Saturday, December 26, 2015

The Little Girl and I Both Exhaled

For the last week I have cared for a 2.5 year-old girl with pneumonia. She had only mild respiratory distress on admission. Pneumonia is one of the most common diagnoses on the paediatric ward. Most of these children respond well to an antibiotic, hydration, oxygen, a drug to open up the lungs, time, and the resilience of the human body.

The initial x-ray on the little girl showed pneumonia in her right lung and the pattern implied a bacteria rather than a virus. She was admitted by the Head of Paediatrics and treated with the usual first line antibiotic available at the hospital. On the third day she got worse and notwithstanding a change to the usual second line antibiotic, she continued to get worse. On the fifth day I was very concerned and shared my concern with the person in charge of the ward. She looked very tired and "toxic," the way critically ill children look. My sense at that time was that she might have a collection of infected pus (empyema, lung abscess) in her lung. Until an abscess is drained, even the correct antibiotic will not work. I repeated the x-ray and to my eyes the image suggested that a collection of pus was likely. The x-ray images at this hospital are not as good as in Canada and the technician was not able to accomplish the views I requested to localize the pus. Since I am not a lung x-ray expert, I could not be sure. Still, I thought this was the likely diagnosis. I talked this over with the head physician but she did not agree. She recommended another antibiotic change. The third and even a fourth antibiotic did not make any difference. I repeated the x-ray on the sixth day and this time, the head physician agreed with my diagnosis. I found the surgeon and made sure he saw her early in the morning. He asked for another x-ray (no idea why) and I made sure this happened early in the day. Once the x-ray was done I found the surgeon and took him to see the x-ray. I have learned to be persistent to insure that anything urgent is done. If I had not personally "driven the system," the x-ray might not have been done until later in the day, by then the surgeon would have finished his holiday rounds and gone home, and an entire and perhaps critical day might have passed. My persistence paid off and the surgeon agreed to operate the same day. I attended in the OR. The surgeon placed a chest tube and drained some bloody pus. My relief to witness the pus drain out of her lung was a Christmas present, both for the little girl and for me. Back on the ward, for the first time in a week, I could hear air entering her right lung.

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