Monday, February 24, 2014

Looking Life--Not Death--in the Eye

The electricity went out in the clinic yesterday.  It was late in the afternoon and the clinic was closing soon. The staff were shutting down their work stations for the day.  It was raining outside and the dark, grey skies did little to light the clinic.  Incandescent emergency lights had come.  They provided enough  light to see where we were going.    A company Safety Officer was giving a talk to the staff about safe practices at work.  He squinted to make out the faces in his crowd.  Electricity fails frequently with our local power grid though it usually comes on after a few minutes.  I had walked   to the front desk to drop off some patient charts when a short, thin man came into the clinic supported on the shoulders of a friend.  Our nurse joined them and walked him back to the ER.  This is no uncommon event at our clinic.  We see over one hundred patients every day.  A handful of them come through the emergency room.  I usually wait for my staff to do their triage, check the vital signs and for the junior staff to examine and report the case to me.  If it is serious enough they  ask for my attention.  Today for no particular reason   I followed the patient to the ER.
The nurse put him on the ER bed and began to ask him questions.  My command of Indonesian language is shoddy at best, but I could tell his answers were garbled and not making sense.  My nurse told me that he had been stung by a bee. 

I’d seen this before:  Anaphylaxis.  He was having a severe allergic reaction to a bee sting and very soon, probably within a minute, he would be in shock.
I began to bark orders to the nurses.

“Get the Propaq on him.  What’s his vitals?  Get the Adrenalin, Promethazine and Solumedrol NOW!  Let’s go, let’s go!  No time here people.”  I looked at my head nurse and told him to get an intravenous line in the patient.  I told him I needed it yesterday.  He looked at me strangely as this didn't translate literally into Indonesian.
The ER was still dark and had no electricity.  I grabbed a penlight from the Crash Cart and shined the light on the patient’s arm to help my nurse find a vein.
“You have twenty seconds,” I told him, “Do not miss that vein.”
 The rest of the staff scrambled around him in the dark.  They placed monitor cables and drew medicines into syringes.
“Vital signs!  I need them now!”
“Blood pressure tujuh puluh tujuh per ampat puluh (seventy-seven over forty—dangerously low).   Pulse seratus (one hundred-high).  Oxygen percentage sembelan puluh tiga (ninety-three-borderline).”

Dangerous Critters
“Shit.  He’s in shock.  Open up the fluids.  Give the Adrenalin IM now!  Promethazine IV now!  Solumedrol and Ranitidine to follow.  Let’s go people, you have to move quicker!”

The patient was still conscious, but writhing and disoriented.  One nurse held his arm while another taped the intravenous securely in place.  This was our only route to give him medicines.  Without it he was dead.

“Medicines in, doc.  Adrenalin, Promethazine and Solumedrol.  Giving Ranitidine now.”
“Okay, okay.  Be careful with the sharps and needles.  Don’t stick yourselves.  Watch what you are doing in the dark.  Vital signs.  Give them to me again.”

The medicines and fluids were working quickly.  We’d gotten to him exactly on time.  Over the next fifteen minutes his blood pressure began to rise.  His heart rate was rapid from the medicines, but regular.  Then the electricity and the lights came back on.  We could see the patient clearly for the first time.  He was bright red.  There were allergic welts on his arm.  His face was swollen and his eyes were inflamed and red.  With the life-saving medicine we gave him this would pass with time.  The worst was over.  We would still have to watch him closely and suppress the anaphylaxis again if it came back.   He’d definitely dodged a bullet. It was too late to get him an air ambulance evacuation to a hospital with an ICU on another island.  The sun would be going down now and no flights leave our island in the dark.  We’d manage him here.  I discussed the rest of his care with my junior doctors and told the nurse not to leave his bedside no matter what.  When I believed he was stable I headed out.  I am the campsite yoga teacher here on The Rock.  My class was due to start in twenty minutes. These emergencies are always  intense. My own Adrenalin was still flowing and I needed  time to switch gears.

In most Emergency Rooms this story ends here.  The doctor goes off shift, teaches his yoga class and eventually the patient goes home.  Never the two shall meet again except by rare chance.  Not the case here on The Rock.  We are a small group of people in a small area cut into the jungle in the middle of a very large Indonesian island.  It is common for me to see a patient in the morning, see his face again in a management meeting in the afternoon and again in the pub at night.  These are our coworkers. These are our friends.  These are our patients.  Like most professionals we try to keep the work in the office, but the lines cannot help but bleed across one another at times.  The rare and exquisite experience of looking into the eyes of a man whose life you've once saved is one of those times.

We had a similar case here two years ago.  A kitchen employee had been stung by a bee and began to feel ill.  He called his supervisor  and asked him for a ride to our clinic.  The supervisor agreed, but had to make a stop along the way to pick up some packages.  When he came back to the car the employee was unconscious.  He raced to the clinic and yelled for help from the ER entrance.  Fortunately my Indonesian colleague, Dr. Anneke, had just returned from lunch.  She started anaphylaxis treatment immediately. She saved his life.   By the time I reached the clinic he was beginning to stabilize. We worked on him for the next hour.  If he'd made it to the clinic five minutes later he was dead or brain damaged.  When he became conscious he had no idea what had happened. He looked at Dr. Anneke and my face in horror. Ours were the first ones he saw. Dr. Anneke explained what had happened.  A very specific look came over his face when he found out that he had almost died.  I’ll never forget that look.

This lucky guy was the brother of one of our employees.   I see his face every Wednesday when he hands me my food at our camp's Pizza Night.  He looks me in the eye and says ‘thank you’ before I get to thank him for the food.  I choke up a little every time and look away. I can’t control it.  Maybe it’s the intensity coming back from the ER experience.  Or it’s that rare spike of emotional compassion creeping into my head. Those dramatic personal moments that poke through the numbness of thousands of cases of patients living and dying over thirty years in medicine.  I’m not sure, but I have to admit it feels more uncomfortable than good.    I'm grateful for his family and friends that would have missed him. I'm grateful that my young staff didn't get the emotional scars you feel from losing a patient.  They never go away. I’m grateful that he’s alive, but in a perfect world we could have all done without the intensity and drama that kept him that way.

My patient from yesterday’s emergency was just discharged from our small hospital ward.  He walked by my office and gave a shy, cordial wave good-bye.  Our nurse gave him  discharge instructions and medicines.  She sent him home.  I saw Dr. Anneke standing at the nurse's station.  I asked her if our patient had any idea what happened to him or how close he came to dying.  She said she wasn't sure.  He didn't remember very much after coming to the clinic.  Good, I thought.  Makes it just that much less awkward next time I see him.
Young but Heroic:  The staff at International SOS Buin Batu Clinic, Sumbawa, Indonesia.
 With one old crusty doctor in the back.


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