Code in the E.R.

Sorry this post is so long. Hopefully its worth reading, at least the first part.

The clinic today was pretty boring; a typical average day in the clinic with average cases. However, thanks to the ER, today was one of those days that I’ll never forget. It was about 10 am and I guess Dr. Lazo had forgotten about our previous conversation the day before because Dr. Gomero’s office was still empty and I wasn’t seeing any patients on my own. He was nice enough to ask me if I wanted to pull a urinary catheter out of this old dude though. Well, thank you so much Dr. Lazo, this will surely be a really important step in my quest to become a great physician. I did it if course; deflated the balloon and pulled, whoop-dee-doo! Well, around this time the ER called and doctor Lazo said, “Okay” and started rushing for the door. He usually doesn’t tell me where he’s going even though I’ve tried to show my interest a zillion times. He was heading to the ER as I knew though, so I followed him. In the ER was a 4-month-old infant who was pale, lethargic, floppy, and had a history of vomiting and diarrhea from the day before. I knew he looked really bad, but I wasn’t immediately aware of how perilous the situation was. I ran and got Dr. Sierra the pediatrician to come help. He showed up as the nurse was trying to put in an IV. We had a kid before us who was obviously dehydrated judging from his look and history, very dehydrated. His eyes were rolling around and his breathing was quite labored. In dehydration such as this the treatment is obvious and simple; give the patient fluids. It doesn’t even really matter what kind of fluids as long he/she gets something. The problem with dehydration is that if it is severe enough it can be life threatening. As the normal fluid of the body is dissipated through vomitus and loose stool, more and more fluid is taken by the body from the tissue outside of the vessels into the vessels to keep the blood pressure up and to keep precious oxygenated red blood cells flowing through vital organs like the brain, heart, kidneys, etc. If the dehydration gets severe enough no more fluid can flow into the vessels. As a result blood pressure drops, the blood becomes like sludge and the brain and heart start to lose oxygen. As the heart loses oxygen, the heart rate falls lower and lower until it stops, the brain has no blood flow, and the patient dies. This precipitous drop in blood pressure and heart rate is caused hypovolemic shock and our patient was suffering from it.

Up to this point, I’ve been impressed with the health care here at La Loma Luz. They don’t have much, but they make good use out of what they do have and things run pretty smooth; the physicians seem to really know what they are doing. I was overall unimpressed with how things ran in this life and death situation though. I’m not here dog on the staff here or anything, because I realize they aren’t used to such situations like this, but things were just chaotic. Like I said, the treatment is simple, but unfortunately we couldn’t gain access to this little guy’s vasculature system. Putting an IV in a baby is hard enough, but putting one in someone who is so dehydrated is darn near impossible. The nurses and doctor probably tried over 10 times in every area they could think of with no luck. The scene was chaotic with nurses running all over, two physicians working, and a screaming, crying mother by the baby’s side. I was just staying out of the way, observing, hoping that someone could get a vein. I had never put an IV in an infant and felt helpless to just watch. Dr. Sierra had them put a nasogastric tube in and start some oral rehydration fluid. I think everyone knew it was futile, but we didn’t have any other options at the time. Dr. Sierra grabbed a 16 gauge needle and stabbed it into the kid’s leg. I asked him if they didn’t have an intraosseus needle and he said they didn’t. All they could use was this huge needle, but it wasn’t working either. An intraosseus needle is a way to get fluids and medications into someone in an emergency situation by stabbing right through the bone and injecting into the bone marrow. It’s fast and easy, but wasn’t happing here. They tried to stick an IV into the neck, but couldn’t get the large vein there either. At this point, I was pretty worried, but didn’t know how close to death this baby was. What added to my frustration was that everything going on was in Spanish. Sure the official language is English, but among themselves everybody speaks in Spanish, so I couldn’t follow what was going on or what people were thinking.


At this point, I was sitting and thinking how unimpressed I was with how things were going. Granted they were addressing the issue of getting fluids into this kid, but there were no monitors on. Nobody was following the oxygen saturation, nobody was checking a blood pressure or pulse and the monitor was right there. Nobody was clearing the room. Nobody was trying to calm mom down and get her out of the room because she was not helping things. It was just was chaos. Maybe Dr. Sierra was too worried about just getting a line in this kid to think about anything else, but I couldn’t understand why they weren’t monitoring this kids vitals. Anyway, I think everyone felt helpless and frustrated.


I was wondering about a central line, but I wasn’t sure if they had the stuff to do that here. That was the last resort though, so Dr. Lazo, being the most experienced, attempted a last ditch try to surgically place a central line into the jugular vein. They created as sterile of a field as best they could and he made his initial incision. In order to create a sterile field they put a drape over the baby and there was one of the lab workers at the baby’s head holding his hand. The fan was blowing the drape around so I squeezed myself in a bit to try and hold the drape down. The procedure was slow and I’m sure very stressful to Dr. Lazo. It was hot, humid, crowded, and a life or death situation. As the procedure was continuing the lady at the baby’s face was stroking his hand and talking to him. Every once and a while somebody would ask her how the baby was doing and she would say he’s okay. Dr. Sierra even checked under the drape a few times. For one reason or another I was hesitant to do much at this point (I hadn’t had hardly any experience with such a situation either!), but tried to help where I thought I could. It was so crowded that I didn’t want to get in the way even though I wasn’t too impressed with how things were going. At one point though I didn’t see the baby moving at all and thought, “what if this baby dies and I just sat here holding this drape,” so I checked under the drape. The lady said the baby was doing okay, but that chest was not moving!!! I grabbed my stethoscope and placed it on the baby’s chest: no breath sounds and a very weak, nearly inaudible pulse were present. I told Dr. Sierra what my findings were and said we better intubate. He grabbed the ambu bag and put it over the baby’s mouth and I began chest compressions. I was going crazy at this point. This baby was as close to dead as he could be, we were doing CPR, and we couldn’t get any fluids in him. I could do CPR till the cows came home, but if we couldn’t get a line in there was no hope. All hope lay in the hands of Dr. Lazo at that point. I was also frustrated with the response to this baby’s cardiopulmonary arrest. Dr. Sierra had handed the bag to one of the staff members and I’m not sure where he had gone. I was compressing the chest and trying to explain to the person how to get air into the lungs. The mouth piece was upside down, there was no seal around the mouth so the air wasn’t even getting into the lungs, and we couldn’t get a good airway. Didn’t anyone there know how to properly bag somebody in a code!! Where were the nurses who were supposed to know these things to help?! They were all just watching! Why wasn’t anyone checking vitals and turning on the monitor like in a normal code! Why did I have to stop my chest compressions to check if the kid’s heart rate had improved! Didn’t anyone think the situation was as perilous as I did! No breathing + no heart beat = death!!!!!! Well, I kept trying to tell the person bagging how to do it so we could get some air into the lungs and we were finally doing okay. The whole time I’m doing chest compressions and Dr. Lazo is trying to put a tiny tube into a vein about the width of the head of a needle and mom is sobbing behind us. At this point, I was 100% sure this kid was dead. Such a simple treatment and we were helpless.


I was wondering where Dr. Sierra was and come to find out he was getting a bolus of epinephrine ready and injecting it, which was a smart thing to do. He came over and took over bagging as I continued chest compressions, but what was the point, this kid was dead. Well, I stopped and placed my stethoscope on his chest. Wait a second! I could actually hear a heart beat a little better. It was still below 60, but definitely better. I looked up at the IV bag. It was running!! I looked at Dr. Lazo’s incision. He had managed to place the line into that tiny vein and was working on securing it and stitching things up. We continued CPR and a few minutes later I checked the pulse again. Heart rate was in the 80’s! Yee ha!!! We continued and a few minutes later the heart rate was greater than 100. I stopped compressions as Dr. Sierra continued bagging the patient. After some time the baby began breathing on his own and Dr. Sierra stopped giving him breaths. I still think he should have been intubated and assisted because he was still struggling, but at least he was alive and stable. To add more stress to the situation though, Dr. Lazo couldn’t stop the bleeding from the wound he had made. They had nearly stitched everything up, but it continued to bleed quite a bit. Dr. Godoy, a surgeon from San Ignacio, had been called and showed up. Luckily, he was able to adjust a few things and stop the bleeding. The baby had lost quite a bit of blood, but was doing okay. The nurses prepared him for transfer and they sent him to Belize City to the pediatric intensive care unit.
When it was all over everyone was chatting in Spanish, but everyone kept saying “Gracias a Dios.” They are a really religious group obviously being an Adventist hospital. They all were grateful the baby was alive and gave all the praise to God which is pretty awesome. Dr. Sierra was sitting there praying at different moments during the whole situation which was very interesting to me. I talked to Dr. Lazo after and told him good job, as I was obviously impressed, but he just gave all the praise to God. I really like how they involve God with everything and I think it really helps considering the mostly good outcomes they have with limited resources.
I can’t be sure the baby will survive. I don’t know how long its brain was unoxygenated and what permanent damage might have occurred. He was stable when he left so hopefully everything will turn out okay. It was a crazy experience as I had never been in such an emergent situation like that (most of my ER experience has been pretty mild and I haven’t done an official ER rotation yet), but it was a great learning experience. I was disappointed with myself that I didn’t help more initially and I spent the evening second guessing my actions, wondering if I had done everything I could, regretting not being more vocal, and regretting some of the little details I didn’t think of during the high stress moment. That’s how I am though. I will analyze every little detail and replay the situation in my mind so I can think of every place where I need to improve. I know as a physician that may stress me out and will drive my wife crazy, but the way I look at it, at least I will always continue to improve and hopefully some day, be a great physician. Then I won’t have to think so much about my actions. While there are some regrets, at least the little guy is alive and he has Dr. Lazo to thank for that. In my mind, I have been a bit critical of Dr. Lazo for a few of the things he’s done while I’ve been working with him. He’s a pretty good physician, but I just don’t understand some of the things he does. Today he was a hero in my eyes. I asked him if he had ever done that before and he said only on adults. Being in such a high stress situation with such a difficult task I was more than impressed with how he kept his cool and was able to deliver. On the other hand, I was not impressed by the nurses and think they need a refresher course in emergency situations.

What’s great about the hospitals in America is that after a situation like that there would be a log of everything that happened, someone would review to check for mistakes, and then there would be quality improvement, retraining, etc. Here they didn’t record one thing and I imagine they aren’t going to see what areas they can improve on for next time. It’s odd because they don’t have any kind of continuing education or anything to ensure that the staff is continually learning and reviewing skills. Once you’re done with school you don’t have to do any continuing education to be sure you can do your job. Crazy!

This situation also made me think of how grateful I am for healthcare in America. Sure, it’s expensive, but it sure is good. The proper equipment for whatever situation is usually always available. Things run much smoother and usually everyone knows their place and what they’re doing. In addition, the training is much better and in general, hospital personnel are much more prepared. Be grateful to live in America and get the care you need when you need it. Sure it’s expensive, but I’m willing to pay the extra cost for the best healthcare in the world.

The rest of the day was slow and boring. The only other thing I can remember is that I had the x-ray dude do a chest x-ray of me. I’ve been feeling short of breath lately, coughing a lot, and not getting over my “cold”. I didn’t think it was anything serious, but I thought I would do a chest x-ray – It’s like $15 bucks here. It was normal so that is good. I’m worried I may have a mycoplasma pneumonia or bronchitis. It could also just be a really bad cold that is closing off my airway a bit and that is actually what it kind of feels like. If I don’t get over it soon I’ll start self medicating.

This evening I headed to San Ignacio to find a Tikal tour. Didn’t take long and I found a tour going on Saturday. It’s an all day trip, 7:30 am to 5 pm over the Guatemalan border about 70 miles away. It includes all the travel, border fees, entrance fees, lunch, and a knowledgeable guide of the area for a good price so I’m excited to go see the most popular Myan ruin in the world! Should be pretty fun. I practically ran the 45 minute walk home to get back to see The Office. They have NBC here! I was ticked when it wasn’t on. I thought it was on Wednesday night at 8 pm, but maybe it was Thursday. Hopefully it wasn’t Tuesday! I guess I’ll find out tomorrow. What a wild and great day. I can’t wait to see what tomorrow brings.

The little one I delivered a couple weeks ago.

Steak dinner from Eva's - $7.50!