Is it possible to be exhausted and invigorated at the same time?

Hi All,
I am going to start by apologizing for my grammar, I realized I misspell every other word and don't take the time out to correct it or add proper punctuation. I am sure you all understand. I am either paying by the minute for Internet, or praying that I don't loose the connection in the middle of writing. ;)

First, going back to the young 8 yo boy, that had been hit by a care earlier this week, I found out that they found a splenic laceration in the OR, but that they were able to get a CT of his head later that day and he had severe brain injury and died later that day from respiratory depression. They didn't have access to a ventilator for him, but with his brain injury, it probably would not have made a difference.

Yesterday, Lisa and I had a very....interesting/challenging day on Surgical casualty. As we were arriving in the morning, the Canadian EM doc we had been working with was not around and there was only one practitioner, who was the equivalent of a NP or PA in the US. Soon after, the police brought in a man covered in dirt. We later put together the pieces that he had probably been hit by a car the evening before, fallen in the ditch where he stayed all night in the pouring (I mean POURING) rain. The police then found him in the AM and brought him to Mulago. He was covered in dirt, soaking wet, had obvious cranio-facial abnormalities and step-offs, abrasions all over his chest/abdomen, open fractures in 3 of his extremities, was non-responsive, with labored breathing. Lisa and I sat back for a while to see how this type of severe blunt trauma was managed. During the next few minutes, one of the nursing students worked on an IV and the practitioner looked overwhelmed and noted that the man was cold. Lisa and I tried to tell people that we needed to get the wet clothes off, but everyone looked at us like we were crazy! Almost a direct quote was "this is Uganda, we don't have hypothermia." Well the man's body temp was 32.4 degrees celcius which is moderate hypothermia (<32 is severe) so I guess we disproved that ;) From there, we pushed for the patient to be taken to the rescusation room next door given his condition. Josephine, the resuscitation nurse agreed. However, once in the other room, the practitioner did not follow! Knowing well that Lisa and I were only medical students, he left us to manage the trauma patient. I tried to get him to come help, but he had started seeing another patient with abdominal pain. So Lisa and I did all we knew, started lines, hooked up monitors/got vitals, got blankets and warm IV fluids, started the primary and secondary survey....but quickly recognized that we had been left alone. Early on during our exam, we recognized that his pupils were fixed and dilated, not a good sign with head injury! We knew that there was probably nothing we could do, but who were we to decide that! Luckily I was able to find the candadian EM doc to give us a hand.

We debated given the resources and situation whether intubating and CT scanning his head would be beneficial, and Dr. Martin (candadian) eventually decided to go with it. I got to try to intubate, but all the intubations I have done thus far where on healthy people in the OR. I set up everything I needed, got the laryngoscope correctly positioned and all I could see was blood, even after suctioning. With all the fractures, the anatomy was very distorted. I then gave it to Dr. Martin who tried to reasure me later that he had just done enough that "he knew where to go even without a great view" and it wasn't bad that I wasn't able to do it. From there we started treatment for increased intracrainial pressure, and eventually got him a CT of the head. This showed that he had a subdural hematoma, with SEVERE midline shift, his ventrical was collapsed. In other words, bad news!!! The decision was then made by the ICU doctor that there was no point in sending him to the ICU, that they would give him comfort treatment and put him in the back of the ward until he stopped breathing from his severe brain injury. Lisa just updated me that he died last night on the ward.

Reflecting on this is really difficult for me. I don't know exactly what to think. From lack of resources resuscitation is much different here. The practitioner did not seem to want to do any resuscitation, was this because he was overwhelmed and wanted someone else to deal with it? Or because he knew the outcome was going to be so poor that there was no use wasting resources? I guess I will never know. After seeing his blown pupils Lisa and I knew we couldn't make the decision of whether to proceed, so that is why we pulled in help. But after all this, Lisa and I definately had our first crack at managing blunt trauma on our own by default.

In contrast to this, I spent today in Acute Pediatrics where I was extremly impressed all day with the skill of the residents! I started by shadowing during rounds where I tried to pick up as much teaching as possible on Physical exam and clinical diagnosis without labratory tests and imaging. I then went to the emergency area for medical pediatric emergency, where there is ALOT of SICK kids, I mean really sick, where we may see 1 a day in the ER at UW. Over the course of the day I saw lots of pneumonia, diarrhea, extreme dehydration, malnutrition, HIV, G6PD deficiency hemolysis, ect. One girl we saw had a Hemoglobin of 3.9. In the US we transfuse for anything under 10 pretty much. Here they transufuse at 5. She also was vomiting some blood. Over the course of the day, it was determined that she probably had Acute Lymphocytic Leukemia and she began to have an uncontrollable nose bleed and blood in her vomit. Her platelet count came back later that day at 14,000. Normal is >150,000. We tried to get her platelets, but there were none in the blood bank. When I left today, she was still bleeding, and people were still trying to hunt down platelets for her. It doesn't look good. I talked with the peds resident here about access to chemotherapy for these kids. The government has a certain amount of all resources, including chemotherapy, and when it runs out it runs out. No matter where you are in your treatment. After the chemo runs out, the family would have to pay, which is unrealistic for the majority of the population.

Going back on my last few days, I think there is alot of value placed on youth. I have seen much more resources used and effort placed into taking care of children than I have for adults. I am not clear if this is just by chance, the people I have worked with, or a cultural importance placed on taking care of the youth. Also the medical community is very different here. Doctors in Uganda do not make much money at all, so in order to make a living dr's at Mulago also work at private clinics. As a Ugandian resident put it to me "we have alot more dr's working at Mulago on paper than in person and there is a problem with people taking responsibility" Those are her words, but I could even sense her frustration with individuals not taking responsibility for patient care, the checks and balances to make sure things get done are just non-existent. On the other hand, they are 100 times better at doing physical exams and do much more through histories than we ever do, we rely so much more on labs/tests. So I think it is important to see the positives and negatives of both systems.

On a brighter note, Lisa and I ate the absolute BEST INDIAN FOOD EVER last night!!! We went to "Haandi" indian restaurant down town and for $9 each we had an amazing fancy date :) I am still dreaming about how good the food was. That was our little treat to ourselves for the week, since most nights our dinner costs more like 40 cents to a dollar. From here I will sign off. Miss you all.

crystal