From James:
I stand at the foot of her bed. Kristin and Augustin are the nurses on duty and the three nursing students, Ndilbe, Honoré and Innocent are gathered around, white coats spotless, notebooks and charts in hand.
The patient has just come out of surgery two days ago for a walled off, perforated appendicitis. At first glance, she seems to be doing fine. She's staring at me with understanding eyes and breathing rapidly but easily. Then, I notice beads of sweat all over her chest, face and arms. I pull off my stethescope from around my neck and press it against her thorax. The heart beat is rapid and irregular. She's mid thirties and shouldn't have heart disease. What is it?
I look at the chart. Her vital signs there are listed as normal. Then I notice that she's been still kept NPO (nothing to eat or drink) but hasn't got IV fluids in 24 hours. I quickly have the nurse put up some Ringer's lactate IV solution. I think maybe she's dehydrated and has some electrolyte imbalances. We can now at least check his potassium thanks to the Danes and I go ahead and give him a little expired Magnesium that I've been hording in my little stash in the pharmacy.
Then, I remember the heart monitor/defibrillators that our two young volunteers for the summer brought over. I go to the OR stock room and find one that still has a charged battery despite never being charged since arrival in Tchad three months ago.
I hook it up to the patient. The screen is so small and the heart beat so fast it's hard to tell for sure, but it looks like atrial fibrillation or atrial flutter.
I stand at the foot of her bed. Kristin and Augustin are the nurses on duty and the three nursing students, Ndilbe, Honoré and Innocent are gathered around, white coats spotless, notebooks and charts in hand.
The patient has just come out of surgery two days ago for a walled off, perforated appendicitis. At first glance, she seems to be doing fine. She's staring at me with understanding eyes and breathing rapidly but easily. Then, I notice beads of sweat all over her chest, face and arms. I pull off my stethescope from around my neck and press it against her thorax. The heart beat is rapid and irregular. She's mid thirties and shouldn't have heart disease. What is it?
I look at the chart. Her vital signs there are listed as normal. Then I notice that she's been still kept NPO (nothing to eat or drink) but hasn't got IV fluids in 24 hours. I quickly have the nurse put up some Ringer's lactate IV solution. I think maybe she's dehydrated and has some electrolyte imbalances. We can now at least check his potassium thanks to the Danes and I go ahead and give him a little expired Magnesium that I've been hording in my little stash in the pharmacy.
Then, I remember the heart monitor/defibrillators that our two young volunteers for the summer brought over. I go to the OR stock room and find one that still has a charged battery despite never being charged since arrival in Tchad three months ago.
I hook it up to the patient. The screen is so small and the heart beat so fast it's hard to tell for sure, but it looks like atrial fibrillation or atrial flutter.
She's gotten a couple liters of fluid and the magnesium and now the potassium comes back normal. She seems stable enough so I leave the monitor hooked up but turn it off to save battery and move on to the next patient. Maybe she'll come out of it on her own.
It's 9:30am.
After finishing rounds and seeing the first batch of ER patients I perform a hernia operation with mosquito net mesh and repair to my office for some ultrasounds.
Augustin knocks on the door.
"Ca ne va pas," he says "Bed 10 is in respiratory distress."
I hurry over to the ward, worried that she's already dead (which is what "ca ne va pas" usually means coming out of a nurse's mouth). Fortunately, not only is she still alive, but she's consious and not really in respiratory distress. However, as I turn on the monitor, I see that her heart beat is still 150-160 and irregular. I feel I should do something but it's been a long time since I've had to deal with cardiac patients and I'm not exactly in the best equipped place to deal with it.
I hurry back my office to look up my little "cheat sheet" on electrical cardioversion. It tells me I should sedate the patient first if possible, put the defibrillator on "sync" and start with 100J. Ok, I feel a little better, it's starting to come back.
I hook up the defibrillator pads, give her some Valium IV, turn on "sync" and see the little dots appear over the QRS complexes on the EKG, turn the knob to 100J and hit charge. I hear the whirring of the charge and then it's ready. But now, I don't know how to make it decharge. I look all over and see nothing. Great.
I turn everything off, take off the pads and return to the OR where I find the paddles with their large, curly-cue phone cable like cords. I hook it into the defibrillator, check out the little buttons and place one over her sternum and the other on her left side under her armpit.
"Everyone back," I announce. "Don't touch the bed or anything!"
She's still staring up at me wondering what the heck I'm doing (as do I). I see that everything is well sync'ed. I hit the charge button and then the two "shock" buttons. Just like in the movies or on TV she bounces a little off the bed, her head thrown back, and then flops back down. The EKG makes a big wave, a brief flat-line and then a normal rhythm of 110 beats per minute starts to play across the little green screen.
I almost can't believe it. I know it's supposed to work according to all I've read and been told in my ACLS courses, but come to think of it, even in the US I don't think I've ever been present for a synchronized cardioversion.
My heart is full with thanks to God for bringing everything together to make it possible for us to save this woman's life first with the operation and then with what I had considered mostly useless defibrillator monitors.
Shocking!
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