Since last Monday (August 30th), I have been in charge of the paediatric ward. The ward only covers children up to 12 years old but most patients are under 18 months. It has four sections – high care (there are four beds which are usually all used up by very sick children), surgical care (this is mainly burns patients as well as minor surgical procedures), gastro bay (unfortunately, this is very common here for obvious reasons such as infants drinking water from the tap but also because many mums give their children enemas as suggested by the sangoma – the zulu traditional healer) and a large bay with all other patients.
I was thrilled (and scared) to be in charge of paeds as this is an area of medicine that I love. My days now involve starting the paeds ward round at 7.30am – completing it whenever I can – and then joining my colleagues in OPD for the rest of the day. This is usually after tea. Once a week, I spend the day in theatre so on that day I only see the new and sick patients between theatre cases.
The paeds ward is run very differently than I am used to. I work hand in hand with the top ward sister (her status is clear from the deference shown by other nurses). I took a few days to adjust to the set-up which involves each mum bringing their sick child, their medical notes, nursing notes to the sister and me. (I feel we should go to each cot where each infant lies (*) But at the moment I am scared to rock the boat. I do worry about confidentiality – as it is carried out in the middle of the high care bay – but sister usually asks the mums to leave. The other aspect that I am not used to is the constant cleaning by the pink ladies. I seem to spend half my time lifting up my legs or moving to one corner of the bay to avoid having a bucket thrown on me. I used to find it frustrating but now it is the norm. I also have stopped pointing out all the cockroaches that I spot. When I did, it caused huge hysterics. One aspect that I do enjoy on ward round is the constant giggling – most of the time I have no idea why all the staff are laughing but usually I join in.
My first week on the ward was good. There were less patients due to the strike and no one died. This week has been much harder, I have four times more patients and have had three deaths in the past two days. Yesterday was quite horrific – a 9 month old child - who I only met yesterday morning - had gastroenteritis (probably secondary to an enema but denied by mum and gogo) which lead to an aspiration pneumonia. When I arrived at the peri-arrest, things looked bad - the infant was gasping and the heart was beating slowly. I phoned my colleague Natalie to assist me and so pleased I did. Soon after Nat arrived, we started cardiac arrest. The arrest was similar to that in the UK except that you don’t have the same high tech equipment. There are of course no paddles/ electric shocks and we used a lumbar puncture needle to create an intra-osseous line (as we had lost the intravenous line). We tried for a good 20 minutes – and managed to get the heart back once – but with no ventilator there is not much we can do. I felt awful when I broke the news to mum (she was 20 years old and had also lost her first born – child mortality is far too common here). I held a debrief session in the afternoon which all the paeds staff attended – I explained why the child died and also did my best to ensure they did not blame themselves.
Today, my colleague Holger (who is in charge of maternity) asked for my help with two very sick twins who had been delivered by c-section just a short time before. I arrived and once again started CPR on one of the 32 week premature babies. We have no surfactant (which helps the lungs mature and work) and no ventilator so I ended up spending a few hours giving oxygen to the baby after we had secured a definitive airway (intubated). We were waiting for the helicopter to arrive. Unfortunately, the little boy died before the transport arrived despite all our efforts. The little girl was still alive when air transport arrived but then exhausted herself and died before they could fly her down to Durban. Luckily, the helicopter was used for a pregnant woman who lost her baby in utero and was bleeding extensively internally. I do not yet know the outcome for her.
Although at times the job is incredibly difficult emotionally, it is balanced out by the occasional good outcome and the hardworking staff who seem to always be giggling.
* At night the mothers sleep underneath the cots.
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