It's early Sunday morning and the drums are pounding. Deep, holding bass thumps with rhythic higher pitched hypnotizing beats wafting through the background. In a few minutes, a mournful call pierces the African pre-dawn calling the faithful to the first prayer of the day with a long, drawn out "Allahu akbar!" Finally, to complete the symphony, church bells start tolling across town as the dawn breaks. But the music is rudely interrupted by a harsh clanging on our sheet metal door that can only be pounded out by the bare knuckles of a nurse seeking a doctor.
"Yeah?!" I mumble.
"C'est moi, it's me, Augustin."
"I'm coming!"
I fumble for my shorts hanging over the foot of the bed and stumble out the door to the porch where I open the screen door and come face to face with our charge nurse bearing a flashlight and a small carnet which serves as our patients' portable medical records.
"I just received a young boy who has respiratory distress. His whole chest caves in and you can hear the noise of his breathing clear across campus."
As I hurriedly put on my scrubs and follow Augustin through the bushes, around Lazare's fire pit, under the mango trees, on top of the straw and horse poop, to the side of the container, and through the gate into the hospital compound I understand what he means as I can hear a high pitched rasping coming from the dimly lit emergency room door.
A young boy is slouched across his mother's lap as she balances on a stool holding him up under the arm pits as his lower chest literally caves in all the way to his spine while desperately trying to suck in oxygen as he lets out a stridorous breath. His eyes are bugging out and almost rolling back. I listen to his chest with my stethescope and hear practically nothing. I place it on his neck and hear loud stridor. I get him to open his mouth and where the back of his throat should be is a smooth, bulging mass.
I'm afraid I won't get him to the OR in time. I call Caroline to help me and pick up the child in my arms as I jog over to the OR, flip the padlock to the secret code, insert the key in the door and burst into the OR. Fortunately, this morning the batteries have held their charge through the night and we have light. However, I'm afraid the power will go out any minute so I send Augustin to wake up Steve to turn on the generator.
Meanwhile, I lay the child on the operating table and give him a shot of IM Ketamine while Caroline searches for an IV. Just then, power goes out but I hear the slowly increasing thump thump thump of the Lister engine starting up and in a few seconds I can turn on the overhead OR lights and we are back in business.
I dump the cardboard box of endotracheal tubes on the floor as I rifle through them searching for one small enough for my patient. I finally find a 6.0 uncuffed tube and grab the laryngoscope out of the bottom drawer of the anesthesia machine as I slip on gloves. Caroline now has the IV running and the boy is now under Ketamine anesthesia. I find a guide wire, put it in the ET tube, check the light on the laryngoscope, raise the bed and open the kid's mouth. There is no way I'm going to see the vocal cords, the entire back of the throat is swollen shut.
I toss the equipment aside, grab a 15 blade scalpel and a suture removal kit, slice vertically down the middle of the neck, find the space between the tracheal and cricoid cartilages and poke through into his wind pipe with a hemostat. I spread it open, suction out blood and shove in the ET tube. I then hook up a bag and give him some breaths. The chest rises and I see vapor in the tube. I check with a stethescope hear breath sounds only on the right. The tube's in too far. I pull it out slightly, confirm there's now bilateral breath sounds, suture the wound closed, suture the tube in place and continue bagging.
His oxygen saturation is now up to 92% from the initial 35% so I stop bagging and just let him breath through the tube. His sats hover around 84-88% which isn't great, but without a ventilator and labs to follow it's more dangerous to bag him then to let him breath on his own.
I then try to place a nasogastric tube so he can be fed past the obstruction in his throat. It won't pass the mass. I stick my finger in his mouth and try to shove the tube in through his nose while feeding it past the mass with my finger. Suddenly, pus gushes out his mouth. I've ruptured the peritonsillar abcess. I quickly suck out the foul smelling pus and am relieved that it was so easily taken care of.
We wheel him out to his room and give his family instructions.
Later that evening, I go to check on him and find his tube choked up with secretions. We have a suction with a trap that allows me to put one end down the ET tube and then by sucking on the other end pull out the gunk into a chamber between the two ends. Very high tech. He starts to breath easier. I tell Jason to check on him every hour and suction as needed.
The next morning, he is awake, but tired and breathing fairly easily through the tube. I have the family members sit him up, suction him one more time even though it's pretty clear and move on to the other hospitalized patients.
In less than 15 minutes, Annie comes running up to me.
"Stuff's coming out his trach, he's not breathing!"
I run back to his room, chase out the family members and see instantly his tube is clogged up with pus that's dripping out. As I grab the suction to clear his airway I see he's not breathing and his eyes are rolled back. He has no pulse. As I suction, Jacques starts chest compressions. When the airway is clear I attach the bag and start breathing for him.
We take him to the OR quickly. We attach our cardiac monitor. He finally gets a heartbeat back with a pulse but after a few minutes it slows down again until we do more chest compressions to bring it back. We try multiple doses of Atropine and Adrenaline. His oxygen saturation stays in the mid to upper 80's when we bag him. But he just doesn't want to come back. Finally, after 90 minutes we are forced to stop. We wrap him in a cloth and call in the family. The dad nods, he's been expecting it. He wraps the boy up in his arms, carries him out and the family mournfully walks out the gate.
The drum beats on. The call to prayer continues. The bell keeps on tolling.
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