James
Our pediatric service has been unusually busy with difficult patients. Not as in uncooperative patients, but those with hard-to-diagnose or hard-to-treat illnesses. Today for a while our small ICU was getting seriously like a “real” ICU, with one patient having uncontrolled seizures, another just admitted for high fever and seizures, our “least critical” patient
(severely malnourished, 11 pound 9 month old with HIV) transferred to the ward. Then there was James, the most critical patient, where we spent a good part of the afternoon.
James has, we think, acute post-streptococcal glomerulonephritis, a severe immune reaction that is damaging his kidneys. He has been here since Sunday and was doing moderately well until today when he developed high blood pressure again, decreased urine output, and congestive heart failure. It was difficult and frustrating to stand by his bed for nearly two hours trying to hold the oxygen mask on his face while he was trying to tear it off, trying to position him over and over in a sitting position to help him breath, getting a suitable oxygen source, and trying to calm him.
I “texted” the head pediatrician at the university hospital (JUTH) about the possible need for dialysis, would they be able to do it? I got a quick answer and half an hour later a real pediatric nephrologist was at the bedside. Isn’t it a great feeling when you can get a specialist when you’re over your head? In fact, Dr. Ocheke arrived so soon because he was already on his way to church, something you wouldn’t expect your nephrologist in the US to be doing Friday afternoon.
We had a good discussion about James’ problems. The bad news is that, although Dr. Ocheke was willing to dialyze James, he doesn’t have any of the needed peritoneal dialysis catheters. Still, he said he might be able to get one from Lagos in the next day or two.
(While I was just finishing writing this at midnight, I got the idea of giving James morphine, which is sometimes useful in congestive heart failure. I called the ward to see how he was doing, and gave the morphine order to the nurse. I’ve never seen morphine used here, but I had heard we now have it at the hospital. The nurse called back 5 min later, though, saying that there isn’t any in the hospital. Dr. Tina Slusher had left some Nubain with us, though, so I went down to the ward, found it, and gave it to the house officer to try on James. It’s good the HO was there since I didn’t have my glasses and couldn’t read a word of the prescribing information … we’ll see if it helps James sleep, at least. While in the ICU I took the chance to get these photos. I also ran into James’ parents, who were walking around the grounds, and who asked me to explain what his problem was. In all the rush today we hadn’t talked to them. So I explained briefly, then told them that we were also praying for him.)