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ICU in the Bush

Story by Diana Zwijnenburg.

The call came on a Friday morning. It was a bright and sunny day as usual, and a medical evacuation (Medevac) was requested from Pyarulama to our hospital in Kompiam.

Pyarulama is a small village about 12 minutes away flying over rugged terrain, by foot it would at least take two full days. If you’re fit, that is.

Earlier that day, a man was working under his house, and it had collapsed on top of him. Fortunately, he was the only one injured, but he was pulled from under the rubble and badly injured. Mathew, the local health worker (CHW) informed us that he had a broken leg and maybe a broken pelvis and was crying out in pain. What else was injured was difficult to assess. So, we instructed him to give some morphine and triggered the request for a Medevac with MAF.

MAF was quick to respond but the plane was busy doing other work in the Western Province, so we had to wait until the plane was available. A few hours later there was finally the awaited message. The plane was free and was heading to Pyarulama to pick up our patient.

It was almost 5 pm when the patient arrived. He was a man in his late forties and was wrapped in a mosquito net and some other cloths, obviously to carry him into the plane. He was not very responsive and together with a group of men, we pulled him onto our spinal board and carried him to our ambulance for the short ride from the airstrip to the hospital.

On initial assessment, though barely conscious, he was breathing ok, however I was concerned about signs of a base of skull fracture with blood coming from his ear. His right upper leg was obviously broken, and there was a nasty graze with developing bruising across the front of his chest. Other than that, he seemed ok. Our X ray machine was broken, and we were awaiting parts to fix it, but we have an ultrasound machine, which was a real blessing in this situation. This showed that there was no collapsed lungs or blood in his abdomen or pelvis, so I was reasonably confident that there was no major pelvic fracture. Then there was the issue about protecting his neck, which is standard in all trauma cases. I had no X ray to check this, but with reduced consciousness and a big distracting leg fracture, his neck could not be cleared anyway. However, his head had been wobbling around unprotected from the time of the accident until now and he was still able to move all limbs. Should I put him in an ill-fitting collar, with the result that I increase the pressure in his head and make the results of a potential skull base fracture worse? I decided that that was probably worse, so I left the neck, assuming it was uninjured. We took blood to check his blood count and his blood group and got the theatre girls in to fit a traction pin. Under mild sedation and a lot of local anaesthetic, I inserted a traction pin in his lower leg and on the ward hung some weights on it. This instantly made his broken leg look a lot straighter.

The next day he looked a lot better. He was now fully conscious, and it suggested that mild head injury, together with the Morphine he was given, was a plausible reason of his drowsiness the day before. He was clinically stable and knew where he was, but he did not remember what had happened. His leg pain was manageable, and he was in good spirits. Bit by bit we were able to get the full story. He had been working under his house when the house collapsed. And the floor above, with the stones that are used as part of the fireplace, fell down onto his chest and a wooden beam onto his leg. These stones are quite large and when falling from a height of 2 meters they will cause significant damage, and it made me worry about his chest. I examined him again but could not find any broken ribs. Then discussed with the other hospital staff, that if his story is true, we could expect his condition to worsen a lot over the next 1-2 days due to lung bruising.

We did not have to wait long for this, because by the next morning he needed nasal prongs to give him Oxygen and over the following 24 hours he deteriorated further. By Monday morning he was on dual Oxygen and by the time we finished our usual ward round and checked on him again, he was working really hard, the double source Oxygen just keeping his saturation level around 60-70% (which should be 100%). It was going to be another few hours or so before we would expect him to pass away. Unless… we could intubate him and put him on a ventilator until his lungs had healed enough for him to breathe again on his own. Now, this would be a straightforward and easy decision in most hospitals in any developed country. But here we are, in the middle of nowhere, with few resources, and staff that had never seen, let alone looked after an intubated patient. Here it was a very different thinking process. However, there was not much time to think. I spoke to the family, who seemed to agree, although I think they would agree to anything that may prevent this man from dying.

I got some stuff together. A simple oxygen powered ventilator, intubation equipment, the suction machine from labour ward, and various drugs I needed. I was blessed with two very competent junior doctors and an HEO at my side, who were very willing to help even though this was completely outside their comfort zone. By now the man was on his last few breaths, bathing in sweat from the effort of his breathing, he could barely manage saturations of 50%.

But first, we prayed.

Then we went ahead. Positioned the patient, pushed the drugs, waited for it to work and inserted the breathing tube. There was a large audience of staff as well as other patients and carers, who were all very curious. It went well and within a few minutes we saw his saturations rise to over 95%. Everyone breathed a sigh of relief. I secured the tube, listed either side to make sure it was not in too deep, connected it to the little ventilator, took care of straps not cutting into his skin and taped his eyes shut. Then commenced some medication to keep him asleep.

By now most of the monitoring had come off due to old monitoring pads and the patient being sweaty. So, we got a group of staff together, sponged and cleaned him, put a new clean sheet on the bed and reattached the monitoring. Until now everything had gone very smoothly, but I was not really prepared for what the next few days would bring. The family had slowly moved away and were now looking from a distance. Any attempt to involve them was fruitless. It was clear that they were not going to come near or touch their relative.

Whilst I had everyone’s attention, I discussed the importance of one nurse to be with this man at all times. Regardless of lunchtime, breaks or other jobs that need to be done, this patient needed to be watched. Then I realized that most of them had no clue what they had to watch out for or what to do in case of a problem. Then discussed suctioning. Every hour the tube needed to be suctioned. More blank faces. Mouth care, eye care, turning/skin care, NG tube feeds, alarms, the pump, at what monitor values to get a doctor. This was not something the staff had ever seen before, let alone done before and they all nodded and said yes, indicating their willingness, but I knew that nothing would be done the way I had explained unless I show them first and we do it together.

So that is what we did, with each new staff change over, explaining again and again, making sure that they all knew how to look after this man. In the meantime, I was trying to get my medication cocktail in the syringe right. Normally, in an ICU setting, there are many medications given through different syringes and pumps, which all can be adjusted to the patient’s needs. We have one pump, so it all had to go in one syringe.

The first few days went well, but we quickly realized that we were going to run out of oxygen bottles before the weekend. Normally we get new bottles supplied, but the road to the provincial capital was still blocked after the election violence. A hospital car had been allowed to pass, but the situation was very tense and the Kompiam drivers were not at all keen to go. This was not the only thing the hospital was short off. We were running out of almost everything, including bandages, gauzes, and various medications. So, a vehicle had to go and after much procrastinating, finally two drivers went and switched over the empty Oxygen bottles for full ones and picked up some supplies for the pharmacy. They came back safely, and everyone was so relieved when they were back that they were almost cheering when they entered the hospital gate on their return.

In the meantime, I had run out of some medications, and I needed to change the contents of the syringe constantly due to some drugs not working, working unreliably (most of our drugs are 5-10 years out of date), or out of stock. This and the continuous supervising of most of his care had become very tiring. One night I had found both night nurses fast asleep, with nobody watching the patient, which was quickly rectified and did not happen again. The patient also had developed some pressure sores, likely because he was not turned every 2 hours. We took care dressing all the wounds and turned him frequently to prevent deterioration.

All this time the family kept their distance. Gradually their fears were verbalized, and they had been terrified. They were sure that this was all caused by a bad spirit, likely the spirit of the first husband of this man’s second wife. They blamed this spirit for letting the house collapse and were afraid that it would bring more trouble. They also did not know what happened to the patient’s spirit, as he was laying still in the bed apart from some coughing when being suctioned.

I decided to try to extubate him on the 5th day. His airway pressures had been quite reasonable, and all numbers were looking good. There also was not as much debris anymore when suctioning. So, we got all our equipment ready again for potential reintubation and stopped the sedation, then we waited, and waited… For about 3 hours we stood there and not much happened. The patient started to breathe again, but not very strongly and certainly not enough to support himself. Three hours waiting was enough. All the different drugs with unpredictable actions very likely had accumulated and this was not helpful. On top of this the people in PNG are more sensitive to some of the drugs. I admitted defeat, put him back on the ventilator and started a different (much shorter acting) sedative. Let’s try again in a day or two. Weaning off a ventilator usually goes gradually when the ventilator recognizes the patients breathing and synchronizes the breaths given. In this case most medication can already be reduced before removing the breathing tube. But our little ventilator is unable to do this, so it was all or nothing and I had to keep him much deeper asleep so he would tolerate the ventilator. The downside of this different sedative was that the syringe finished much quicker. This meant that about every 4 hours it needed to be changed regardless of whether it was day or night.

Another two days went by, and I decided to try again. We repeated the set up as before, and all equipment we had prepared earlier, we had dumped in a box, so it was easy to get it ready again. We prayed again, leaving it all in God’s hands. Then the syringe was stopped, I suctioned all the debris that was coughed up and the patient started breathing stronger. The ventilator was stopped, and oxygen was connected to the end of the tube. Initially saturations dropped to 50%, but slowly increased to 60%, 70%, then a coughing fit again and it was down to 50%, but it quickly came back up, now to 80%. Over time it was gradually improving, and I took the breathing tube out. He was now on his own. We put on double source Oxygen, made sure he sat up as much as he could tolerate, and we waited. The next hour would be crucial. Would he be able to have the energy to sustain his breathing? His lungs were still very stiff, and it would take effort to overcome this. But gradually we saw his breathing rate come down and his effort less without the saturation dropping. He was successfully extubated. And God had done it!

The family now had approached a little closer. And another two hours later he first opened his eyes after a family member called his name. This was the first time that the family was standing around his bed again.

From here on he improved quickly. Initially confused, he managed to stand out of bed on his good leg, wondering why on earth we had tied his other leg to the bed. He was reminded again that his leg was broken and in traction. This time by the family who had moved closer and closer and were now very much involved in his day-to-day care. We took his feeding tube out and he was able to eat and drink. At the moment he is still in hospital, waiting for his leg to heal. Hopefully we can remove the traction soon, so he can get out again.

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