Multiple Choice...

If a three year old comes into your ER in respiratory distress would you:

A. Give him paracetamol...US tylenol (without knowing if he has a fever or how old he is/how much he weighs)

B. Decide we should try normal saline nebulizers every 20 minutes for an hour (when you have been told that salbutamol nebulizers did not help him this morning)

C. Start IV fluids but when they stop halfway through just leave them that way

D. Wait 5 hours until you decide oxygen is needed

E. All of the above

In the best hospital in Mozambique today I watched them choose E before ever thinking oxygen or an oxygen saturation might be a good idea. Here's how my day panned out...

It's been one of those days. My alarm went off and I decided I'd sleep a bit longer and take a shower later in the day. Apparently that was a mistake because before my alarm could go off again there was a faint knock at my door. Aleya (my roommate) was on call for the baby house last night but knew I'd was working today. She had just taken a call about one of our little guys who wasn't breathing well and needed to go chase down some other kids for GATV stuff (the program that sees all of our HIV+ kids on a regular basis) so wanted to see if I could help out.

So I threw on some clothes and headed up the baby house to find Dino in respiratory distress. I had seen him yesterday after church, and he wasn't looking great but wasn't terrible and certainly did not look how he looked this morning. I tried salbutamol nebulizers...2 in a row didn't change a thing. Next I called Jannie (another nurse) to come take a look at him and we decided together he probably needed to head to the hospital. In the midst of getting all of that sorted I discussed the situation again with Erin and Jannie together. We decided since we do have an ER doctor on base at the moment visiting that it would be good to have her look at him.

So I found Kim (the ER doc) and brought her to see Dino. We decided waiting an hour to see if we could get rehydration fluids into him and see if that made a difference (he hadn't held anything down without vomiting since yesterday morning really) was worth a try. About 45 minutes later I had gotten a little over 200mls of rehydration fluid in him but he started not making great sense. Erin took a look at him and we just decided the hospital was our best bet.

So, Tracey (one of the missionaries who works in the Baby House who has a great deal of experience at the hospital), Kim, and I headed into the city. The hospital is a good 35-45 minutes from our center. Upon arriving I quickly learned that you can't just sign in you have to go be seen in the treatment room (where I think no medical people work)...they gave us a small square of cardboard that said asthma (not his problem but at least they got it was a lung issue right) on it and asked if he had a fever. I said yes and they promptly gave him paracetamol...I have no idea what dosing they used considering they hadn't weighed him, didn't ask if I had already given it to him (which praise God I had given him ibuprofen in the car not paracetamol).

Next he went to go see the doctor. I did not go on this adventure because Tracey's portuguese is much much much better than mine. But, he was seen by 2 doctors, oxygen was discussed, along with nebulizers, blood work, and a chest x-ray. Ok...sounds pretty positive right? So Tracey called me because in the midst of blood work Dino decided he needed to pee...and soaked the exam table. I sunk my little way back (because only one person can stay with the kid) with diapers for Mr. Dino. Well they had started an IV (in his hand praise Jesus...usually they just go for the neck), drawn blood work, then we were taken back to another area (I guess I could describe it as our ER rooms). They started giving him normal saline nebulizers and inhalers of ipratropium. Here comes the best part...they weren't using a spacer for the inhaler...instead their make-shift idea was to use a cut in half water bottle. So they had cut it and were using the cap side for the inhaler to go into and had put tape around the cut off part so it wouldn't cut your face when they put it on you like a mask. WOW! Well he never got any of the meds because they would spray the inhaler and immediately take the "mask" if you could call a cut off water bottle a mask off his face immediately.

Alright so for the next 4 hours we sat...they gave him nebulizers...which really meant we held him down and held the mask on his face and then inhalers (where he got no medicine). Absolutely nothing changed. His respirations remained 60/minute, nasal flaring continued, he was grunting sometimes...altogether not good. Oh and another situation...they started an IV drip of glucose but about halfway through it stopped. I even asked the doctor/med student/intern that was attending to Dino, "Doesn't he need that?" His answer was only one time...WHAT? Well in another hour or so we got another attending doctor/med student/intern who finally noticed it had stopped, had a nurse flush out his IV (which was infiltrated), and start a new one so he could get the rest of his fluids. Starting the new IV was a situation...I'm pretty sure the first nurse stuck him 5 times (several times with the same needle) before she finally called someone else who got it on the first try. But I was amazed that after stick #3 she went to get me gloves since I was holding Dino's arm for her and cleaning up the blood from the other sticks was not her strong suit. So on we continued with no change. This new doctor also noticed his fever was up again and ordered 4mls of paracetamol...I got a little excited thinking they are actually going to give this kid liquid, a novel thought. Well they did give him liquid but who knows what the dosing in 4mls is because liquid means yet again another water bottle filled with crushed up paracetamol in water/sugar water. Yea...great idea. Anyway we got that down him...ok no I got that down him because of course the nurses don't give medicine they just pull it up.

Well then a miracle of God happened...someone called a pediatrician!!!!!!! Praise the Lord! She walked in and immediately said...he hasn't changed...why's he not on oxygen and where is his chest x-ray?? So we were rushed back to the baixa (or ICU), he got his chest x-ray taken (something that usually you would have to walk to the adult hospital, wait in line, wait for it to be printed, and return with) right there in the baixa. AND HE GOT STARTED ON OXYGEN...only 5 hours after we arrived. Mind you it was 10L of oxygen...a bit much for a 3 year old but oxygen nonetheless. What a situation?!

So I'll ask your prayers for Mr. Dino who is still in the hospital. He was admitted, and we assume will at least stay the night in the ICU and possibly be moved to the peds floor tomorrow. One of our tias is with him...her name is Tia Sandra if you would pray for her as well. The care takers in the ICU are not allowed to sleep or keep any personal belongings with them. They just have to sit at the patient's bedside and wait for instructions. I have also heard they are not allowed to sleep. So please keep them both in your prayers. I will keep you updated as we hear more this week.