Batting 1.000! Well make that .750 if we include Lorolwane

Three up, three still up! Let’s begin from the end.

Just so I’m clear; there is nothing as fun and rewarding in my profession as pulling a child back from the ragged edge. Today, Friday, I had a little time on my hands to explore some clinics that I might visit in the Kanye District. On the way out to Kanye I always pass a cool little town named Nthlanthle, pronounced with clicks. Kinda like your tongue is disarticulated at both ends. It has a clinic outpost staffed by a nurse. I found it and parked outside the now empty clinic and walked in, saying the Setswana greeting for “hello”, and no one was around. This is usual on a Friday afternoon as the nurse who works at these outposts generally sees patients in the morning and they thin out by 1:00pm. I showed up at 1:30 to an empty clinic and nosed around into various rooms seeing what they had to offer and how I might help them.

After the tour I walked outside to see a grandfather cradling a young child who looked big sick. Now I always emphasize to the staffs at the various places I visit that “sick kids look sick” and this child was going to the light. I thought ‘how the bleep am I going to do a resuscitation on this little guy here if I have no idea of where things are kept?’

The nurse came along (they usually live on site), I introduced myself, and we got busy. Let’s see, two day temp of 40, respiratory rate of 60 with paroxysmal movement, pulse of 130…Now I’m definitely not the brightest bulb in the box but even I know this represents sepsis.

So we weighed him and found him to be 1.2kg less than last week, presumably from the diarrhea and vomiting he had had for that time. As we were doing this he coughed a deep cough and the problem became clearer. Just from the vital signs he had pneumonia, but this cinched it. We took him back to an exam room and Diziro, the nurse, got things ready as I prayed to find a vein. This kid was precisely the wrong age and race; a chubby African, 7mos of age, dehydrated and septic, with no veins. We must have stuck him 15 times. I was thinking if an intra-osseous but thought I’d give it another shot. I said a quiet prayer (I’ll cut back on the swearing, see “bleep” above, if only I could get the Big Guy on the side of this child and his aged doc) and slipped in a line into a scalp vein as sweet as you please. In went fluid (LR, it was the only thing we had Amber, sorry) at 20cc/kg x3. At this point the child fell into a deep sleep but not without me checking his vitals every five minutes. By now my back was up and if Death wanted this child he’d have to go through me.

Next was an antibiotic (Ceftriaxone) at 100mg/kg. Then I wound this kid’s head with anything I could find to secure the IV, looked like he had a turban. He awoke about half an hour later and started to coo and chat! Man this stuff works great. The ambulance came from Kanye, about 40km from Ntlanthle. and we loaded him on to send him to Lobatse. I called my friend Roger there who got things set up at the hospital. He should make it. I was able to congratulate Diziro about the clean save and shed a little mist. Man that was three hours of intense work but what a thrill. If I had been in Sudan I would have had no time to reflect on it as it would be on to the next patient. Here it was driving home to the Gypsy Kings.

Wednesday we were in Malwane, a clinic in the Mochudi district, way out there. In other words, my kind of place. I was discussing with the MO there how taking time to treat patients with four types of pain (literally) was a waste of his time, and was at some level co-dependent, and that the “sickest patient is always in the queue” Sure enough half an hour later and many somatising and malingering patients later, in walks (barely) an HIV+ woman with a BP of 80/palp, pulse of 170, and R’s of 32. Sepsis, it hits you over the head sometimes. In went an IV, three liters of saline, some antibiotics, and she was transferred to Mochudi. The receiving doc was unimpressed with her sepsis (that because we already gave her FOUR LITERS) and treated her as a simple case of pneumonia in an HIV+ woman, like THAT is ever simple.
Never the less, it was clean save number two. This time I was able to congratulate the med student accompanying me as he rode in the back of the ambulance securing the IV’s. Sweet save!

In Tsabong (we fly there as it is WAY out there, I know--cool) on Tuesday I was rounding on the wards with Julien, a doc from DRC who was confused about an obtunded HIV+ woman with low blood pressure. “That’s because she’s septic” says I. We got busy, he started an external jugular and five liters and some antibiotics later she was back from the brink. Save numero uno.

These were all great teaching case especially because they lived (!). It DOES happen in threes just not always this good….