My First Pediatric Airway and My Second Week!

Clearly, from last two posts, you’ve appreciated that I’ve abandoned the quick synopsis bullet points. If you’d like those back in, let me know. Otherwise, let’s just jump right in.

The cover picture, by the way, is a dinner we made just before the power went out (as it usually does when it rains hard). Pasta under candlelight,  there’s not much better than that.

My second week here in Mekelle helped me realize that although my leap (turned free fall) was terrifying, and still is terrifying, I have many safety mechanisms to slow my descent. I have to take time to appreciate my support system here and back in the states.

Here in Mekelle, my roommates Jon and Alaine (and her sister Elisa) immediately made me feel a part of their family. Not only does my new home actually feel like home, they have made so much effort to invite me out to dinners, coffee, and even pancakes (yeah, they were pretty good, I’ll make my own for them later!). Of course, the only reason I found them in the first place was because of Erin (UIC OBGYN; who is now back in the states) and I only hope I can return the favor of support when she returns to Ethiopia in the winter. Of course, Yilkal (the head ENT here) has been there for me for everything I need. He truly is an amazing leader, driven to do well and is made of pure kindness. I’m also very thankful for our residents. Not only do they inspire me, but they clearly want me to feel at home here and have made every effort to do so. You’ll see examples of this in my stories.

My support in the states is so powerful. From my parents to good friends, to coworkers to future coworkers; thank you so much for your support. I elicited the sage advice of my good friend Cori. She has just completed 2 years of selfless work in Liberia and was a gigantic inspiration for me to do this year in Ethiopia. She may be the only person on this planet who actually knows what I’m going and will go through. I will listen to every word she tells me.  On the other hand, one of the most surprising sources of persistent and effective support comes from someone I’ve only met in person twice in my life, but we have been close friends for 2.5 years. For anyone who read my older blog before my fellowship, you’ll know her as the “train girl” as I originally met here on a fellowship interview in Seattle on the train in from the airport. Since that time Mariah and I have formed a bond that only Pen Pals can. Her perspective on life is unique and I know that she will be a pillar of support throughout this time. Of course, my twin in Pediatric ENT, Lori will always be my better side and I know that I can rely on her when I need professional and personal advice.

Ok, enough of the sappy stuff for now, lets get into the week.

On arrival to Ayder Monday morning, Seid, one of the R2s leads me to the room of our friend with the gigantic ulcerating neck lesion. Now, one of these days I’ll take video of some of the areas of the hospital (there have been requests 😊 ), but for now, let me attempt to describe. I met Seid in our Out Patient Department (OPD) which is an attached, but not connected building to the side of the main entrance to the hospital. We share a dark, dank hallway lined with metallic benches in various forms of disarray with the pediatrics department (I’ll make a video of this one day too). Seid and I leave out the side door to the outside and up a gradual stone ramp which is always lined by families who sleep, cook and bathe just outside of the hospital waiting for their loved ones to improve or pass. A right turn once onto the second floor brings us to an alternating duo of lackluster middle-aged men carrying AK-47s guarding this side entrance to the ward. Immediately past them to the right is the adult ICU and to the left the pediatric ICU,  humming the familiar tunes of unhappy ventilators, hypoxia, tachycardia and all too frequent asystole.

Down three hallways and up a flight of stairs leads us to a similar forking of wards. To the right emanates a bouquet of necrosis, melena, Pseudomonas, and urea marking the entrance into the OB/GYN ward. To the left, your first cranial nerve clearly identifies the path of least resistance into the surgical ward. This long corridor of tall, stained white walls interrupted by open doors reveals patient rooms lined with patients and filled with the family members taking care of them. Each room varies in size and number of patients, but the average single hospital room in America houses 6 patients in Ayder. All ages and sexes struggle together in the same room to fight the odds of recovery. The ever-present balance of curing one’s current disease before contracting another from the hospital itself. Finally, past the orthopedics patients is the ENT part of the ward.

Walking into the room of our patient, we are immediately assaulted with the scent of tissue death. Although the man I had met just 4 days prior was already disfigured from his huge ulcerating wound, he was now edematous, uncomfortable, sitting up in bed struggling to breathe. His ipsilateral face was flaccid and he had the knowing face of impending doom. It was clear this disease was aggressive, and still without a treatment plan in place, he was dying in front of me. I had the residents grab the flexible scope and portable light source and bring it up. In front of his roommates and family, my flexible scope does not relieve my anxiety. I cannot visualize any normal structures, all effaced in angry edema. I looked at my resident team hoping they were understanding what I was thinking. They did: my first open neck case in Ethiopia was going to be an emergent awake trach.

Once in the operating room, we sat the patient at about 60 degrees and unwillingly unwrapped his neck bandages. At this moment, for the first time, I hoped flies would land in the middle of his wound, so maggots would grow and debride this wound for me. He was scared, but I could tell he trusted me. I’ve done my fair share of awake trachs, but this one was special. There was significant cellulitis and tumor crossing midline making it impossible to determine the location of the hyoid, thyroid notch, cricoid or really even the trachea itself. I planned a midline incision, horizontally 2 finger breadths above the sternal notch. His comfort was provided by <10cc of local and a couple mg of morphine. We prepped and draped, suspending the facial drape up so he could breathe.  I myself took a deep breath and with a heavy hand, opened his thickened skin and subcutaneous tissue with one movement of the scalpel. That was all I needed to at home in the OR and after an hour of meticulously digging through tumor, thyroid and cellulitic tissue, we discovered his trachea. I prepared my first assist (Seid), the scrub tech and the anesthesia team to be ready to sedate once I entered the trachea because this usually caused panic in the patient. The syringe of lidocaine pierced the trachea and on retraction of the plunger, air bubbles confirmed its target. Plunging in about a CC induced a strong cough, indicating to me it was time to enter the airway. With the 15 blade, I made a horizontal incision through the membrane between the 2nd and 3rd rings and quickly, aggressively dilated the hole. What I thought was going to induce panicked breathing, was actually more like a sigh of relief and calm, purposeful breathing. I took the time to fashion an inferior Bjork flap and in went the fenestrated cuffed 6.0 shiley trach (that’s all we had, I know). The trach was secured and I turned my attention to cleaning the wound an obtaining specimen for pathology. Breathing comfortably and in good spirits, I taught the residents and nurses in the PACU good trach care. He would stay there for the night and then head back to the floor until pathology would be interpreted. He was started on dexamethasone IV q8hr and broad-spectrum antibiotics.

Often after a difficult procedure, the nerves, anxiety, and fatigue rush at you while you walk across the threshold of the OR. It was no different here, my body was shot, mind fatigued and anxiety peaked. Nonetheless, we were very successful and gave this man his only shot to survive, obtain a diagnosis, and to find a cure for his horrible, rapidly progressive disease. As I hand-wrote the op note carefully outlining the details of my post-operative plan, I get a call from the on-call R1, asking me to come down to the ER.

It’s around 4pm now. The ER is so chaotic at all times, I’m not really sure how to describe it. Just imagine, in order to get to the consult patient, I literally needed to wade through sick people to find the pediatric bay. Here your ears are blasted with cries of children in various forms of distress to a point in which your mentation is affected. Amongst the cries, my ears analyze a sound familiar to me from fellowship. I could feel my right posterior auricular muscle tighten with my brains attempt to echo-locate the sound that was just over my right shoulder. I turn to see a distressed mother with a small moving object under her shawl, which beaconed that familiar sound of stridor with a predictable, but accelerated rhythm. Uncovering the baby, we find a 3 month old with reportedly progressive stridor, fatigue and cyanotic spells at home. She had been evaluated at this ER 2 months before and found to have a large neural tube defect and sent home. Already on nasal cannula for oxygen, I immediately slapped on the pulse ox and seconds later it blinked 70% on the screen. Without immediate intervention, this child would be dead soon.

Just a couple of days before, I was discussing possible research projects with Yilkal and the idea of myelomeningoceles popped up. Apparently, here in Ethiopia, the incidence is much higher than in the rest of the world and their ensuing respiratory failure accompanies a high mortality rate. There is a well-known relationship between this neural tube defect and larynx, but its intricacies are not well studied due to its rare presentation in the developed world. With variable predictability, the myelomeningocele results in a cerebellar dysmorphism sometimes presenting as a Chiari II malformation. What is important for me here is that this malformation along with increasing ICP from obstructive outflow hydrocephalus results in compression of the brainstem and the structures vital to controlling the ninth and tenth cranial nerves. With this comes vocal cord paresis and increased work of breathing. Normally, when you breathe in your vocal cords open, but since one or both are paretic in this disease, they often sit close to midline. Thus, when the diaphragms trigger negative pressure to take in a breath, the increased airflow between the vocal cords decreases local air pressure and causes the vocal cords to collapse completely to midline and obstruct the flow of air to the lungs. The body can compensate, using intercostal, abdominal and even neck muscles to increase the intrathoracic negative pressure, but at a certain point, the obstruction becomes too much work to overcome. This baby was at this point.

This was uncharted territory for me. Normally, we would intubate this child in the ER, consult neurosurgery for some type of decompression (shunt for hydrocephalus or skull base for the chiari) and give the vocal cords sometime to recover. If they didn’t recover, perform a tracheostomy and wait longer. A quick check with the PICU confirmed no open ventilators. Without another option, this child needed an emergent trach. Luckily the residents found this dusty bag of pediatric trachs in the PICU, clearly untouched in quite some time (or ever). Surprisingly, there appeared a 3.5 Neo Shiley, exactly what this 3 month (probably pre-term) baby needed.

I then sat down with the Anesthesia tech on call and explained how we were going to handle this airway. Get the baby on the table, give O2 and anesthetize with halothane gas only. I would then take the airway, spray the larynx with lidocaine and pass a 4mm endoscope through the larynx to confirm there was no other reason for this impressive obstructive distress. Intubate the baby with an uncuffed tube and then perform a trach. This was the routine I performed hundreds of times in fellowship (replacing halothane with sevoflurane). I was used to this; I was even good at this.

What I never really appreciated but now do more than ever, are the little things in bronchoscopy. All the things I had in residency and fellowship but lacked here; a strong suction, good lighting, adequate anesthesia, room to work, a table that raises to my height, smooth communication, appropriate suture and good tape for the tube. The now obvious absence of these made what should have been simple, very difficult and anxiety provoking. Nevertheless, the procedure was successful and the baby breathed comfortably on only supplemental O2 ready to await the decisive treatment from the neurosurgery team.

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3.5 Neo Shiley in place with “R” and “L” stay sutures.

Since the trach only bypasses the pathology, injury to the brainstem continues to occur until decompressed. Expedient diagnosis and treatment is, thus, theoretically important. However, over the week, myself and my team would struggle with the ICU and neurosurgery team to obtain definitive imaging and move to a treatment plan. We’d enter the weekend with absolutely no progress. In this case and the ulcerating neck mass, I feel defeated.

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Stepping away from despair. My life was becoming slightly more routine and organized as the week developed. I figured out how to get to my place to the hospital in the morning and at night. I got a key to the ENT office so I could have a place to put my bag and sit during the day. I was organizing days for me to cover in the Out Patient Department (OPD). I’ll be taking a half day from each of the attendings so that I could teach in clinic and so that they could have free time to do other things. I started taking lecture assignments from the attendings and will teach my first medical school classes next week. I started formal rounds with the residents (which they actually seem to like). Life was seeming more double, academic and exciting. Stepping back from the chaos, this week showed me I could actually help a lot here.

On Thursday, I helped one of the other attendings with his cases which he performed very well without my assistance. I was happy to scrub in and show him minor changes in technique to maximize exposure or make his dissection easier. I’m starting to feel comfortable in my teaching role here.

Friday, everyone took off to help with a hearing aid campaign held in the stadium of the Business campus of Mekelle University. Starkey, a big hearing aid company from the states goes around the world fitting hearing aids for little or no cost to those with loss that can’t have surgery or that are beyond what surgery can fix. In a 2 day campaign, they aimed to fit ~1000 hearing aids. This is a ridiculously difficult task, but they executed with ease. It was amazing to walk around their tents and see how this massive organization efficiently provides public international aid. It was inspiring. The residents helped at every level to interpret, diagnose and treat those looking for hearing aids. I’ve included some pictures here for perspective.

Friday night began with me doing Yoga for the first time ever. I won’t get into it because I was terrible, but only mention it to put in context future pictures of us doing random movements. We then met with one of Jon’s friends Clark and some Belgium newcomers. Clark is an American Peace Corps volunteer who has already done two years in a remote village and now is in Mekelle for a third year working for an NGO. The Belgium students are studying their masters here for the next 3 months. They all do various forms of agricultural and forestry science and are studying the ecosystems nearby. We took them to the popular Tibs house, ate, drank and had great discussion. An unexpected benefit of this trip has been meeting so many interesting people from all over the world. Their life stories are fascinating and shine such a bright light on humanity that is all to often obscured during my life in the states.

On Saturday, the four of us (Jon, Alaine and Elisa) took a taxi into town and we trekked through the streets towards the “Big Cross.” I’ve been told since I arrived to go on this 2-hour long hike to the top of a hill overlooking all of Mekelle. The beginning meanders through a very rural village leading to a looping gravel road to the top. It took only an hour to reach the top and there were no obstacles, but the combination of the elevation and relatively poor nutrition left me drenched with sweat. The top revealed perspective I haven’t been able to appreciate until that moment. Although while standing on street level the city really doesn’t feel that large, this bird’s-eye viewpoint painted a completely different picture. Mekelle is expansive in reality and its reach far. I couldn’t do much but stare in silence, absorbing how real the city felt now. That was until Elisa demanded yoga photos which I did my best and post here for your amusement.

 

That night, I was invited to join the dinner of the visiting International Medical Relief (IMR) team that had just arrived for a week-long mission. I had never heard of this group until a PICU nurse (Allie) from my fellowship told me that she was doing a mission at the very same hospital I was moving to Ethiopia for. As a result of the ridiculously small world that global health provides, I was graciously invited to join where I met 30 wonderful people, distilled my 2 weeks worth of Mekelle knowledge, and spent the night sipping on beer on the balcony of their hotel. For an hour or two, I forgot I was in Ethiopia. The visiting group features floor, ICU, PACU, OR nurses, PAs, NPs a general surgeon, anesthesiologist and an Oncology Surgeon. Now, this was the first time I ran into an oncology surgeon; with a general surgery residency and head and neck fellowship, she hosted a unique set of skills. Perhaps she would be useful to our team this week! Since it seemed like a lot of the team did not have specific plans in place for the week, I offered to take a couple under my wing and introduce them around Ayder on Monday. Perhaps an outside perspective could provide more efficient ways of completing every day tasks. I was excited to have Allie here since I knew she was a pediatric trach expert and could teach the PICU nurses and residents everything they could ever want to know about trachs and vents. It’s a great opportunity for global improvement that I will undoubtedly put to the test with more pediatric trachs.

Sunday, I made the most American gluttonous breakfast I could think of. American style pancakes with Ethiopian Nutella, bananas, and crushed Reese’s Cups that Allie had brought for me from the States.

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They thought it was heaven but it quickly reminded me how much happier I was eating healthy, unprocessed local food. This was a one-time deal. Skype, the dog was given a bath and the day was spent shopping, cleaning, getting ready for the week ahead and capped with another Yoga session.

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I could get used to this…

2 thoughts on “My First Pediatric Airway and My Second Week!

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