Status Asthmaticus

One of our visiting family medicine residents1 called me late in the evening to report on a child she was admitting to the ICU. She had an 8 year old patient to whom she had already provided all of the standard treatments for asthma (multiple albuterol nebulizations, steroids, and oxygen) yet he was still breathing very fast, requiring too much effort, and his oxygen saturations remained low. She was working her way down the treatment algorithm and getting near the bottom where it recommends:  “transfer for resource and time intensive interventions available at your pediatric referral center,” “Admit to your PICU for specialized consultation and care.”

I have two principles that I use to help me weed-out and avoid pediatric disasters.
1) Sick children look sick.
2) Children are very resilient, so they crash with minimal warning signs.

This patient was scaring me on both fronts.  He looked sick to the resident physician, he was breathing in a way that was burning through his reserves, and at some point his body would get too tired to sustain breathing like that. If that happened he could very well die.

So I went down to the hospital and asked a visiting veteran physician to meet me there so we could put our heads together and assess the situation.  On arrival I had a strange reaction from the family.  Even as I determined that we were at or near maximum intervention and their child was not responding satisfactorily, they started to relax as I spoke with them.  When I then told them things were very serious and I was worried they started calmly discussing their plans for the evening, including me in the discussion. (The father was thinking about going home to watch the other kids and wondered if he would be ready for work the next day.)

I was confused by their reaction.  Was I unclear? So I stepped up my communication of the situational gravity by asking if we could pray together for their son.

As we prayed for their son’s life and breathing, with his chest rising and falling too rapidly, sweat beading on his brow, I looked at his face which was slightly obscured by the non-rebreathing mask and recognition slowly dawned on me.  I had had an unplaceable sense of familiarity with this family since walking into our ICU, and suddenly I began to understand why this family had relaxed after I took charge of their son’s care. This 8 year old was one of our church kids, he and his parents were semi-regular attenders of our hospital church.

(One my biggest social anxieties is meeting someone out of context.  I think it has to do with the way my male brain compartmentalizes things – but outside of whatever social or geographic location which I typically associate with you, let me apologize now, I don’t remember your name or how I know you… Sorry. If it’s any comfort, your face is vaguely familiar. So without my wife in the ICU to remind me who this family was and how we knew them- I was very slow on the uptake.)

I preach at our hospital church about once a month. And my normal style is to invite all our kids (10 to 20 kids) to the front of our sanctuary and have them help me present and talk through the scripture reading and its application before the entire congregation.

My insufficiencies aside, they had trusted me to preach at our church and to lead their kids, they knew my heart and knew I would do everything our hospital could do with God’s help to save their boy. They were able to relax, despite the terrifying possibilities, because they trusted the doctor and more importantly the God, who held their child’s fate in his hands. 

With such trust, I sent off a text to my wife and the head pastor of our hospital church (he is also our hospital CFO and children’s sanctuary home co-director) asking for prayer and got to work with the resident, the visiting veteran physician, and our head of nursing putting together a plan and multiple tubes and older machines, to create a pediatric Bipap, continuous nebulization, 100% oxygen delivery system.

If you had asked me prior to that night if such a system was feasible at our hospital I would have said no.  Each of those 3 things is possible at our hospital, but combining all three to work safely and effectively together on a kid was miraculous.

We receive tons of great donations that keep our hospital running.  But sometimes for less frequently needed application all we have are well meaning donations that do not quite fit the bill. Sometimes our tubing is incompatible, a seal dry-rots, the quality is one-time or home-use grade, a motor is burned up by erratic electrical power, or we never found or received the specific tube, plug-cord, or what-have-you that is absolutely needed to make things work together.

In addition to the miraculous way we were able to put together a system to help this boy keep breathing. The resident who had admitted him stayed up through the night watching him and giving him various carefully dosed IV medications, monitoring his responses and staying vigilant for signs of decompensation. Furthermore our nurses broke open countless glass vials and refilled his nebulizing chamber every 10 minutes through the night (using almost our entire hospital supply of albuterol). Finally, as the morning dawned, it became clear that he was turning the corner for the better. A few days later he was discharged well enough to go home. Praise be to God!

This story brings two thoughts to mind:
1) I come into contact with so many new people each day, that I can easily fail to recognize the value of each person and the potential importance of my interaction with them. C. S. Lewis (as usual) says it best for me:

There are no ordinary people.

You have never talked to a mere mortal.

Nations, cultures, arts, civilization—these are mortal, and their life is to ours as the life of a gnat.

But it is immortals whom we joke with, work with, marry, snub, and exploit—immortal horrors or everlasting splendors.

2) Being a medical missionary gives me many opportunities to be anxious. Its easy to lay in bed at night thinking through endlessly looping problems that I cannot solve. I want my prayers to be like this this boy’s parents conversation and trust in me. Even when bad things are getting worse, I want to be able to trust God, relax, and plan out my next steps knowing that He is trustworthy and faithful.  As the serenity prayer says,

God, grant me the serenity to accept the things I cannot change,
courage to change the things I can,
and wisdom to know the difference.

Reinhold Niebuhr
A Serene Sunset that happens many evening right off my porch

1 In the USA a resident is a physician who has finished the theoretical and practical exams and training necessary to be awarded a doctorate in medicine but is undergoing a further intensive multi-year training to acquire a board certification such as Family Medicine, Pediatrics, Internal Medicine, General Surgery, Anesthesia…

The views and opinions expressed in this blog are not the views of Samaritan’s Purse or World Medical Mission.

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