I heard my wife outside the clinic door asking “what happened.” Since we were accustomed to seeing any number of maladies and nasties, that question in our rural clinic didn’t necessarily mean anything significant. I walked out of our pharmacy and headed for the door. As I opened the screen that headed to the waiting area, I saw a heap of human lying on the tiled floor, face down. Since I was the only thing close to a doctor in the area, everyone came to us with their problems. The only concern I had right now is that my newest patient didn’t seem to be able to tell me what the problem was.
There was one other lady sitting in the waiting area and she said the girl on the floor collapsed as she arrived. I carefully rolled the girl over and was taken back by what I saw. In her condition it was difficult to determine her age, although I could see she was young. Her eyes were sunken in her sockets, the skin on her face was tightly bound to the facial bones, her expression was blank and she stared straight up into nothingness. I have to say she looked exactly like the photos I have seen of holocaust victims, skeletons with skin.
This girl obviously had some problems. I started by asking if she was ok, her name, if she could speak. Nothing. She just kept staring straight at nothing. Death had come a knockin’ and she was about to open the door.
I picked her up and carried her into my consult room, putting her on the exam table. I told my wife to go out and see if there was anyone outside who knew who she was. I began assessing her situation, very shallow, rapid breathing, feverish and faint pulse. I barely got her blood pressure. No sign of trauma or other external reason for her despondence.
My wife returned, thankfully, with this girl’s mother. Mom proceeded to inform us that Dulia, now we had a name, had begun throwing up and suffering from explosive diarrhea three days ago. Last night she started losing her head and talking nonsense, and today she could barely walk and talk at all. One other problem, every time she pukes, a bunch of worms come out. Nice!
Sounds like the poor child is severely dehydrated and sick as a dog to boot. She is also at a very critical stage and she should be under the care of a “real” doctor, not a dentist playing one in the jungle. Mom said she was not able to go anywhere else because they simply had no money. She had heard there was an American working at this clinic and she managed to get the girl here for help.
We didn’t have a truck at the time and all the jalons (pickup trucks that serve as “taxis” in the Honduran countryside) had already moved through for the day and wouldn’t be back until tomorrow. Dulia wasn’t going to make it that long.
This means that the buck stops here. Now the pressure was starting to hit me, this girl was going to die without any help and there was no one else around that could help her. She was in a clinic with a dentist who had been dealing with a little bit of everything from a health perspective, but he still didn’t usually deal with life and death stuff that wasn’t trauma related.
First things first, get fluid into her. I had a pretty well-stocked clinic for being in the middle of nowhere. I went to my storage room and grabbed a one-litre bag of Lactated Ringer’s. I dug through my drawer of IV catheters and picked out the smallest ones I could find. Grabbed some betadine scrub and a latex strap and headed back to the treatment room.
I had to start IVs in dental school, but hadn’t done it since. That was five years ago and I was out of practice to say the least. As I got all my stuff set up, I grabbed Dulia’s arms and started looking for a vein I could go for. The girl was already tiny, but her dehydration made everything worse. The only vein I could find was a blue thread just barely visible beneath the skin. Seeing how that was as good as it got, I said a little prayer and prepped her arm for the first of what I figured would be many sticks in my efforts to get a line in her. One deep breath, and in the needle goes.
To my total disbelief, I felt the needle go in the target vein and saw the catheter fill with blood. I hit it with my first shot!! I was so surprised by my unexpected success that I almost forgot to put the line in from the IV bag.
Great relief went over me as the first hurdle was jumped successfully. There was still plenty of work to do. I set the drip slow and steady and kept close watch on Dulia’s vital signs. After the first 500ml made its way into her system, an amazing transformation began to take place. Almost with every drop, she started breathing more normally and was becoming more and more aware of her surroundings. Shortly after she began to come back to us, she said she was thirsty. I would rather have her drinking on her own than pumping fluid into, so I let her take a couple of sips of water.
Approximately 14 seconds after swallowing the water, she began heaving. I grabbed a trash can and pulled it over to the bed and little miss Dulia proceeded to pump about a quart of yellow/green fluid into it. But that’s not all, always signed on for the bonus plan, not only did she lose the water that I’d given her plus a little bile, down in the can were two seven inch long round worms that I could have used for catfishing! Yes it was gross.
Well we wouldn’t be able to put any water in her mouth right now, so let’s keep the IV running. Now many, no-most, of my patients have worms, but they don’t barf them up and have explosive diarrhea and high fever to compliment them. I figured she had some other bug on board that was causing her problems, so that needed to be dealt with. Luckily a surgical team had left some IV antibiotics and on her next bag I began to send them in.
Another problem with her throwing up any time anything went in her mouth was that we wouldn’t be able to get some other meds, namely Phenergan, in orally. In one of my most unpleasant moments ever, I had to teach Dulia’s mother how to place a Phenergan suppository, not part of dental school training. I think mom was about as freaked out as I was about the whole thing, but the girl needed help. Do what ya gotta do.
A few IV bags later, Dulia was talking and walking, with assistance, again. Her eyes didn’t seem as sunk in and she was definitely more coherent. I sent her to a local villager’s house and gave instructions for sipping water-PLEASE work Phenergan- and come get me at my house up the hill if she turns for the worse in the night.
My sleep was restless that night, not knowing how she was doing, and at 4:00am I headed back down to the clinic to wait for the day’s patients as well as be there a few minutes early in case Dulia and her parents were there (we opened the clinic at 5 normally).
The hours ticked by and a few patients came and left and I was about to go looking for Dulia and her family when I looked out the window and saw miss Dulia walking on her own and sucking down an orange like it was her job! She pulled through and life went on.
It is a shame, but there are a lot of “Dulias” out there that don’t have a dentist with lucky aim on a vein and some good pharmaceuticals on hand. They don’t make it.
Make a difference. Miracles still happen but you have to play your part.