The time is 0830hrs on a Monday morning, at the hospital ICU. Mr M. and I have headed there early, hopeful to catch the morning care routine of a patient with a tracheostomy tube. This is for learning purposes in our ENT rotation. We have no idea what is awaiting us.
We meet a nurse, whom we ask about the patient of interest. Soon our conversation shifts to general questions on the equipment in the ICU, such as the respirator, cardiac monitors and suction machines. “Mbona mnakaa nje? Ingieni muone,” 1 she says, inviting us inside.
At the bedside of interest, there is a young lady, hooked up to cardiac monitors, with a breathing tube, urinary catheter, etc. Many tubes. I take one look at her and find myself quietly asking Mr. M., “Huyu atasurvive kweli?” 2 A rather insensitive comment, I know.
The lady is gasping for breath, her hands restrained to the bed so that she doesn’t extubate herself in her distress. Two nurses are trying to get a blood pressure and SpO2 reading. A quick analysis of the situation by Mr. M. leads him to pick up gloves and adjust the blood pressure cuff. A reading of 76/28mmHg appears on screen. That’s low. The patient is hypotensive.
The doctor in charge comes in to collect blood from the femoral artery for a blood gas analysis. He collects his sample and the ABG 3 analyser is at the bedside. We quickly gathered around the nurse to see the results and refresh our clinical chemistry knowledge. The pH indicates acidosis at 6.99, pCO2 is high at 56.2 mmHg, and bicarbonate low at 14.0 mmol/L. Blood sugar and lactate are elevated at 27mmol/L and 3.5mmol/L respectively.
We are debating whether she has metabolic or respiratory acidosis when a consultant arrives. As usual, the patient file is brought to the doctor and new information is blurted out. We learn our patient is a 23-year-old para 2+0 gravida 3 mother, at 8 weeks gestation. (This means she had 2 previous pregnancies and is currently 8 weeks pregnant). She had been brought in from a peripheral facility and admitted to the ICU 2 days previously, with a diagnosis of diabetic ketoacidosis.
The Conso 4 checks the treatment sheet and sees norepinephrine which he knows will box her kidneys in even further. She looks puffy and he wants to dialyse her. He asks for a light and I hand him my black pen torch. The patient’s pupils are fixed, slightly dilated and unresponsive to light, in both eyes – a bad sign. He asks for some cotton to test the corneal blink reflex. This tests for brainstem activity. (If you touch the cornea with a dry wisp of cotton, you blink and lacrimate). There was no response. The Conso decides that we should initiate CPR (Cardiopulmonary resuscitation).
We have now been joined by Mr. S., a curious student who wondered where we were and followed us. I began performing 15 sternal compressions followed by 2 breaths of oxygen via bag-mask ventilation. I’m quickly reminded that it’s actually 30 compressions per cycle and I intensify my efforts. On the screen, the heart rate reads 155 beats per minute, and the ECG is a blur of strange lines which I cannot interpret.
Mr. M. takes over. He is gentle with the force of his compressions, but does it correctly, counting out loud with each, and stopping promptly to allow for bagging after a cycle of 30. Mr. S., when it’s his turn, is dramatic in comparison. He is putting his entire weight behind the compressions and doing them at a higher speed. You can see the abdomen protrude with each compression.
Mr. S. stops and now everyone looks at the screen. The famous flattening of the line we see in movies is now right in front of our eyes. “Kwa nini mmeacha CPR? Haiya…” 5 I ask as I take over. With each stroke of mine, bizarre ECG lines appear on the screen, so I think, maybe the CPR is helping. But with each pause, the flat line appears. I get tired and auscultate. There are no heart sounds but I hear breathing sounds only to understand later that as I was auscultating the bagging was continuing, mimicking the sound of a spontaneous inhale and exhale. It has proven futile. “Time of death, 0953hrs,” declares the doctor.
There are no major feelings going through me from the time that statement is made and onwards. The only thought on my mind is that it might have been me, in another life. We were the same age, anyway.
Glossary
- “Mbona mnakaa nje? Ingieni muone,” – “Why are you staying outside? Come in and see for yourselves.”
- “Huyu atasurvive kweli?” – “Will she survive?”
- ABG – Arterial blood gas
- Conso – Consultant doctor
- “Kwa nini mmeacha CPR? Haiya…” – “Why have you guys stopped the CPR? Okay…”
