Stanford University
Center for Innovation in
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Rural district hospital with no ICU

Posted 4:48 AM, March 3, 2012, by Lena

On a Friday afternoon, we finished early in ARV clinic and so I stopped by the peds ward to check on a few of the patients I had seen the previous day - one with suspected epidermolysis bullosa and who presented with progressive weakness and difficulty walking over last 7 months, concerning for a muscular dystropy.

Upon entering the ward of 35 filled beds, I was immediately drawn to a single bedside where the other doctor and two of the nurses seemed to be occupied. Even from the other side of the room, it was apparent that child was in severe distress. His eyes were only partially opened, he was breathing rapidly and deeply, and his extremities all sat limply on the bed. The other doctor briefly filled me in on the history: this a 10 month former twin presenting with fever, vomiting, and diarrhea.

The child was found with a bicarbonate of 3, but the source of the excess acid in his system was unknown. Unfortunately, blood gases are not available at Church of Scotland Hospital (COSH). In addition, the creatinine, a measure of kidney function, was 10 times the upper limit of normal. Luckily he was still making urine. Still he was clearly in shock. We'd already given him antibiotics, presuming that the source of his distress was sepsis. My colleague was in the process of pouring intravenous fluids into him, when he had a brief tonic clonic seizure.

Our patient clearly needed a higher level of care, ideally intensive care, than we could provide. Unfortunately, the hospital we usually refer to had no beds available. I was very skeptical that without intubation this patient would survive. We could intubate him at COSH, but the nurses were not qualified to take of ICU level patient, so intubated patients had to be immediately transfered. I was at least glad to hear that we had a portable ventilator available for transport.

At this point, we called one of the most senior doctors in the hospital. He's been at COSH for 16 years, and although he's internal medicine trained, he spent 5 years running the peds ward. By the time he arrived, we were bag mask ventilating the child and had inserted an oral area, which seemed to help a lot. Still it was only a temporary solution. This experienced doctor made additional management recommendations, but essentially confirmed that if the referral hospital wouldn't accept the patient, we had no choice but to avoid intubation and do our best to manage the patient ourselves with the resources we had available.

I have only ever been at the referral hospital who is receiving patients from other transferring hospital. This was a less familar kind of frustration for me: knowing what to do, even being able to do it, but ultimately to the detriment of the patient. Finally we were able to find someone who was willing to accept the patient.

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