Ta lege ti koussala la! (That's the way to work!)

 Baby steps:

PICU is admittedly not all that intensive, given absence of pressors, vents, portable imaging, CR monitoring, EKG, chem panels, micro studies, heme labs, specialists.  But, if we deploy everything we have with optimal efficiency, we can and do save some otherwise doomed kids.

Night coverage is the "on call intern" who is a 6th year med student, covering the whole hospital. I have to schedule point of care hemoglobins and glucose checks, to identify actionable reversible decompensations before they become irrecoverable - typically when the kid presents agonal breathing they call the intern, do some hopeless cpr, maybe a round of epi then pronounce the kid dead.  So, scheduling interventions and tests when I am not there is high value but also difficult.  Previously, my yield on orders to be carried out in my absence was between 10-20%.  The "Nurse Activity Manager" came up with a brilliant idea - a whiteboard with tasks, dates and times.  We did a quick PDSA and came up with this:

 and look!  All the little boxes are checked!  So awesome!  Sometimes, they look at the kids and see, gee that one doesn't look so good let's do sooner rather than later!  

Then today after lunch break (yes, I go home for lunch) I walk into the ICU and they are doing CPR on a kid after two very appropriate dextrose boluses!  All by themselves!  Kid bounces right back.  So apnea with malaria hypoglycemia requiring two sugar pushes within 20 minutes that's a little extreme but it happens, kid's waiting on blood with a hemoglobin of 3.  circulation ok, even a little awake, sat's fine - then eyes roll back and unresponsive.  Check a sugar again, please! "we just did, it was fine!"  "I know, please check again."  It's 22.  Third sugar push, kid bounces back.  On and on like this for 2 hours, very labor intensive - they are on top of it.  My PICU team!  They do - sometimes - a great job.  Of course this kid may be septic and will die tonight since ceftriaxone resistance is quite high, but if all he has is malaria he should be fine.

In defense of the staff, my "nurses" have average schooling through 6th-9th grade, plus 8 months of training.  They are paid a "temp worker" salary from the ministry (or, more often, not paid) plus a "supplement" from my NGO.  If they succeed in getting formally hired by the ministry to continue doing the job they have been temping at for years, they are more likely to get their salaries.  But, I am told, getting hired ("integrated") typically requires something extra (know what I mean?) to get you the  job.  In Sango that's "goro" which means kola nut - and also an inducement given to someone in authority.

Also, the charts are a challenge.  This is at hour 36 of hospitalization - papers, pages, forms rapidly multiply and easy to get lost within:

And for those who enlarge, yes he hit the door in shock with a sugar of 60 and a hemoglobin of 2.  I don't remember if he lived or not, but these kids often do, as long as they improve within 24 hours, present early in course of illness and don't start off malnourished.

So, definitely a good day.