Where Do You Go?

Written by Dr. Doug Boudreau, pediatrician

Monday, November 8, 2010

Woodley "Jeff" Meriska is a chubby 8-month-old with big cheeks and short braids all over his head. We have had an easy morning in clinic and are about to head up for lunch when Jeff is rushed into my room. He is having a seizure. His arms and legs are shaking rhythmically and his eyes are rolled back in his head. His mom says that he's never had a seizure before, that over the last 3 days he's had a fever and a cough, but this morning when she went to get him, he was doing this shaking. That is bad news because it means that he is in status epilepticus or uncontrolled seizure. Short seizures, less than five minutes, are usually harmless, but the longer they go on, the more ominous they are. Status epilepticus for more than 45 minutes has a 90% mortality rate.
Jeff comes to us after more than 4 hours of seizure.

The first order of business is to stop the seizure. Chantel loads him with the anti-seizure medicine Dilantin by intramuscular injection because Jeff is a difficult IV stick. Then Burney Miller, one of our two anesthesiologists, gets an external jugular line in, and we give Jeff Versed, a different anti-seizure medicine. The seizure stops. Jeff, though, isn't looking good. He is posturing, meaning that his body is stuck in a rigid position, a sign that all is not well with his brain. He also has very tight "crunchy" breath sounds. We suspect pneumonia and/or meningitis. We don't have a way to check for either. No X-ray or spinal taps are available so we give him antibiotics just because we want to start treating again. A little while later, he starts to go into a seizure again, so we give him another dose of Versed. This again quiets the seizure, but between his lung problems and the seizure medications, he deteriorates and starts to need more support for his breathing. Now we are bag-mask ventilating. He doesn't improve, so we intubate him. Dr. Lori Borella, our anesthesiologist, gets in an endotracheal tube with considerable difficulty. She later tells me it's the most difficult pediatric airway she remembers. He still does not oxygenate very well, so we give him some more seizure medication and a muscle relaxer. We continue hand ventilating him for a while.

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In the meantime, we discuss where we might go to get some more help. We finally get word that we might find some help at a hospital run by University of Miami on the other side of Port-au-Prince, an hour and a half drive away. We pack him up in an ambulance run by the local Mennonite Mission and we are off.

Rush-hour traffic in Port-au-Prince is an experience in itself, cars and trucks and motorcycles and pedestrians everywhere, continuously cutting each other off, merging in, suddenly stopping. Our ambulance driver, Matt, seemed very mild-mannered and calm, but he drove like a madman, very skillfully, but fast, sliding the ambulance into spaces and changing lanes with inches of clearance. The traffic does not respect the flashing lights and sirens, but it yields to the sheer daring of the driver.

Hand or bag ventilating means that we are essentially breathing for Jeff. If we don't compress the bag rhythmically, he doesn't breathe. I find that after about an hour I don't have to think about ventilating him. My hand has fallen into a rhythm and is working on its own. We have to put a little tension on the tube to keep it from obstructing, and we have to guard Jeff from the constant bumps and swerves. We plow through Port-au Prince, car by car, intersection by intersection, and finally arrive at the Miami Hospital. As soon as we open the doors, the head shaking starts. They need to check. Who did you talk to when you called? Doctors and nurses walk past the ambulance, glance in, and then avoid eye contact. Some do stop, talk with us briefly, and regard Jeff with sad eyes.

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Finally, Autumn, the acting Chief Medical Officer, appears and tells us that they can't help us, that we'll have to try a different hospital, Petits Freres et Soeurs, a pediatric hospital that we already sort of passed on the way and one that has been less that helpful to our teams in the past.

We have been hand ventilating Jeff for 2 hours. My forearm starts to ache. My hand starts to cramp. Sabine, Erika, and Chantel start to take turns. Erika, who we met just last night, is a nurse from Santiam Memorial Hospital in Stayton, Oregon. She and Chantel watch Jeff tirelessly though both are, to an extent, carsick. Sabine talks to Jeff's father, who has come with us. Jeff has a 5-year-old sister. He is the only boy.

Forty-five minutes later, we are in Petits Freres et Soeurs. The doctor there is not pleased, but we are arriving with an intubated baby and we are nearly out of oxygen. We get a bed in the ER. We look around, and there are desperately ill children around us everywhere with IVs and oxygen tubes. None are as sick as Jeff. The doctor says that they have one ventilator, and she will have to check to see if it is being used. Forty-five minutes later, she gives us a choice. There is no available ventilator. We can stay there and hand ventilate Jeff ourselves, teach the father to do it, or take him somewhere else. As soon as they swap out our oxygen tanks, we leave. They agreed to give us oxygen, we think, to get rid of us. We have been hand ventilating Jeff for 4 hours, by far the longest I've ever gone. Thirty minutes later, we arrive at the third hospital. Sabine goes in. We don't take Jeff inside, but just continue to take care of him in the ambulance. Ten minutes later we have our answer. Our only other option is the General Hospital of Port-au-Prince. No one wants to go there. We head back to Fond Parisien.

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Matt explains that this is all too common in his work. He is here on a one-year mission as part of the Mennonite church.

We arrive back at the Haitian Christian Mission. We have been hand ventilating Jeff for 6 1/2 hours. He is starting to wake up. Inside, as he wakes up and starts to fight the bagging, I have a decision to make. I know his lungs are compromised. I know he's had some sort of brain insult. I don't know the severity of either, and I have no way of knowing except for what my eyes, ears, and hands tell me. My preference would be to keep him intubated, on a ventilator, and follow him with serial x-rays and measure his blood levels of carbon dioxide and oxygen. I don't have that open to me. The other option is to give up my secure airway and see what he'll do on his own. It's possible that he will do better on his own.

We watch him. He is vigorous, coughing. He opens his eyes and seems to be moving purposefully. I decide to extubate, to pull the tube. We are excited. He looks good. He is keeping his oxygen level up. We had hand bagged him nearly 8 hours. I watch him for a time, then head to bed, planning on taking the 2 a.m. to 6 a.m. shift. If anything goes wrong in the middle of the night, someone will wake me anyway. Maybe now I can get 3 hours of sleep. I am tired.

Jeff is tired, too. His lungs are very stiff, and it takes all his strength to breathe. Then his strength is gone. I am writing this blog, when they come and get me. I rush down.

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Lori has been watching him. As he tired out, he went into respiratory failure. Jeff simply couldn't keep up with the work involved. Lori tells me she tried to intubate again, but was unsuccessful. We are back to hand bagging, with a mask, to keep him alive. His lungs are bad. Where do we go from here? There is nowhere to go. I knew that this was a better than average possibility when I started this. Jeff, if there was ever a time to rally, buddy, this is it. I stroke his cheek. His skin is so soft. Chantel comes down. She was going to sleep until the 2 a.m. shift. She looks at my face and tears start to well up. I look around, everyone who has been involved with this baby all day is around the bed--Lori, Sabine, Chantel, Erika, and me. "Does anyone have any other ideas?" No one does. We continue to hand ventilate, to bag. The father goes to get the mother. Our plan is to continue bagging until the parents get back, so they can hold him. We bag. At this point, if I could will that my life would transfer into his body, I'd do it. The parents aren't back. We bag. Jeff's oxygen level starts to decrease, slowly but inexorably. I can't bring myself to stop bagging while his heart is beating. We disconnect the tubes, the monitors. I continue bagging. Chantel periodically checks his heart rate and calls out the number. No miracle is coming. The parents have not returned. We disconnect the oxygen. Chantel listens and calls out the number. Then she listens and just shakes her head. I listen. There is no heart beat. "Time?" "11:17pm."

We spend a lot of time holding him. We talk about the day, what went right, what went wrong, what was frustrating. Sabine tells us that the father said he was very grateful that we were there. That he could see how frustrated we were and how much we cared. We talk, holding him, waiting for the parents to come back. Finally, we need to go to sleep. It's 2 a.m. and there are patients in the morning. We wrap Jeff carefully and place him into an incubator in a quiet corner of the hospital.

We find out in the morning that the father came in about 3 a.m. and took him home. He was grateful.

Woodley "Jeff" Meriska March 1st, 2010-November 8th, 2010.