First day as the attending...

Bryan mentioned yesterday that he was running rounds in the nursery. He'sbeen learning   the challenges of being an attending and has been in awe of the complexity of these patients we've been given responsibility for. I am right there with him. We are providing relief for some of the long time missionaries here, which means some days of being the most senior person in the nursery or, in my case, on the ward, while they tend to some much needed admin or personal time. Humbled is probably the best word to describe how I feel about this. I am by no means qualified to take care of these very sick children on my own. I am still overwhelmed by the complexity of their diseases as they are so different from what I typically see. However, I am so thankful in this moment for my education which allows me to think critically, identify problems and do my best to lead our team in solving them. Cecilia was my first patient as the attending, and I doubt I will ever forget her. I came in yesterday to find a five and a half month old who had been admitted with hydrocephalus, wounds that had developed from pustules on her chest and thigh, a cough and fever. She was very ill appearing with shallow breaths and poor responsiveness. Her wounds were unlike anything I have seen. They were well demarcated but the flesh was completely gone, exposing her deep tissues and musculature. We obtained a few labs and ordered a few tests. I was concerned about a deep soft tissue infection and possibly necrotizing fasciitis, so I started her on empiric antibiotics to cover for the common bugs associated with these problems. When I reviewed her Chest film, she had what appeared to be pulmonary edema or acute respiratory distress syndrome. Thankfully, her renal function was good so I could give her a diuretic to help get rid of the extra fluid making it hard for her to breathe. I gave her pain medicine and then we waited for her to be taken to surgery for debridement. Today she is doing a little bit better. In the OR they found infection tracking from her chest wound into her mediastinum, the part of her chest that contains her heart and other important structures. This confirmed our suspicion of necrotizing fasciitis. Unfortunately, the CT scan here is broken so we will continue to aggressively treat her and pray she improves as we can't completely visualize where the infection has affected or monitor her response other than clinically. We have a few labs pending, a wound culture and blood culture. Her white blood cell count had come back at 41,000 (very high) and her peripheral blood smear doesn't show any ongoing destruction of red blood cells which can happen in serious infections. There was no infection surrounding her brain either. Please pray for her and her mother who sits by her bedside day and night. She will be taken to the OR again today for a dressing change and then will have a cranial US to  evaluate her hydrocephalus. 

Medicine is definitely different here. With limited tests and lab results, you rely heavily on your physical exam and clinical judgement. I am so thankful for our medical education which has taught and is teaching me well. I know that there are things I'm missing in taking care of these patients, and I hate that. However, I'm doing my best and praying for God's wisdom, knowing that ultimately He is their healer, not me.

We appreciate your prayers so much! Love you guys.