Sunday, October 14, 2007

Sick Children

Last night I did a rotation in the Pediatric ICU at the MCG Children's Hospital. While it was extremely educational, I have to say it was a rather heartbreaking experience. I don't believe I have seen anyone as sick as some of these kids anywhere that I've been. It was like the SICU the other night - very high acuity all the way around. But the other side of this is the care that the docs and nurses give these children is also extremely good. Plus while I was there I got to be another pair of hands on a trauma patient that came in while I was there, and that was extremely gratifying for me.

I worked with three different nurses: Tricia, who was there when I arrived, Missy, her relief, and Jennifer, one of the other nurses who was on the unit during my rotation. All were awesome, and Missy and Jennifer were a riot; they were both outgoing and direct, which I liked a lot. They kept apologizing to me whenever they would swear - my response put them right at ease. All I told them was that in my part of the world everyone has a potty mouth, and they eased right up with me. They also thought that was pretty funny because they seemed to know that it's true.....

I got directly involved with three of the patients there. One, the first one I was with, is a three month-old male with an anoxic brain injury. I didn't get the whole story as to how it happened, but this child had been down for a while before he was brought in. He has some level of brain swelling as one of the drugs he was getting is Mannitol, an osmotic diuretic whose mechanism of action is to work on reducing edema in cerebral tissue. The action is different than that of a loop diuretic which acts on the kidneys, and it isn't indicated where bleeding in the brain is present. Poor kid was intubated, had a Foley catheter in place (the smallest catheter I'd ever seen, but I was assured that there are smaller ones out there), a central line, lots of monitoring. He definitely had a brain injury condition going on as he would intermittently posture and shiver. I don't know what the outcome will be for this child, but I suspect it won't be good.

The second is a nearly three year-old male with a congenital heart defect. He had a two-wire pacemaker inserted; apparently his heart's pacing ability is somehow compromised and the pacemaker is something he's going to have to live with unless he can get a transplant. Fortunately his outcome is looking good; although he is on multiple drips and has pleural drains in place for now (both of which are doing their jobs) he is awake and alert, the drains should be coming out soon, and from what I'm told his condition has improved immensely since his surgery. The major complaint he was dealing with last night was some abdominal pain - he had a CT scan done on his belly before I arrived, and what they found was bowel impaction, likely due to the pain medication he had been receiving. I believe they were working out a plan of care to deal with that. I got to talk with the family a bit; very good, hard-working people just like most of the rest of us, just really worried about their child and making sure he gets what he needs. That's what it's all about.

Last one was the trauma I mentioned earlier. Approximately 7:30 last night an 11 year-old male was brought onto the unit from the ED. He'd been flown in from approximately 60 miles away. Front seat restrained passenger involved in an MVC. Vehicle went off the road into scrub. Mother was driving, 21 weeks pregnant, apparently in the midst of having a mis-carriage. Vehicle was crossing the center line, our patient grabbed the wheel and pulled the car back onto their side of the road. From what came up in the report, if he hadn't done that the vehicle would either have been hit head-on by oncoming traffic or they would have rolled. Either way, I suspect his action saved both his and his mother's lives. He had some significant injuries, including 5 fractured ribs, a laceration to his liver, and a mediastinal hematoma which caused the attending ED physician to order a CT scan to his chest so as to rule out a tear to his aorta. If he'd had that, I suspect he would have gone to the OR first, but he came to us. He was boarded and collared and in a lot of pain. His CSM status was good, present and equal in all 4 extremities, pupils equal and reactive to light, no loss of consciousness on scene. He was awake, alert, and oriented to person, place, and time, and he was in a moderate amount of pain and very anxious about his mom. He had two IV's in place, clear breath sounds with no sign of paradoxical movement to his chest, able to follow commands and answer questions with no difficulty. He was a real trooper as he did everything that we asked him to do and didn't cry. His grandparents arrived not long after we got him situated, and he was glad to see them. We also got him off of the board not long after he came in, but they had to keep the collar as he hadn't been completely cleared up to that point. That didn't make sense to me as I would have thought he'd be cleared before coming to us. My inclination is to think that they needed the extra precaution, for whatever reason....

Anyway, I got out of there at just after Midnight, and it was a pretty intense shift done there. It has given me a lot to think about, in terms of how I consider care of my pediatric patients when I get them. This whole experience so far as really made me think hard about the way I provide care and how I can do it differently and better. But isn't that what doing stuff like this is all about? Re-thinking your perspective on care and how to provide it better? I think it is. And it is working for me.

Now - I'm going back to the books to read more about the pathophysiology of shock. Then it's a review of the flight physiology and stressors that we did this past Friday. Most of the weekend has been spent reviewing what we've done. This coming week will include skills and cadaver lab and more clinical time. I'll keep posting as sharing what I learn is helping me to retain it.

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