Yesterday was my last day on the PICU.  I ended the month with mixed emotions.  There were some very hard days throughout the rotation, where it seemed like parts of critical care were futile, that we were fighting a losing battle with technology that only delayed death.  But there were days, and patients, where we saw it work, and saw kids who otherwise would have died, get better. 

There was one little girl who was already in the PICU when I arrived last month.  She was just over a month old, and had spent her entire life in the hospital.  She was born with a congenital heart malformation called Tetrology of Fallot (tetrology meaning four specific malformations, Fallot being the guy who got to name it).  Because of the severity of her malformation, she underwent surgical correction within a few days of birth.  Following her surgery, she went into cardiac arrest and required CPR.  This lead to kidney failure, and she needed dialysis.  She became extremely swollen, gaining almost twice her body weight in fluid distributed throughout all her tissues.  When I came on service, they were trying to figure out WHY she was so swollen and how to make it go away.  For weeks, they'd made no progress.  In addition to the swelling and renal failure, she had an open chest wound because after her heart surgery they were unable to close the skin and tissue over her sternum because of the swelling.  This open incision was covered with a wound vac and could not be closed until the swelling went down.

For the first two weeks or so I was on service, we seemed to make little progress.  Her kidneys didn't work so dialysis was the only way to get fluid off.  We cut down the amount we gave her between medications and feedings, but it didn't seem to help.  She had profuse diarrhea and was becoming malnourished, but nothing seemed to stop it.  She was on a ventillator because she couldn't expand her lungs with the pressure in her chest from extra fluid, and we couldn't wean it at all over those two weeks.  For the first week I was there, we were pretty sure she wasn't going to make it.

But we kept tweaking medications, and gave her a little time.  About the beginning of my third week, she started making urine again, a symbol that her kidneys might be starting to work again.  Her diarrhea slowed down.  She was negative for the first day ever (negative meaning she lost more fluid that she gained in a day).  She lost a little weight.  And day after day, she got a little better.  Some days were not good, and she made no progress or backslid a little.  But overall she continued to improve.  I called her the little biggest loser baby, losing weight each day to get back to her normal weight.  This week we were able to send her to the OR to have the incision on her chest closed. 

She was still on the ventillator when I left Friday, still getting dialysis to help remove fluid.  She was far from ready to go home, and not out of the woods.  But she went from probably dying at the beginning of my time in the PICU, to probably going to be ok at the end. 

So, 1 4th year rotation down and 11 to go.  I think it's going to fly!  Next up is study month.  I will spend 4 weeks making my own schedule, studying for 8-10 hours a day and doing something with the others.  I won't have interesting stories to share... well, I will.  But they won't have anything to do with the hospital.  On June 11th, I take Step 2: Clinical Knowledge.  And then I go on vacation.

Until next time,
Kari