December 2nd, 2017 by georginagreen

Motigo

It’s going to take several days to fully process that first day in the hospital. I’m on the children’s wards for the next three weeks. To orient you, the interior part of the hospital is open to the air, with covered walkways. The buildings look like white painted cinderblock, with glass paned windows that open to the outside. On the interior wall there is an opening near the top, open to the outdoors. The climate is Garden of Eden: sunny, birds, flowers, occasional rain showers. Wherever you are, you may hear people or birds singing. The floors smell of bleach, and there is constant cleaning. The wards also smell of illness, close quarters.

The older children are in one ward, beds close to each other, parents in/on the beds with the children. The younger children are in an adjacent ward. Parents take care of the children, along with the nurses. Parents are expected and welcome. On the first day, I showed up for rounds early and found a group of women singing praise songs just outside the wards.

The other place that I work is in the nursery/ NICU. We took off white coats, put on gowns, and washed- as you do when you go into any NICU. There are babies in incubators, which are wooden with glass front doors. The heat is provided by light bulbs underneath, and the humidity by water in a plastic bowl. If the baby is too hot, they turn off a bulb. There was a 28 weeker who recently had surfactant (pretty high tech, reduces surface tension, helps the lungs to inflate). There was another 28 weeker under bili lights. The mothers are with the babies or are close by, nursing, holding, cup feeding, washing. I also hear that kangaroo care is coming soon. The nursery has protocols and well-trained nurses, and babies often survive and do well at 28 weeks.

Your medical topic for the day deals with Adenotonsillar hypertrophy, when adenoids and tonsils get too big. There was a 15 month old child with large tonsils who came in with malnutrition and heart failure. This has taken me a full day to wrap my head around: the enlarged tonsils led to the heart problems. I knew this was theoretically possible from med school, but I’d never seen it and honestly forgot that it was a possibility.

In simplest terms, your blood leaves the left side of your heart, goes around your body delivering delicious oxygen, then comes back to the right side of the heart. From the right side of the heart, the blood goes on a short trip to lungs for more oxygen, then back to the left side of the heart and out to the body again.

If parts of the lung don’t have enough oxygen, the alveoli (tiny air pockets in grape-like bunches at the ends of the lungs smallest branches) sense there’s not enough oxygen and close up shop, sparing that part of the lung. It’s meant to be protective, to let the well-oxygenated parts of lung do more work. But when parts of the lung aren’t open for business, you get back pressure in what is usually a very low pressure system. The blood that is trying to go from the body to the right side of the heart has to push harder to try to get through to the lungs. Pulmonary hypertension (increased blood pressure in those pulmonary arteries that go from the heart to the lung) ensues, along with remodeling of arteries that are trying to cope with the increased pressure. And the right side of the heart can stretch out, dilate, and fail. We call this cor pulmonale, when the right side of the heart starts changing and doesn’t function properly. The back pressure can cause problems in the liver, fluid in the abdomen (ascites), swelling in the legs, etc.

And if you are unlucky enough to also have a hole in your heart (this child has an ASD, atrial septal defect), you can end up with shunting in which the unoxygenated blood from the right side gets pushed through to the left and out to the body without getting oxygen put into it. Making it even harder for the child.

What can cause hypoxia? COPD (chronic obstructive lung disease), lung disease, OSA (obstructive sleep apnea, high altitude. We’re at 6700 feet here, but that shouldn’t make a big difference. For this child, it’s his tonsils. We call them kissing tonsils when they are so large that they touch.

I wasn’t there when he was admitted, but the symptoms could include shortness of breath, fatigue, lower extremity swelling, increased abdominal girth (ascites). How does a toddler tell his mum and dad these things? On arrival he looked like a child with heart failure. And an echocardiogram, an ultrasound of his heart, helped with the diagnosis.

So the child gets oxygen and sildenafil (AKA Viagra), which helps. I remember an episode of Top Gear, the British TV show about cars, in which the presenters were trying to win a race from Bolivia to Chile and wanted to take a shortcut across the Altiplano at about 16,000 feet. They thought they might fare better if they took Viagra at high altitudes to prevent pulmonary hypertension. In the end, they had altitude sickness and oxygen saturations of 84% (not cool), so they turned back and went a different way. I remembered that show when I was at KU Med and the pulmonologists were prescribing “Viagra” (using a different name) and its friends for pulmonary hypertension.

Sildenafil works by decreasing the activity of PDE5 (phosphodiesterase-5) so that more cyclic GMP is available for the blood vessels inside the lungs. Think of it as helping the muscles in the walls of the arteries to relax. When they’re relaxed they can open wider and let more blood flow through.

The solution for the child is to have the tonsils and adenoids removed. There is a hospital an hour a way with an ENT who can do the surgery, but the child has to gain weight first. He’s malnourished and has to “make weight” before he can have the surgery safely. He’s now off oxygen and getting ready to go home. The discharge plan involves the social worker helping them get fortified milk.

The families have to pay their bill before they leave. So they sometimes get “discharged in,” which I think is the time between settling up with the hospital and going home. So the next time I round, he will have been sent home: stable, off oxygen, with a plan for sildenafil, fortified milk, and hopefully surgery in the near future.