Wednesday, February 13, 2013

Saving Kids

Its a big dangerous world out there.
I am not a pediatrician.  When I say that it feels like an apology, but when I was a young and ambitious medical student it didn't interest me.   I wanted to be knee deep in the blood and the guts and the action I’d seen every heroic TV doctor show.   Vaccines, runny noses, diarrhea and crying didn't seem like an exciting career path.   I considered children to be smaller, louder, less compliant and more annoying than adults (most adults).  I did, however, have to complete pediatric medical training.  My pediatric training was in 1984 in an old, busted, rundown children's hospital in Downtown Brooklyn, New York.  The most intense part of that training was the walk from the hospital entrance to the dark, unlit parking lot across Linden Boulevard.  The security guard would only guarantee my safety to the end of the handicapped ramp.  Sadly, the neighborhood has fallen on even harder times and the hospital has closed it's doors.  Last I heard it is now Kamal Singh's   Alcohol and Cigarette Emporium.  Times change.

All the pediatric medical equipement
you will ever need.
This is not to say that I am no good at taking care of sick children (especially if you   are one of the parents who bring their lovely children to my little paradise of a jungle clinic).  Like most people, having a child of my own gave me a greater appreciation for other children.  Also I've lost significant hearing over the last 20 years.  The screaming no longer fazes me.  I can work right through it.   At my clinic I’ve enforced the simple and effective  Happy Child  Protocol:  at first contact I give the child  a balloon  made from an inflated surgical glove.  Sometimes I draw a face on it.  Then I leave the room quickly before the injections start.  I didn't invent bribery and complicitness with children, but I'm a big fan of it.  My stock with the little ones has never been higher.

My clinic is the last line of defense in the middle of a remote and dangerous jungle in central Indonesia.  The company that runs this little piece of paradise has done an amazing job of creating a facade of relative comfort and civilization.  But make no mistake:   We are in a place of potential biological and physical disaster of massive proportion. The diseases and injuries that roll in daily that would challenge the clinical skills of any tertiary medical center in any Western country.  Dengue Fever, Malaria, Tuberculosis super-infections, heavy trauma and nonexistent prenatal  care are all just outside the gates.  The basic Indonesian diet is high in carbohydrates and oil. Too many people here are one plate of Nasi Goreng away from a heart attack.  Not one cardiac care center is closer than a two hour flight away.  And then there are the animals:  Vipers, Cobras, poisonous centipedes, flesh-destroying "Tomcat" bugs, rabid dogs and the scores of monkeys living outside our homes.  (Except for an occasional bite, the monkeys are not a source of clear and present danger, but they can be annoying.  Last week I left my car window open and a monkey had rifled through my console, stole a pack of mints and left  a big wet shit on my driver's seat.)

One uninvited Jungle Clinic visitor.  You
tell him to leave!
I believe that there are no great rewards in life without great personal tests.  That’s  why I took this job.  Instead of working in my friend’s Beverly Hills liposuction, botox and laser clinic I'm here slugging it out against the elements.  The pay is not great, the hours are long and generally my on-call schedule is listed as: ALWAYS.  Most of my American medical peers think I've lost my mind.   I submit to them that they've never really fully tested their medical skills, nor explored their personal limits.  I believe every doctor is obliged to do so at some point in their career.  Still, there are a lot of bad and dangerous things out there and if you decide to put yourself in harm's way, you better be able to do something about that harm.

Thus, the sick baby.

Every doctor has his or her own demon of worst case scenario. They run the gamut.  Least concerning, yet significant:   an office full of patients and your best (or only) nurse incapacitated with relentless diarrhea. Some believe the worst of the worst case scenarios is a violent mass casualty attack, too many victims or massive cases of dysentery.  My clinical crew and I have seen all of those things this year. We met the challenges and, frankly, did not lose much of sleep from them (though the Dysentery outbreak of 2011 did sacrifice many appetites).  My worst case scenario is a sick baby.  These are the cases that hit my soft pink underbelly like a nail pounded through a balloon. There are obvious, inherent difficulties in taking care of babies:  they are fragile, their parts are tiny and getting medicine into them is like trying to fill your gas tank through a cocktail straw.  They are helpless.  Add the emotional factor--especially when you have children of your own--and a sick baby is the perfect storm for disastrous outcome.

I never worried about sick children when I worked in Los Angeles.  Sick babies went to sick baby hospitals where the care was geared specifically for them.  They had small devices delivered by the hands of experienced clinicians   used to getting small things in small places in small people.  In Los Angeles my sick patients were always sick adults.  Here I don't have that luxury.  On this island we are the top of the food chain of referral clinics.  If the kids are sick on this island, they are coming here.  When we do have a child who is too sick to handle, the closest Pediatric hospital is one hour's flight by  seaplane or helicopter.  We have no commercial airport here.  We don’t even have a runway.  When we can arrange these special flights they can only be done during daylight hours.  Our planes and  choppers cannot fly after sundown.  No matter how sick you are, if you come here after dark you are ours until the morning.   Perfect storm.

One day last raining season our head nurse came to my office to report that a child was on the way to our Emergency Room. The child was coming from the local Pukesmas in Sekongkang,  the village next to ours.    Puskesmas means “general clinic” in Indonesian.  These clinics are generally quite basic and unprepared for serious emergencies.  The child was too sick to be managed there.  Sekongkang is only fifteen minutes from our camp so things were about to happen fast and furious.    I try to stay positive and generally not assume the worst case scenario in life, but it has become part of the job here.  We’d already experienced this type of case at our clinic.   I knew that if they were sending  a sick child, they might be sending him  too late.

Bad News X-ray
Four months earlier we’d gotten a similar call from the same clinic.  They were sending over a five year old boy they could no longer  manage.  We waited for a long time for him to arrive.  The roads are generally bad, but worse, slower
and more dangerous during  rainy season.  When the boy arrived he was already in cardiac arrest.  His lungs were full of fluid and he’d stopped breathing on his own five minutes earlier in the ambulance.  The pupils of his eyes were becoming dilated, a sign of impending brain injury.  We tried everything in our power to resuscitate him, but he was too far gone.  His lungs were full of infection blocking any oxygen we tried to force into him.  After thirty minutes of resuscitation, oxygen,  medicines, CPR, IV’s and fluids I knew that resuscitation was not possible.  I called off the CPR and told the staff to stop.  I’d made that call at least fifty times before in adults, but stopping it on this child was one of the hardest decisions I’ve ever made.  If you’ve ever had to call off an attempt to save a life, it’s one more time than you’d ever want to.  It is part of the job, though.  His brain gave out before his heart and he had died in our ER.  It was a horrible and sobering experience for everyone here, especially our young clinic staff.  This was a reminder of how rapidly intense it can get when you are everyone’s  last resort.   I will never forget the cry his mother made when she found out he didn’t make it.  I’ve been present at a lot of bad news over the last twenty years, but her cry will never leave my head.  That night after work I tucked my son into bed and stayed with him until he fell asleep.

Today needed to end differently. 

I called the staff together and gave orders to prepare the Emergency Room.  The secret to good emergency care is good preparation and   military management of delegation.  Our head nurse is young, but she is excellent.  She is a machine at emergency response and is as quick and intuitive with medical response as anyone I’ve ever worked with.  Our nurses rotate on and off the island each month.  I was thankful this was not her time off.  Within minutes she had set up the ventilator, intubation tubes, intravenous, crash cart and emergency medicines around the  ER bay.  My junior colleague Dr. Nhani was on ER duty.  I told her I had a bad feeling about this one.   I asked her to prepare her team and delegate emergency response positions before the child arrived.  Everyone needed to know their job.  This was going to be loud and confusing and intense.  When we were as prepared as possible we wheeled the ER bed out to the ambulance port and  into the sticky heat of the Indonesian jungle.   We waited.   

Worst case scenario. As expected   

Another delivery to our ER.
The ambulance pulled into the emergency driveway and flung open the doors.  This was no child.  When I hear “a child is on the way” I’m picturing a five year old with visible parts and diagnosable issues.  This was a baby.  A two month old, tiny, helpless, unable to express his needs infant.  He was barely breathing.   A local doctor was in the back of the ambulance.  He held an adult sized oxygen mask over the infant’s face.  The mask was bigger than the baby’s face and oxygen hissed out the sides.  The local doctor gave his report to our doctors while we ran the baby into the emergency room bay.  I watched his little chest fight to pull air into his lungs.  He was struggling.  He was breathing almost forty times a minute—twice the normal rate for a baby. His immature, undeveloped breathing muscles were starting to fatigue. 

The nurses were having trouble securing monitoring equipment onto his little body.  We have specially sized equipment  for children, but not for infants this small.  An oxygen monitor was taped and retaped to the baby’s tiny pink foot.  It was too big and kept slipping off.  Fortunately the doctor had already gotten a tiny intravenous line into a small, tenuous vein in  the baby’s foot.  This was a huge stroke of luck.  Getting an intravenous into a baby this small is like trying to thread a cocktail straw through a smaller cocktail straw.  Even the best pediatricians struggle with this and without it there is almost nothing you can do for a critically sick baby.  I pulled a paramedic over and told him to tape the fragile line more securely than he’d ever taped anything in his life.   We lose the line, we lose the baby.  If we could get some lifesaving medicines quickly into this little guy he’d have a chance.

I pulled Dr. Nhani over.   I knew what was about to happen.

“Doc, watch him closely.  I think he’s going to stop breathing. ” It was as if he’d heard me.

He had finally fatigued from trying so hard to get air into his cluttered little lungs.  He was so small, weak and fragile that he had simply run out of juice.  He lay on the bed motionless, even too weak to cry.

“He’s not breathing.  Ambu Bag to me, now please!  Let’s go, let’s go, let’s go!”

I tilted his little head back to open his airway as much as possible and fit the tiny mask over his mouth and nose.  Our mask was for larger children, but I was able to get it to seal reasonably.  The mask covered his whole face.  I rhythmically squeezed the bag and watched the LED of the oxygen meter taped to his foot.  It had dropped down to eighty percent.  This was the danger zone.  More than a few minutes at this level and he would be brain dead. His tiny chest expanded with each squeeze of the bag and soon the numbers on the meter began to rise.  I looked at Dr. Nhani and rolled my eyes.  This was only the beginning.  I asked her to take over so that I could do a full exam.  I grabbed the stethoscope from the crash cart and listened to his lungs.  Both sides sounded like crackling bubble wrap with every breath.  Double pneumonia.  Best case scenario, this was early and he still had some functional lung left.  Worst case, both lungs were full of infection, it was about to block off both lungs and he would suffocate.

“Rehana, Dexamethasone one milligram IV now.  Nhani, watch the oxygen meter.  That number drops, you bag him faster!  Watch the numbers!  Keep it above ninety. Azithromycin  fifty milligrams IV after the Dexa.  We’re not losing this kid.  Not an option.”  If the Dexamethasone worked we’d buy a little time.  If not, more bad news that a parent never thinks they’ll hear

I told one of the nurses to move the baby’s mother out of the ER.  Nothing good was going to come from seeing this tense, invasive on her baby.  If he lived it would be forgotten.  If he didn’t it would be all she’d remember.  We pulled the curtain from the ER bay closed, but I could see her through the gap where the curtains met.  She was leaning forward trying to listen for any sounds; any progress.  The thought of my wife,   five months pregnant at this time, jumped into my head.   

Bottom line was that this baby needed to get to an Intensive Care Unit for infants as soon as possible.  The absolute best we could do here was to stabilize him and keep him alive.  The nearest possible pediatric hospital that could handle a baby this critical was in Bali.  Bali was two islands away from us--a one hour flight by Seaplane or helicopter.  Depending on traffic, the hospital would be another hour from the airport and it would take thirty minutes on bad road to get the baby from the ER to our airport.  There was a world of obstacles and logistics to be dealt with between my ER and that ICU and very little time to do so. 

Seaplane:  Your way off the island.
My company is involved in a lot of international medical services, but the best of them is emergency medical evacuations.  We are arguably the best in the world (aside from the military, but even they contract us for certain jobs).  While Dr. Nhani and Rehana traded turns bagging the baby I got on the phone to our Alarm Center in Jakarta and briefed them on the case.  They would make the arrangements for the ground ambulance and the hospital.  Next I called the manager of the flight services and told him we needed a flight as soon as possible.  We got lucky.  There was a seaplane on standby.  I asked him to get it ready as soon as possible.  No way we could wait.  The last call I made was to a friend of mine in America who is a Pediatrician.  Our day was her night.  Fortunately she was still awake.  I wanted to see if I had missed anything or if she had any advice.  She gave me a verbal pat on the back and said keep doing what you are doing.  That was reassuring.

The Dexa was starting to work.  It was a little easier to get oxygen into the baby’s lungs.  There was less resistance when I squeezed the Ambu bag, but he would breath on his own for a few breaths and just as quickly stop again from exhaustion.  This evacuation had to go now.  I tried to place a small tube in his lungs get him on our ventilator, but his airway was just too tiny.    I couldn’t get even our smallest tube in his windpipe.  The only thing we could do was to continue bagging him by hand for however long it would take to get to the hospital.  It could be hours.

Usually my junior staff accompanies the patients for  any airplane or helicopter medevac in Indonesia, but I wanted to do this one myself.  This felt personal.  I did not want to let this baby out of my sight until he was handed off to a hospital ICU team in Bali.

I could not go. 

My senior Indonesian colleague was off the island this week. One of us has to be here at all times.  There are fifteen thousand others people here to look after and just two of us in charge.  Painful as it was, I’d prioritize and delegate.  We’ve spent a lot of time training our junior staff, but to me they still look like kids straight out of school!  I’m sure I used to get that a lot too when I started out.  We’d just have to trust them.

I pulled Dr. Nhani aside and briefed her.  I sounded like an overprotective, nagging,   mother.

“Watch that oximeter.  Don’t let it out of your eyesight.  Keep him above 93%, but don’t blow out his lungs.  Make sure the nurses secure those lines.  Do you have your pediatric meds pulled out?  You can’t be fumbling around with them in the plane.  Did you bring enough oxygen in case you are stuck in traffic in Bali?  Report back to me with every change of vehicle.”

I was relentless.  She was kind enough not to show any annoyance with me.  I chose two of our best nurses to go with her, Rehana and Imelda.   I knew they were good under pressure.  I told them to keep taking turns on the ambu bag, not to get fatigued and to keep talking to each other. 

Our ambulance pulled up to the emergency entrance.  The smell of hot air and petrol filled the ER when we opened the doors.  The baby was placed on a big orange scoop stretcher twenty times his size.  The nurses hovered over him keeping his face in contact with the ambu bag, not missing a breath.  Within five minutes we loaded     the equipment into the small ambulance.  The doctor and two nurses squeezed inside and tried to position themselves as best as possible for the ride to the port.  The road was rocks, dirt and gravel all the way.  It was going to be uncomfortable.  When they pulled away I watched until they headed up the hill, out of sight.  My mind  was second guessing everything I had done.  Was it enough?  Should I have tried harder to get that tube in his lungs and get him on the ventilator?  Did I give him enough Dexamethasone?  It didn’t matter now.  We just had to wait.  I went back inside the clinic.  The remaining nurses and paramedics were cleaning up the ER, putting equipment away and restocking medicines.  There were patients waiting to be seen.

The baby remained stable, but still didn’t have the strength to breathe on his own.  Our team breathed for him for the entire trip.  When their arms ached and cramped they traded positions.  Almost three  hours later the ICU team at Hospital Umum Pusat Sanglah took over the baby’s care.

The doctors and nurses of our Jungle Clinic.  They clean up nicely.
Dr. Nhani called me after the handover.  She was exhausted.    I told her that she and Rehana and Imelda were heroes.  I told her that this might be the greatest thing she ever has to do in her medical career……if she’s lucky.  None of us ever wanted to to do this again.  These trips leave scars on everyone.   She said they were heading to a hotel near the airport.  It was too close to sundown to bring the seaplane back to our site.  They would have to return in the morning, at first light. 

Anyone see a KFC or Burger King?
 Keep searching!
I had one more mission for our medical team (keep in mind that we live on a remote island in the middle of Indonesia with only traces of civilized luxury at our grasp):

“Doc, one thing left to do.  There’s a KFC in the airport.  On the way home bring as much back as you can carry for the team here.  You fly, I buy.”  I figured we all needed a little luxury comfort food.  Out here in the jungle, KFC is as good as gold.

We got reports over the next few days whenever we could.  Getting medical reports from government hospitals in Indonesia is not simple.  The doctors are busy and the hospitals are full.  We found out that the baby was able to stay off of a ventilator and with proper antibiotics the infection in his tiny lungs began to resolve.  He started breathing on his own.

Two weeks later his mother brought him to the clinic for a follow up.  He was, again, a normal baby.  Soft, pink, eyes wide open and laying on my treatment table cooing and smiling.  Perfect baby.  It was like it never happened.  When his mother took him home I went to my office, closed my door and sat at my desk holding off tears.  We have unwritten rules about these things.  There’s no crying in medicine.  Not on this side of the patient anyway.  This was the greatest thing I’d ever done.  At least it felt that way.  If there was ever a time where I felt like I’ve done enough in my career to retire, this was the day. I’ve been doctoring for a long time now and in a lot of bad places.  I’ve seen terrible things happen to people, but I was always able to keep my  personal and emotional responses out of the clinic.  Now I have children of my own and suddenly all bets are off.  Am I losing my edge?  The suffering of a sick child has started to sting.  It’s harder to control.  I figure when I can’t control it anymore, it’s time to leave the game.  I’m not there yet.


  1. Boy oh boy , what a tough day. I couldnt agree more its about being organised, decisive and doing the basics of resus well. Well done my friend.

  2. Wow. I mean, wow. You're heroes. Seriously.

  3. Still hold my breath when I read this. I wait for the next update which I am sure is going to be even more personal...hugs