SVT

      Yesterday it looked like we would finish seeing patients at about noon. It was a little before 12:00 and we only had a few patients left. One of my patients was a little baby, about 1 month old. I took her temperature, then put the pulse ox probe on her foot to check her heart rate and oxygen saturation. Her oxygen was good but her heart rate was elevated. The monitor said her heart rate was 266 so I listened with the stethoscope to verify. Yes, her heart rate was greater than 260. We have an old monitor so I verified again, yes, the baby was in SVT. So, how do I treat this here? The first thing we try at home when a baby comes in with SVT is to apply ice to the face. It looks scary because you literally put a bag of ice over the baby's mouth and nose and hold it there for 15- 30 seconds. It is supposed to make them do the vagal maneuver which often makes their heart rate go back to normal. I wasn't sure if we even had ice at the clinic. We do have a small refrigerator/ freezer unit where we keep the vaccines and yes, there was some ice. Someone had filled an empty Tylenol bottle with water and frozen it so there was some ice available, I just had to figure out a way to crush it. Throwing the bottle down on the cement floor only broke the lid, it didn't crush the ice so I went on the hunt for some kind of a tool I could use. I found a wrench out in the depot that I thought would work. It did! It worked very well. The tylenol bottle was made from thick enough plastic that it didn't shatter when I hit it but it did crush the ice. I put the crushed ice in a bag then explained to the family what I was doing to try to help their baby. The first time I applied it to her face I only put it over her mouth and nose and obviously didn't hold it there long enough because nothing happened. So I tried it again, this time covering her whole face and holding it in place a little longer. This time it partially worked. Her heart rate came down to 190- 200. Still high but not as high. She was fussy and I didn't know how much her heart rate was elevated because of that so I gave her to her mom and told her to breastfeed her to see if that would calm her down. She breastfed but it wasn't even 5 minutes later and she was puking it all up. By now her heart rate was back up to 250- 270. I had been in contact with Jay and he wasn't at the clinic yet but was coming. While I was attempting the ice to the face maneuver he had been researching to see if there were other options of things we could try. I tried the ice twice more, keeping it in place 20 seconds each time (by the way, 20 seconds seems like a very long time when you are occluding a baby's airway!) Each time her heart rate would come down when the ice was on her face but as soon as I removed it she jumped right back up to 250. Jay suggested using a rectal thermometer to try to stimulate the baby to bear down. This also is supposed to stimulate the vagal maneuver.  We did not have a rectal thermometer but I  used a q-tip with some lubricating jelly on it. It worked the same way, when I removed the q-tip her heart rate went right back up to 250. By this time Jay had gotten to the clinic and we concluded there wasn't anything else we could do at the clinic for the baby. She needed to go to the hospital for more testing and medications.  We told the family that they needed to take the baby down that evening.  They could not wait until the next day. I think they understood the urgency but said they needed to go home and get some clothes first. So that was the first patient I sent down yesterday.

     The second patient I will write about was on a moto that pulled up to the clinic shortly before the baby and her family left. It was a lady in labor. This was her 8th pregnancy so we thought it should be fairly straight forward. That's what we get for thinking... I checked this lady and it seemed like she was ready to have that baby, whenever she wanted to push. She was having pretty regular contractions but said she did not have to push yet. We waited around a while, I restocked the pharmacy, etc... she still said she did not have to push. Suddenly she was hungry... I thought surely after some food she would have "strength" and be ready to get this over with. No, she still did not have to push. We got her up to walk but that idea turned out to be fairly short lived. We tried to convince her that the baby was right there, couldn't she just push? Yes, she agreed, but did absolutely no pushing, at all. Finally, we decided to put in an IV and start some Pitocin. That takes a while though because it has to be titrated up slowly. It seemed she was having contractions but was trying her hardest not to push, rather she was putting all her efforts into doing some kind of maneuvers with her mouth during each contraction. She definitely was not acting like she had ever done anything like this  before. We kept trying to encourage her, her family kept trying to encourage her, but we were not getting anywhere. I was beginning to wonder if there was a reason she did not want to have this baby. Finally Jay told the family members that were there at the bedside to go get the dad, he was apparently outside. Shortly after he came in the room either the mom decided it was time to push or else she could no longer fight against the contractions. In a few minutes a little boy was born. He was a very cute little guy, weighing in at 2.75 kg. I got him dressed and gave him to a family member while we waited for the placenta to be delivered. Nothing happened...nothing at all. We tried pulling gently but the placenta was very firmly attached and not letting loose. It had been thirty minutes and still no progress. Finally we decided one of us would have to try and manually help with the removal. I gloved up and followed the cord up to... I don't know what. It felt like her cervix was totally closed. I was getting no where and was causing the lady a lot of pain so I stopped. We tried to research what might be causing this problem.  She was continuing to bleed some off and on. Finally we decided that she would need to go down to the hospital also. She needed more care than we were able to provide at the clinic. The patient still had her IV in so we gave her some IVF's and a dose of medication that is supposed to reduce bleeding. Meanwhile Jay was calling hospitals to see if they would accept her and also calling the ambulance driver and getting him and the ambulance on the way to the clinic. He found a hospital that accepted her so when the ambulance arrived we loaded her onto the stretcher and sent them down. Jay got the dad's phone number so he could call and see how everything worked out but so far we haven't heard back from them. So, I put in a long day and sent two patients down to the hospital. We got home a little after 7 in the evening. 

     We start each day at the clinic with a prayer. This is a good time to look over the crowd to see if there is anyone who looks particularly ill and might need to be at the front of the line of patients to be seen. This morning I noticed an older man who was shaking off and on, almost like as if he had chills. He was very thin and looked sickly but not deathly ill and he was in the front row so I didn't call him in early. He came into my exam room about 45 minutes after we started. His blood pressure was okay, no fever, but his oxygen sats were 62% on room air and his heart rate was 130. Practically no lung sounds. I asked Jay to come help me decide how to treat this patient. His complaint was that he had a "fever" and he hadn't been able to eat for about 2 weeks. I did the rapid tests we have for HIV and syphilis and Jay did a rapid COVID test then we put him on 5 liters of oxygen. That only brought his oxygen sats up to the mid to upper 80's. His rapid HIV test was positive and so was his rapid COVID.  Now what? We decided to send him to the "ti kay" for a couple hours while we tried to figure out the best plan for him and while we saw the rest of the patients who were waiting. We finished seeing the clinic patients by lunch time. The sick man in "ti kay" had oxygen sats of 87% on 5 liters. His family had went home to get clothes so they would be ready to go when we found a hospital to accept him as a patient. It was rather odd, the first phone call Jay made they accepted him. Didn't care about his age, etc... just said to bring him. So Jay loaded him up in the ambulance and headed down the mountain. He is still in Port, he has been waiting for hours to get diesel. The are supposed to start pumping soon but who knows? He is first in line though... so to leave now probably wouldn't be the smartest move.