Dead or Alive!

Critical Care and Emergency Medicine in Uganda

13:00 hours East African Time.

Outside it was a friendly warm Ugandan afternoon but inside, within the cold sterile walls of the Intensive Care Unit, a tired, sweaty team battled on. ONE, TWO, THREE!!!…….ONE, TWO, THREE!!!…..ONE, TWO, THREE….. echoed through the corridors,occasionally punctuated by the helpless cry of a woman in the nearby Neurosurgical ward. The battle was a short-10 minutes!! but to tired team, it felt like an abyss of time.

It was a hard judgement call, but the frail warm body of the 10 day old neonate gave the team hope. What was seemingly a quiet day had suddenly become turbulent as the ICU team, tired from the long morning round was without warning handed a limp, blue and apnoiec neonate. This child, rushed into the Intensive Care Unit by the Paediatrician without notification of the ICU team, was by all standards dead-but warm. Led by the ICU doctor, the team was quickly jump-started to begin resuscitation with chest compressions and oxygen through bag mask. They quickly accessed a vein and administered epinephrine, bicarbonate, Dextrose 10% while a 3-lead ECG was set up, the child had a PEA.

In the midst of all this, the inevitable happened; a sudden regurgitation of stomach contents into the oral cavity!!! The ICU doctor, like a general commanding his troops in battle, asked for size 4.0 Endo Tracheal Tube and Laryngoscope, calculating that he 10 seconds utmost to successfully intubate this child. When the time for pulse check came, he did it despite a poor view as milk in the larynx obstructed his path, but he saw the open door between the cords as they stood still. In it went!! Now the battle was against time.

Through all this, the question that lingered on their minds. Was this worth it??? Did we make the right call? The cardiac arrest was not witnessed, and the time it took to get to the ICU was long. Even if the heart function returned, the brain function was no guarantee. The catastrophic outcomes would be comparable to a Richter scale seven and beyond. Only one glimmer of hope, the child was warm.

Suddenly, a shout-PULSE!!! That soft thud against the finger that confirmed the heart was pumping sufficient blood again. The plethysmograph confirmed it. The CPR could now be stopped, but the bagging continued for a while till the ventilator was set to take over. The child was alive- or at least his heart was. The brain? Maybe-maybe not, but the real answer to that question would be got later on and in the days to come. At that time, the team had to do the best with what they had, and hope for the best.

The Paediatrician was amazed that the resuscitation had been successful. The parents even more. They had all given up hope. Later, during a detailed discussion the mother confirmed that the child had been having difficulty in breathing since birth, but she was not worried about it. However, when the child failed to breastfeed she was concerned and took him to a clinic where they were referred to the hospital. An echo cardiogram done earlier had revealed the child had an “insignificant”Patent Foramen Ovale (PFO)and a repeat echo cardiogram had been advised when the child turned 3months. But this had all changed.

After about a month and a half, the child is still ventilator dependant, with some abnormal movements, spontaneous eye opening but poor respiratory effort and pattern. This, a clear case of difficult weaning, comes with the high possibility of never getting off the ventilator . The parents are thankful and have not given up. The child is alive! His body is functioning to some extent.

Did the team create false hope? Perhaps. But with the limited critical care structures in Uganda. This was the best place for the child to be. There are a limited number of ICU beds in Uganda as a whole - only one ICU bed for every one million Ugandans or 0.1 ICU beds/100,000 (Table ​(Table1).1). [1].  This compares poorly with South Africa (8.9/100,000), Sri Lanka (1.6/100,000), and the United States of America (20/100,000) [2]. This limitation is further compounded by a well-documented dearth of anaesthesiologists- a critical human resource for intensive care units [3,4]

How does Emergency Medicine fit into this picture?

Can Emergency Medicine Training prepare you to manage Critically sick patients?

We like these answers on the EMCrit blog http://emcrit.org/critical-care-fellowship-faq/

References:

1.     Kwizera A, Dünser M, Nakibuuka J. National intensive care unit bed capacity and ICU patient characteristics in a low income country. BMC Research Notes.2012;5(1):475. doi: 10.1186/1756-0500-5-475. [PMC free article] [PubMed][Cross Ref]

2.     Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet. 2010;376:1339–46. doi: 10.1016/S0140- 6736(10)60446-[PubMed] [Cross Ref]

3.     Gerald D, Sarah D, Kelly McQueen KA. Global anesthesia workforce crisis: a preliminary survey revealing shortages contributing to undesirable outcomes and unsafe practices. World J Surg. 2010;34(3):438–444. doi: 10.1007/s00268-009-0229-6. [PMC free article] [PubMed] [Cross Ref]

4.     Hodges SC, Mijumbi C, Okello M, McCormick BA, Walker IA, Wilson IH. Anaesthesia services in developing countries: defining the problems. Anaesthesia.2007;62(1):4–11. doi: 10.1111/j.1365-2044.2006.04907.x. [PubMed] [Cross Ref]

By Cornelius Sendagire