The doctors at Hospital Loma de Luz, take 24 hour call 1-2 times a week. That means that from 7am to the next morning’s 7am, any emergency or obstetric problem that comes into the hospital will be primarily the responsibility of the on call doctor. For my first 2 months here, each time I was on call I had someone assigned to back me up and show me the ropes. This is necessary because the norms of treatment, follow-up, and getting things done are so different from how things are done back in the USA that you need someone to walk you through a lot of different scenarios before you can really work independently.
For instance, if you need to give your patient a medicine through an IV at a specific rate in the US, you simply enter the order and wonder why it takes the pharmacy and nurses so long to do it. Here you go to the pharmacy, retrieve the medicine or find an adequate substitute for the medicine you wanted but don’t have, find syringes and fluid bags, then mix the medicine into solution at a concentration that will allow you to run it through a pump (A lot of moderately complicated math). Find a IV pump, place an IV if the patient doesn’t have one, hook it all up and program the pump to run at your desired rate… and then wonder what happened to the last few hours.
After about 2 months of call with back up, I recently started taking call independently. My first two independent call shifts were rough.We have an awesome team that is very supportive of one another, but we also try to take care of each other by handling anything we can independently, and only calling for help when it is absolutely necessary (especially during the night). During my first shift I had about 6 medically complex admissions topped off by a young man who came in with 4 gunshot wounds – 2 to the neck, 1 to the chest, and 1 to the abdomen – whereafter I promptly called and received help. But all of the patients did well, and were pretty clear cut from a diagnostic and treatment perspective.
My second independent call shift was not so clear cut.
Things were generally okay during the daylight hours, but as dusk settled I started getting calls.
Out of the several ER patients that I was called to come in and see, I can now only remember two. At about midnight I saw an older gentleman brought in by his son because he was having trouble breathing. I was able to determine that he was fluid overloaded due to advanced liver failure and a recent medicine change. This was based on the history that I obtained from his son and my physical exam because we do not have lab or X-ray available during the night (except for clear life or death decision points that prompt us to call staff to drive in from the surrounding community during the night). So I talked with his son about our treatment plan, his good short-term but poor long-term prognosis, and then started the treatment which I would modify based on the labs that could be done in the morning.
I went back up my house, but before falling asleep I was called again. It was about 2am…
A 21 year old girl with abdominal pain and nausea was brought into the ER in middle of the night. Her blood pressure was too low but she was conscious and it was not worsening, her abdomen was rigid, her blood sugar was too high for our machine to read and she was becoming deathly pale. She had a strange history of going to a different hospital the previous night, going home, resting, eating, then coming into our hospital for the same unbearable pain that had sent her to the other hospital.
I began to treat her identified problems individually, but was not sure of her unifying diagnosis. As I was trying to decide if I should call for help or lab, one of the nurses asked me to come quickly. I followed and she took me hastily to the room of my patient with liver failure explaining that she had just gone to check on him and found him dead. I entered the room where the patient’s son was by his bed – unaware that anything was out of order. I confirmed the patient was dead and then tried to gently but clearly explain to the son that his father had just died unexpectedly. After taking as much time as I felt I could, I went to check on my 21 year old female patient and found that her oxygen saturation was dropping. With my confidence shaken and my patient doing worse, I promptly called for help from the more experienced physcians.
Ultimately, we determined that she had a very dangerous condition called diabetic ketoacidosis (DKA) coupled with the even more deadly condition called sepsis. As we tried to treat her, we came to an impasse. The treatment for DKA is to rapidly but carefully lower the blood sugar while simultaneously addressing the acid-base and electrolyte disturbances created by both the disease and your treatment of the critically elevated sugar. To do this right, one needs to monitor and replete the electrolyte called potassium, while monitoring and correcting the acid-base status, and constantly titrating your insulin to lower the sugar (in the USA most hospitals purchase a proprietary software uses a complex computer model to anticipate the patient’s blood sugar responses and guide insulin titration).
Problem #1: Our acid-base test is so finicky it cannot be trusted.
Problem #2: Our electrolyte machine broke 2 days ago.
Problem #3: The country is shut down for COVID-19 so getting the replacement part will take at least a week.
Problem #4: Septic shock is the body’s final, unregulated and often devastating response to an overwhelming systemic infection. It’s treatment is to give copious fluids, broad-spectrum antibiotics, and start life-support measures like pressors and a ventilator while rapidly determining the source of the infection.
This is the tight rope we were walking:
If she becomes to acidotic she will die – and both DKA and sepsis create acidotic states.
If we leave her sugar that high she will die of sepsis – if we drop her sugar too fast and she goes too low – she will go into a coma and likely die.
If we do not give her adequate potassium near the time when her potassium begins to drop due to our treatment of high sugar – her heart will not be able to keep pumping – if we give her too much potassium, well, potassium is the drug of choice for lethal injection.
With these limitations, we did everything we could to help this young lady. We prayed for wisdom and healing and made our best educated guesses on what to correct – when.
For a while the patient was stable on two forms of life-support: pressors and a ventilator. I had spoken with her mother and our chaplain about the gravity of her situation (she had already required chest compressions and life saving medicines once that morning, which decreases the odds that she would survive to be discharged). I then went and saw my clinic patients. I checked on her several times throughout the day and I started to be hopeful that she might pull through. We arranged to split shifts to run her ventilator between 3 doctors who were not on general call that night (we do not have any respiratory techs or dedicated ICU nurses). I went home, explained to my girls in very basic terms why they hadn’t seen me for so long, and we said a prayer together for my patient.
That night, my patient’s blood pressure started dropping and despite chest compressions and meds, she died.
The next morning my 5 year old asked me how my patient was doing, the one for whom she was praying. I told her that she had died during the night.
“Why?” she asked.
“I don’t know.” I answered. And I don’t know. I don’t know why she died.
Medically, I don’t know if she died from an infection for which I wasn’t covering, an electrolyte imbalance I caused or didn’t correct, or something I had no control over. Spiritually, I don’t know why God didn’t answer our prayers for this 21 year old girl, when other times he so miraculously intervenes (like in my previous shift when the man who was shot 4 times, twice in the neck and head, walked out of our hospital after prayers and surgery).
I understand the philosophical arguments for why bad things happen. Abstract discussions of love, free-will, the effects of sin on creation. But I don’t believe there is a simple or straightforward answer to my daughter’s question. I believe the best answer is either silence or “I don’t know,” followed by an example of continued faith and prayer that mourns and wrestles with what happened while faithfully doing the next right thing. The Bible says we walk by faith and not by sight. Despite what we see or cannot see around us, we keep walking in faith.
I was hurt and saddened by the loss of two patients from the same call shift. But I keep walking by faith. I trust that God is good and faithful.
Nevertheless I went into my third call shift with some trepidation and prayer that God would give me a little more time to recover before my next medical disaster. And I am happy to report that my third call shift was rather uneventful. That morning, as I was nearing the end of my third call shift, I gave thanks to God that instead of severely ill patients I had the opportunity to be on the other side of things. I helped a mother deliver a healthy baby boy into the world in the wee hours of the morning. And as I went home, I stopped at our overlook and took in this view:
Clearly to me, God is at work in our world. I don’t always understand how He chooses to work, nor do I always know how I should pray. But I hold onto the faith of Jesus Christ and trust that He will not allow us to be tested beyond what we can bear.
Blessings on you all,
Please pray for our family as we continue to settle in, push through culture/COVID shock, and the newborn phase of sleep deprivation.
And please pray for the preemie baby in our hospital. Bethany provided breast milk for her until her mother’s milk came in, and the baby has survived almost a week now, but she has several more weeks before she’ll be out of the woods.