June 2nd

Today I ventured back to the hospital to conduct a videotaped interview with three of the nurses. My plan was to also interview the doctors but my camera died. One of most interesting things that I discovered is that the hospital lacks a gurney. They have no way to transport patients, not that there is much need for transport except to the morgue, but as of right now the wrap their deceased in a sheet and ask family members to carry the body the 200 yards to the mortuary.

Just out curiosity I asked a nurse what she would do if a patient’s heart stopped. She looked at me slightly confused and the stated that she would get the vital signs (blood pressure if they can find a cuff and temperature), then they would push adrenaline and solumedrol if there was IV access, and then she stated that they would do CPR. I asked her to walk me through the steps of CPR. She stated that she pushes on their chest a few times, five times to be exact and that is it. When I asked the doctor how they do CPR he stated that it is 5 compressions per 2 rescue breaths, but he also stated that he is never there for the ‘codes’. I also asked how they would manage a patient that stopped breathing the nurse stated that they would push a steroid through the IV, but they would not do rescue breaths. She actually seemed confused as to what rescue breathing was. When I asked about defibrillating a patient she replied excitedly “oh like what you see in American movies! Have you ever seen one!?” I am not sure what I expected, but it seems that the hospital staff would at least be educated in the excepted method of resuscitation regardless if they lack the means to execute them.

Today I also witnessed a child seizing for twenty minutes; it could have been much longer than that since I just timed it from when I arrived. The child was diagnosed with malaria and had been on medication for 48 hours; the child was afebrile and lab values were stable. The mother informed the doctor that the child had not eaten in 17 hours. The most common side effect of quinine, the medication used to treat malaria, is hypoglycemia, or low blood sugar. It was assumed that the child was experiencing a hypoglycemic seizure as opposed to cerebral malaria. Since there was no IV access the doctor pushed 10mg of Diazepam rectally with no response while the RN tried to gain IV access. When a line was finally established 10mg more of Diazepam was administered along with an amp of D50, which is concentrated sugar water.  When the seizures finally stopped the child remained postictal only withdrawing from pain for an hour until I felt. I sadly do not know the outcome of the patient, but the doctors seemed optimistic that the child would be fine. I am not a pediatric nurse nor do I have much experience with seizures, but from my limited knowledge and experience I was still able to stop about 15 potentially dangerous acts during this whole ordeal.  First and foremost administering 20mg of Diazepam in a 10 minute period on a child weighing only 15kg is very risky; the doctors are lucky that they did not kill the child’s respiratory drive.

I am struggling with intervening and giving advice on issues that I am not positive about, since my advice already lead to the circumcision of one man. Although I did protest the issue I do feel responsible. Without the proper resources I am afraid that by giving advice I may actually cause more harm than good unless it is a subject that I am certain about. For example there was a patient with a rheumatoid arthritis flare-up and they were treating her with Aspirin. Aspirin may reduce her risk of heart disease and reduce some pain but it will do little diminish the inflammation or resolve the flair up. I believe that you should use an anti-inflammatory such as naproxen or acetaminophen and that maybe in certain cases use a steroid if the RA is bad enough; but of these two things I am not entirely certain about and I hesitate sending a patient home on a steroid that will lower their immune system when they are drinking unclean water.  So I am torn between not helping when I know the treatment is inadequate or helping at the risk of giving wrong advice.