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Nuts kill

We discharged a two and half year old infant from the ICU yesterday – conscious, oriented, neurologically sound, without any fever, taking feeds orally. And this child could have died, like a large number do, before she reached the hospital or during the surgery.

This toddler had been given some peanuts to eat. It’s a toddler. She toddled while eating, didn’t chew well, laughed or cried, took an extra deep breath to shout, stumbled and fell, who knows what she did, but she managed to inhale half a peanut into her trachea, where it lodged halfway between her vocal cords and where the trachea divides into two branches going to the right and left lungs. She must have had a coughing spasm. Nobody noticed. It was too small to cause complete obstruction, so she didn’t die then. But it was large enough to cause partial obstruction to breathing. It was organic matter and caused inflammation and increased secretions in the surrounding mucosa, which worsened the obstruction. Then the inflamed mucosa was infected and the child became feverish.

The parents took her to a doctor in the neighbourhood. The child was in respiratory distress, had fever and had abnormal sounds in the lungs. It requires a higher degree of suspicion than this physician had to think of a foreign body. She was treated as a child with a respiratory infection for nearly a week. She worsened. Then she was sent a 100 kilometers to our hospital.

The pediatric residents in our hospital see a lot of cases like this. One of the first things they do is take a chest x-ray picture. If the foreign body is metallic, or even of some types of plastic, it would show up. In this case it didn’t. But there was something else. During inspiration, the airways inside the chest widen and allow air to go past the partial obstruction. During expiration, the airways narrow down. All the air cannot be pushed out of the lungs against the resistance of the narrowed airways and the obstruction caused by the peanut. So the lungs keep getting hyperinflated. This shows up in the x-ray – a piece of circumstantial evidence. If only one lung is hyperinflated, you are happy, because the foreign body is presumably in one main bronchus, and you have one healthy lung. If both are hyperinflated, the obstruction is more proximal and can at any moment cause a complete obstruction, by moving up against the vocal cords from below or moving down and blocking the place where the trachea divides into two.

Oh, there would be other problems as well. The child would not be eating or drinking well during this period, so she would be weak and dehydrated. She would have been fighting to push the air out of her lungs, so she would be exhausted. The increasing amount of air in the lungs would increase the pressure in the chest and decrease the filling of the heart so that the heart has to work harder and faster to maintain the blood flow to the body. And if the obstruction had been severe or prolonged, the child could have suffered damage to the brain because of lack of oxygen.

Even after 22 years of administering anesthesia, I get an adrenaline rush consistently with one surgical procedure – bronchoscopic removal of a mobile foreign body from a child’s airway. The child is usually very sick. In some proportion of cases the foreign body is mobile and can catastrophically block the airway completely. During the procedure, a rigid metallic bronchoscope is inserted into the airway, a forceps is inserted through this and the foreign body retrieved using this. You can’t oxygenate the child well during these periods, which by itself can be fatal. At the same time, you need to keep the child completely immobile, to help the surgeon do his job, and to prevent any trauma to the child’s lungs.

The surgeon has his own problems. The visibility is bad because of mucosal swelling, increased secretions, blood, and pus. The telescope part of the bronchsoscope has to be taken out repeatedly and cleaned to allow him to see anything at all. He has to keep suctioning through a very narrow channel in the instrument to keep the secretions at bay. And the anesthetist keeps telling him to stop doing what he is doing and let him (the anesthetist) oxygenate the child.

In this child, we suffered a catastrophe. The surgeon couldn’t see anything. And then the peanut moved up against the vocal cords from below and the trachea was completely obstructed. The child’s heart slowed down till it was beating around 20-30 times per minute. It would stop at any second. I did the only thing I could have done at that time. While the surgeon was doing external cardiac compression to keep the blood flowing, I introduced a tracheal tube into the trachea and pushed the foreign body blindly, hoping it would turn and go into the bronchus leading to one lung, allowing me to oxygenate the child through the other. It happened the way we hoped it would. After resuscitating the child over the next few minutes, I took out the tube, the surgeon reintroduced the bronchoscope and removed the peanut in short course.

Happy ending? Not a bit of it. This was the point at which the child developed what is called a “Negative Pressure Pulmonary Edema”. Basically the child’s lungs were flooded with large amounts of watery secretions with blood mixed in it, causing the blood oxygen levels to drop steeply. This is known to happen just after a severe or prolonged airway obstruction is relieved. We don’t know exactly why or how this happens. But we do know how to manage this. We put the child on 100% oxygen, gave her some morphine and a drug to produce urine, forbade anybody to suction the child’s tracheal tube and put the child on a ventilator in the ICU. Luckily, the child responded, did not develop further chest infection and we took the child off the ventilator in two days.

What is the one lesson I want everybody who reads this to realise? Don’t give a child below 4-5 years anything hard and small enough to fit into its mouth. If you give them something to eat, please supervise. In an average year in our hospital, we take out 100 to 120 foreign bodies from children’s lungs. Most are different type of nuts. Then come coins and caps of pens. 2 or three of these kids end up with major problems or even die. We don’t know how many children die before reaching our hospital, though I don’t like the numbers I can guess.

Robin Hood

There are twelve beds in our ICU. At any given time 4-6 of these are occupied by what we call “Poor Free” patients. These are patients who are poor and can prove it by a Government-issued card. (There are enough bureaucratic hurdles to establish this that treatment is delayed to a certain extent in a large proportion of patients. But that’s another story.)

If you have this card, the hospital does not ask you for the daily charges, which amount to about 1-1.5 USD. The hospital also provides you food and some medicines free of cost. But these are basic drugs, including antibiotics for which our resident bacteria in the ICU have already developed resistance. And then there are the disposables – suction catheters, central venous catheters, urinary catheters, endotracheal or tracheostomy tubes etc. which the patient has to provide, whatever his economic status is. If the patient (or rather his family) can’t, what do you do?

Rarely, about once a year, some family member of one of our patients volunteers to provide for another patient. One of my residents spends about a couple of hours each day phoning up charitable agencies and philanthropic people for specific assistance for specific patients. The hospital has the provision of giving approximately 50 USD per day per patient for medicines etc. But this can occur only on working days. The forms need to be submitted each day and the money comes late in the day. You can’t ask for it in advance. And there is an official cap on the total amount. So the Medical Superintendent sometimes complains that we in the ICU are monopolizing all the money, while it is needed in the Casualty, in the Labour Room, in the Medical Emergency. And sometimes he is right. So what do you do?

That’s where Robin Hood comes in. None of us will officially admit it, but most paying patients have extra items prescribed. These are then used for the poor patients. I know this is not fair to these patients; many of them are not so well off that they aren’t at risk of bankruptcy themselves. But what is the alternative? Watch while the “Poor” patients die of septicemia, receiving only ciprofloxacin and amikacin, and putting all other patients also at risk by increasing the pool of antibiotic-resistant organisms? Some of us do it more and some of us do it less, but all of us do it.

Hello world!

Welcome to Little Matters. I am an anesthetist and intensivist working in a teaching hospital in a large third world country. As you can imagine, we have problems of limited resources (money, equipment, staff, training), uneducated and poor patients, and bad management … to begin with. I am sure I can add to that list.

But it’s not all grim. Funny things happen. Sometimes you see a good student. A patient gets well. Occasionally a paper of yours gets published. You go for a pizza.

This blog contains (obviously) my personal opinions. I do not speak on behalf of my employers. I will not guess whether they endorse or condemn these opinions.

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