Operation Malawi part
2
Monday, September 2:
I need to begin this by starting with last night. Last night around 2200 I got a call from
Shymol stating that there was a vent in the ICU now, asking if I would come
in. So I said sure, I’ll be there as
soon as I can. So I go in and take a
look at the ventilator and all the settings were good (Dr. Saunders and I had
already discussed initial vent setting and such). I talked to him about the plan and the
history (patient had been drinking a little too much, vomited, and developed
aspiration pneumonia) of the pt and everything looked good for now, so I went
back to where I was staying. This
morning I went in and the pt was doing OK at best. Oxygenation was good. But we were still suctioning out a lot of
secretions. He was also sounding very
tight and wheezy, I would have sworn that he smoked but family kept denying
that he smoked. We got a gas and it showed
metabolic acidosis with partial respiratory compensation. So Dr. Saunders and I talked and decided to
start him on Salbutomol and Methylprednisolone. The question was how were we going to give
the Salbutomol? I couldn't find any
t-piece adaptors for a nebulizer. I did,
however find an in-line spacer. So I
taught them how to give an MDI in-line with the ventilator. I also got to go more in depth in the
ventilator education with the nursing staff.
Now they could see the ventilator working on a patient and put together
the settings with what they mean. Now
they could see how they affect the patient.
I was able to see a lot of light bulbs turning on and that was
AWESOME. I also worked with them on
suctioning technique (bizzing the patient to loosen up secretions) and started
teaching them breath sounds and how to properly listen to the patient. I stressed to them the importance of securing
the ETT when repositioning the patient and suctioning. Though something that did drive me nuts, and
I didn't say anything to them about it because there really isn't anything that
they can do about it, is that they don't practice sterile suctioning and they
re-use the same catheters. The reason
for this is due to cost and to preserve equipment. So I didn't even bother trying to fight that
fight.
Tuesday and Wednesday, September 3-4:
These three days were pretty much spent all
doing the same thing. I was sitting in
the ICU helping to take care of the ventilator patient. I kept going over with the nursing staff
about listening the breath sounds, taught them how to do ventilator checks on a
flow-sheet that goes in the chart (they actually already had one, they were
just inconsistent with it because they didn’t know what it was for and what
they were writing down), suctioning and care of and minding the ETT. It was amazing seeing the information click
in their heads. I also had them teach
each other, every time a new shift would come in I had the old shift teach
them. It was awesome seeing the info
click and seeing them share it with their co-workers. I also spent this time teaching the nursing
staff about non-invasive ventilation.
The ventilators that they have actually have non-invasive mode on it,
and I was asked to try and figure out how to use it and teach them how to use
it. They had been having problems with
patient comfort and synchrony. So I
figured that out for them and taught the nursing staff how to use it and how to
care for a patient on non-invasive ventilation.
I even made them all put the mask on and discover how it feels to be
placed on non-invasive so that they could understand how the patient feels and
why they may fight it. The only issue I
was having is that for some reason the machine kept cycling itself when it
shouldn’t have been. I will have to work
on that some more to figure out what was going on there. On Wednesday, September 4, a team from Loma
Linda University Medical Center’s Emergency Department arrived, though nobody
got the meet them till Thursday.
Thursday, September 5:
Today, the morning went pretty much like the rest of the week did. Went to the ICU to and helped to take care of
the vent patient. He is coming along
very well and I am having a blast taking care of him and teaching the nursing
staff to take better care of him. I also
got to meet the team from Loma Linda, they seem very nice. Anyways, this morning when I went in the
patient was on CPAP, Dr. Saunders just wanted to see how well he would do. He seemed to do pretty good and we kept him
on it most of the morning. In the
afternoon I was asked to do another CPD class.
This one was on trach care. They
had asked the trach patient to come in special just for this class so that I
could teach the nursing staff how to do trach care and what special precautions
are needed when taking care of a patient with a trach. The issue here was that my demo patient was
late in arriving so I had to kill time talking and trying to get them to ask
questions. I even resorted drawing a
neck on the white board and demonstrating trach care on the white board. But my patient finally arrived and we got it
done. It was awesome being able to see
things click with them. Right before the
CPD, though, Shymol and I were called to the ED to help take care of a critical
patient that had arrived from an outside clinic. We arrived to a patient that was unresponsive
doing Biot’s respirations. He was just
responsive enough to take the oral airway out and occasionally pulling on the
NRB mask. They kept trying to put the
oral airway back in, finally I was able to convince them not to. It was obvious that he still had a patent
airway and didn’t need it, plus if he kept pulling it out that means that he
may still have a gag reflex. So I ran to
get a nasal trumpet and put it in to make everyone feel better. He was so clamped down, though, that we
couldn’t get a SpO2 reading on him anywhere and it was very difficult to get a
peripheral pulse and blood pressure on him.
When I got done with the CPD we went back to the ICU and the stroke
patient was in there with the Loma Linda team working on him. I was talking to Dr. Saunders and he told me
that normally in this case they would just provide palliative care and let the
patient pass. There was really nothing
they could do for him, didn’t have the right supplies/equipment or the
knowledge to take care of his condition.
The CT scanner was down so they couldn’t do a scan to find out if it was
hemorrhagic or a clot. Plus the patient
was HIV+, not that it makes a difference, but that means that the patient
likely had other issues going on as well.
Though they were letting the residents from Loma Linda do what they
could for him just for the experience and so they could say they tried to save
him. Anyways, they were trying to put a
central line in him. It took them a long
time, but they did finally get one in him.
The entire time, every time they would get it, it would immediately clot
off. It was no wonder he stroked
out.
Friday, September 6:
Today I arrived in the ICU to see that our stroke patient had passed in
the night. It was expected. The vent patient that we had been taking care
of all week was on CPAP/PS again, and doing amazingly. I started experimenting with the vent and
looking at how it did respiratory mechanics to get weaning parameters. This vent is able to do the RSBI, VC and
NIF. Though it had a little quirk that
the only way it would calculate the RSBI was to turn off the pressure support
and leave the patient on CPAP without any pressure support. I didn’t really care for that, but I did it
just to see how well he would do. He
actually tolerated it for a while. Then
he started to putter out and started to breathe fast and shallow. So I put the pressure support back on. That helped a little bit, but not
enough. So we started to suction, and he
was rather difficult to bag and we weren’t able to pass the suction
catheter. We had to bizz (they were
still having a difficult time grasping that concept) and he ended up hacking a
big ole mucous plug into the bag. It was
AWESOME! After that we suctioned him out
a little bit more then let him rest for a few more hours. At this point in time I was getting nervous,
and I think Shymol was getting nervous as well.
I was getting nervous because I felt that my credibility with the
nursing staff and physicians was on the line.
Shymol was nervous because her reputation and the reputation of the
hospital was on the line with the community that this patient was a part of
(they don’t trust the hospital and the care provided, even though it is the
best hospital in the country. Being from
India, they were used to first world care).
Later that afternoon we decided to risk it and extubate him. Turns out there was a huge dried mucous plug
at the bend of the tube that causing him his problems. Shymol was getting on the nurses pointing it
out to them saying that this was why they needed to suction and why suctioning
was important. Placed the patient on a
mask initially and quickly weaned him down to a cannula. I don’t know much about what the Loma Linda
team was doing today, other than teaching BLS classes to the nursing
staff. I was able to attend a little bit
of one of the classes. They were doing a
good job.
Sabbath, September 7:
Went to church today. But after
church there was a huge gathering at one of the physician’s houses. The pediatrician, Dr. Varona, invited a lot
of people, new people old people, birthday people, pretty much everybody, over
to her house for Sabbath Potluck. Also
today Dr. Priester returned from South Africa where she was attending at
continuing ed conference the past week and a half. It was fun eating good food (not hospital
food) and fellow-shipping with everyone.
Week Recap: This week
was much better. I felt like I was
finally doing what I was there to do: teach and help take care of
patients. I had fun this week doing what
I love to do. I really do need to thank
and God for helping me get through the slump I was feeling during the first
week and Jewel for putting up with me and helping me through that first
week. I also need to thank Shymol for
helping me into this week and helping to instill confidence into her nursing
staff so that would trust me.
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