Tuesday, November 26, 2013

moving and BiPap

I know my last post was medical and I said my next one would be more about life so I will start by saying I moved this weekend. Since arriving at Tenwek I have been living in the home of one of the long term missionaries who was in the states for a year. She returns this week so it was time to move out. My roommate had left a few days earlier so that left me to pack up the house, most of it was mine anyway. My new home is right next door to my current one, which you think would make moving easy, just a few steps. However there are currently people living in “my” house who will be there for another month. So I have moved to a temporary home. This is the biggest place I have lived in yet and the walk from the kitchen to my bedroom feels long. I was thankfully able to move many of my things from my former place to my future place to store in the bedroom, however, I now have things in storage that I wish I had access to. It’s one ofMurphy's laws that you do not need something until it is placed in storage. So the weekend was spent moving and now that’s mostly done and I have been back to work.

I always find it interesting how things at the hospital go in trends, currently we are on a Bipap trend. Bipap is a way of helping someone breathe without putting a tube in their throat. Before I came it was done infrequently but we keep using it more and more. We have a few “home” style bipap machines that work well for some of our patients but they don’t work well for our patients who need a high percentage of oxygen. For these patients we would have to intubate and place them on the ventilator. However a few weeks ago when we had an elderly, hypoxic, COPD patient who I really did not want to intubate  I tried something different. I hooked the bipap mask up to the Servo 900C ventilator and popped it on the patient. It worked like a charm I was able to set the sensitivity so it would not autotrigger, the alarms were easy to set and that patient did well. Since then I have used the servo 900c for multiple patients as a bipap machine and it has helped save many lives. Earlier this week I had a young man who developed a PE and consolidation after he was in a motor bike accident. This man was fully awake however his oxygen levels were low despite oxygen via non rebreather mask. Rather than intubate him, onto bipap via servo 900c he went for 24 hours and then he was fine.   I am thankful for the machines I have to use and the ability to use them for various purposes.
BiPap via Servo 900C

In  closing I ask for prayers for a few patients I intubated a 6 month old (the first time I have intubated a baby) and she is very sick and we are not sure why. Please pray she will recover. We also had a young lady come in the other day after a motor bike accident and her leg had to be amputated, Picture is below, don’t look if you can’t handle gross medical pictures. 
to give reference the tourniquet is between her thigh and where her knee should be

Saturday, November 16, 2013

Not What I expected

Before I start I should warn all you non-medical people this is a highly medical post, I'm sorry if it is boring or confusing for you.

  When you do anything for a while it becomes your normal. There are occasional variations in the normal but you have the expected variations that you are prepared for. Working at Tenwek there is a type of patient that I have gotten to know very well – the “poisoning patient” these are individuals who have attempted suicide by ingesting chemicals, often pesticides that they have on hand.

We have 1-2 of these patients a week and the treatment is usually along the lines of gastric lavage, intubation and ventilation if unconscious, atropine for low HR, watching electrolytes and if all goes well in a few days extubate them.  They get them some counseling and they go home. Depending on the poison taken some patients end up dying due to electrolyte or other abnormalities but this is still in my thought process of “this is normal for a poisoning patient”. 
So when I got called to help set up a ventilator for a poisoning patient I did not think much of it.  The patient came, I placed him on a ventilator – no problems. A few hours later I got a call from the physician.  The patient now had subcutaneous   emphysema and it was getting worse. My immediate thought was my ventilator did something funny – so I asked the staff to bag the patient and went up the hill to see what was up. The ventilator was working fine – well not fine, it's old, but it was not doing anything that would cause a pneumothorax. However, an x-ray was done and it showed a large left pneumothorax the surgeons came placed the chest tube and things went back to normal. Not sure how he got the pneumo as his ventilating pressures were normal – did he have a pre-existing bleb that popped? After a few more days on the ventilator,a chest tube removal, reinsertion and removal again. The patient was eventually transferred to the ward and I pray that with the help of counseling from our chaplains that he will make a full physical, spiritual, and emotional recovery.

                This patient was not my only abnormal poisoning that week. This time it was a 2am page – we have a poisoning patient and we cannot get him oxygenating well on the vent can you come help? So up the hill I went.  When I arrived I saw the patient settled on the ventilator with Spo2 -80’s. I took a listen and didn't hear any air entry on the left side. So I took a look at his x-ray and saw that his left side was completely whited out. OK,not normal. I didn't think this was in relation to the fact that this man had taken poison. So after fiddling with the vent – high PEEP, low PEEP, high rate, lower rate etc. I finally got to some vent settings that the patient managed to oxygenate with. The next day he went for bronchoscopy and he had a huge mucus plug blocking of his left mainstem bronchus – not normal. The next morning I also try to put together more of the history, he had seized in casualty – secondary to hypoxia? Had this man even taken poison? This patient had questions continually running through my brain. Sadly I never found out the answer, I left to Nairobi for a few days and when I came back I learned he coded and died. I pray that he knew The Lord. 

 Sorry to have this post end on a sad note. My next post will be much less medical and be a little more fun.