and I can’t wait!

I could write a book on the cases that we come across on Paediatrics – each one is more of a challenge than the last. I’d like to point out that in the UK, these children would be in intensive care with a team of specialist consultants treating them – this is what I remind myself when I’m working out what doses to give a 6 month old with Tuberculosis, or indeed this month when treating a baby for CMV Pneumonia (an infection which attacks the immunocompromised). This child was HIV Positive – the grandchild of a traditional healer, her parents were instructed not to give her the ARV treatment to protect her from contracting the HIV virus form her mother. As a result, she’s HIV positive, has spent her entire life in hospital including 6 weeks in ICU and will have to take medication for the rest of her life.

One of the challenges in Paediatrics (in my opinion) is respecting the cultural beliefs of my patinets with regards to traditional healing, and also protecting the rights of the children. December brought with it a nasty strain of gastroenteritis – I had 6 differnet children admitted with it. One of them passed away from complications in ICU a week after we transferred them out – 10 years old, a complete tragedy.

Unfortunately one of the traditional treatments used for AGE (Acute gastroenteritis) is a ‘Sunlight’ enema. This is the instillation of washing up liquid into the anus of babies and children. Of all of the children who die of AGE in our area, most of them have had this treatment. Other prescriptions include potions containing shoe polish, bleach and various other household chemicals. I ask for samples to be brought to me every time a child is admitted but unfortunately none have appeared. The electrolyte imbalances and fluid losses from these treatments are often fatal unless the child is brought to hospital promptly. In the last hour before I went on annual leave a mother came running into casualty clutching her dead 12 month old daughter in her arms. One week of AGE coupled with herbal intoxication had caused her to die of a combination of hypovolaemic shock and sepsis. It shouldn’t happen and it never gets easier. We tried for 40 minutes to revive her, but the senior charge nurse took one look at her on arrival and set the ‘dead on arrival’ record book on the side of the resuscitation trolley for me to complete.

We did have quite a few victories on the ward though, it is definitely not all doom and gloom! My superstar baby who has been an inpatient for more than half of her life with partial thickness hot water burns has finally healed! No more dressings for her and she’s now ready to go to the orphanage. Even happy endings are tinged with sadness here, I shall probably warrant some sedation when they come to take her away – four months on the ward and she is definitely beloved by every one of us.

One of our AGE babies who had such severe electrolyte derangement on admission it was not compatible with life went home this month too! She’s a miracle. I checked her blood results and almost threw up before finding her sitting quite the thing, if as dry as a stick. She was so sick on admission that we couldn’t get an IV line to give her fluids. I pressed a needle into the bone marrow of her leg and we rehydrated her that way. These babies are hardcore.

That seems like a bit of a whistlestop run down of Paeds this month, I’ll leave the festive on call run down for the next post!

See evidence below - I did leave the hospital eventually!

Local propaganda?

Official TBH Christmas Party 

Pre Christmas Festivities at my house