My morning schedule has been a shambles. Right off the bat my simple follow-up patient became a forty-five minute ordeal of an admission, and I've been behind since. Finally I am sitting down with Ange to go through the medication refills that have come in today. I recognize the name of one of our palliative care patients attached to a request for pain killers. "Oh, he can have whatever he wants," I say, starting to register a repetitive squeaking sound coming from the waiting room. I assume it's Austin, a forty year old man with cerebral palsy who lives in a group home and makes little vocalizations when he is overstimulated.
But it is not Austin. It is Ember, a one year old with wide brown eyes and terrible recurrent skin infections. I usher them into my office - his mum and nan and five barefoot siblings, mostly in swim suits. ("Togs," in local parlance.) Then I look at him, grunting, the whites of his eyes showing all the way around the irises, his fingers mottled and bluish; and I herd the whole clan down the hall to the treatment room, where there is more space and more equipment and a wide door that leads out to the reserved parking space for ambulances.
I am in the midst of a collaborative project with the nurses to organize our emergency equipment. We have made checklists of materials and ordered new laryngoscopes and looked at wheeled carts. But so far the only part of the project that has been actualized is that our existing emergency equipment has been tossed into one large cardboard box that someone has labeled "RESUSE" in black sharpie.
I sit Ember and his mum on the exam table and listen to his lungs. No wheezing. They actually sound pretty clear. But he is breathing 70 times a minute and his heart just sounds like a little whir. His skin is warm to the touch. The nurses Ange and Micki have followed us into the treatment room, and Tania the practice manager has shepherded the other kids back out.
Ange and Micki and I begin a scavenger-hunt style "resuse" of our patient - I suggest a piece of equipment that I fancy using, and they paw through the box to locate it. We assemble a set of vital signs - not a single one is within the normal range. We put him on oxygen and deliver some antibiotics via injection. I gather all the smallest IVs and attempt to place a line. But he is a baby, and very dry, and the dark line on his hand that I thought was a vein came off when I rubbed it with alcohol - not a vein after all, just dirt.
And while this goes on, I am keeping a running tally of the items that I have requested that have not turned up in our box and I am wondering how long until we need these things.
Have I mentioned that the ambulance is 40 minutes away? The ambulance is 40 minutes away.
I internally debate the merits of throwing Ember and his oxygen bottle in the back of the RAV4 and driving him to the next town myself. In the US, this would be fraught with liability concerns. But in New Zealand? In Opotiki especially, we're a practical people.
Then he starts vomiting. Clear but viscous it comes forth from his mouth and nose, filling the oxygen mask before Ange pulls it away from his face. And there is a terrible pause in the rhythmic squeaking that has been like a metronome to the whole exercise up until now. Pause, sputter, squeak.
Even fully equipped and organized, we wouldn't have suction. Which seems like it would be helpful, I think as I watch another bout of gelatinous sputum pour out of my patient's face.
Last time Ember was in the office, he had multiple open skin sores as well as an acutely exploded poopy diaper. ("Nappy.") Now I'm not what you call a germophobe, my kids both enjoy the post-dinner course we call "floor food." But the poop in the skin sores situation was too much for me to handle. I recall now that my answer was to carry him down the hall and bathe him in the staff shower.
This mum is going to think I am completely insane. But that can't be helped and isn't that far off.
I wrap Ember in a towel and trot across the parking lot, holding him to my chest so I can feel the little whir of his heart. We arrive at the Opotiki community hospital and I put him down in their treatment room, next to the suction set up. I eye the clear plastic tubing and then my patient, daring him to attempt to aspirate his own vomit again. I'm ready for him now.
Of course by this time, the antibiotics are perhaps kicking in. His breathing is marginally slower and his color looks excellent.
The ambulance arrives and the paramedics give the IV placement a go themselves. Nothing. We debate the merits of an intraosseous line ("bone drill," for the non-medical folks), but I feel certain this thrashing toddler will not respond well to this. In the end, they just package him up and load him into the ambulance, leaving me to pick my way back across the parking lot to my waiting room full of patients.
Normally I am not too affected by experiences like this. Since my college days and perhaps before, I have suffered from complete adrenaline failure, even in situations where it would be decidedly useful. I once came across a bear and her cub while hiking in the woods and thought to myself, "surely a surge of adrenaline and cortisol will soon be released by may adrenal glands and allow me to outrun this claw-covered human-eater." I waited and waited, but nothing. Intellectually, I knew it was sub-optimal for me to be standing between a large bear and her cub, but physiologically, nothing happened. No fast heart beat or feeling of flushing. I eventually just turned and hiked on, figuring the bear would follow me and eat me or she wouldn't but there wasn't much I could do about it.
Ditto for medical situations, except for one thing. The only bit of the physiologic stress response that I get is the sweating. No hyperactive focus or super-human strength, just sweat dripping off my body and face to the point that it stings my eyes. The paramedics, who I tend to encounter in these situations, must think I have a serous BO problem.
Today was the same. I was certainly worried about the kid, but it didn't occur to me to be panicking until I heard that anxious edge to Ange's voice and thought, "oh, yes, this is a bit touch and go, isn't it?" I was, of course, already drenched in sweat.
Emotionally, it was different. In the best of circumstances I struggle to keep that balance between cold detachment and crippling over-involvement, but my over-involvement tends to be more material than emotional. Ember was different. Maybe it's because he is a week younger than Pax, or maybe I feel responsible - if only the crash cart had been ready, if only I had treated his skin sores effectively in the first place, etc. Whatever the reason, I took this one home with me.
(Not literally, Benjamin won't let me literally take home any patients; he's quite strict about that.)