Friday, 5 April 2013

A sense of urgency - or not

Zimbabweans are "chill," "relaxed," often without a set schedule. It's nice. Until it's your patient.
There is an emergency system. That you pay for. These are private ambulances that may be covered by your employer or self-purchased insurance plan. 

Nonetheless, I have been struck by the general lack of urgency when it comes to very ill patients. Maybe it's because there are limited resources, it's easy to move slowly since it probably won't affect outcome. But, that's quite a pessimistic view. 

I have watched 2 patients die, and wondered if urgent care would have changed the outcome. One was in the casualty ward (ED) in the trauma bay (right). I happened to be eyeing a TBI patient next door, when I noted a 3rd year resident quietly asking the nurse for a functional Ambu bag. I meandered over and saw a patient with very shallow breaths. Unclear if there was a pulse. There was no crash cart. When I asked if he wanted to intubate, he responded, "it's too late" and there was apnea on the monitor. He asked the nurse to confirm absent breath sounds and covered the patient with the sterile, tan blanket. I inquired as to the history, and I got "obstructive uropathy;" the urologists placed a suprapubic cath and asked "physicians to see" = admit to medicine. No help there. He was moved back to the trauma bay with the nurses noted shallow breathing, and the admitting medicine physician was eventually called. Unclear what the delay was to arrival-at least 20 min. There is no loudspeaker, pager, or code team. The casualty officer (nurse) then informed the wife and son, and they cried out loud. I watched, and cried inside.

It felt like deja vu when I was looking for a resident, and instead found two clueless interns asking for help on a patient. "We are resuscitating (=coding), but we've never done it before." I stick around to ease their fear; remembering my ABCs. This time there is a crash cart and an Ambu bag. The patient has a pulse but has paradoxical breathing. There is no "sister" (nurse) in sight, and therefore no vitals except the pulse I ask the intern to keep a finger on. I run respiratory arrests out loud with the interns - fluid overload? PE? obstruction? They have no clue and just recite the history. 35 yo HIV+ ?TB, jaundiced/liver disease x 2 weeks, previously healthy, exam+abdominal fluid. I ask the nurse to give the diuretic ordered that the patient never received. Sister responds, "out of stock - you can ask the family to go buy it from private." In my mind, are you kidding me? We're in a code! BP? There is only one machine working and it's on another ward. CXR? Need to organize funds. EKG? Not sure where the key for the closet is. I step out to text the senior resident to get over here and offer some insight on how they handle these low resource codes - no response. I come back in and the tan blanket is covering his head. The patient is deceased. Sigh.

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