When all else fails...

About a month ago, a young boy arrived to our outpatient department (OPD) in severe respiratory distress. He was gasping for each breath, and we were fairly certain he was going to die. Based on the initial history (a few days of URI symptoms), he was immediately placed on oxygen and treated as an asthmatic (he had essentially no air movement and a prolonged expiratory phase). However, despite a full court press (back-to-back and then Q1-2H nebs, SC epinephrine, IM magnesium, IV dexamethasone, and aminophylline), we made almost no headway. He persisted to have essentially no air movement. A few days into his course, he became acutely more distressed and developed massive subcutaneous emphysema and a large left tension pneumothorax, requiring an emergent needle decompression on the floor, followed by placement of a chest tube. Once the tube was placed, we could finally hear some air movement, and we were able to hear a fixed, monophonic wheeze emanating from the trachea. He had a foreign body! We rushed him to the OR for a bronchoscopy... and no foreign body was found. At this point, one week into his stay, he had shown no improvement with asthma treatment and although he clinically looked like a foreign body, there was no foreign body on direct bronchoscopy. What was the next step?

He was presumptively placed on antibiotics with risk for super-infection, and then we waited. Our ENT was out performing surgeries at a different facility, but was due back in town in a few days. So we weaned down on our asthma medications, but continued high dose dexamethasone to prevent further airway edema. When our ENT returned, 3 days later, he went back to the OR for a second look. This time, we weren't even able to pass the vocal cords because of the edema and inflammation. What was our next step? On repeat history with the family (which, by the way, is next to impossible to obtain), we "confirmed" our suspicion about a foreign body as mom indicated he had been eating peanuts (called "groundnuts" here) prior to the onset of respiratory distress (although this was the fourth completely different history obtained in as many attempts).

We continued the steroids and antibiotics and removed the albuterol, and waited for a third attempt to localize the foreign body. He made small improvements with the steroids, but a few days later, he again acutely decompensated, becoming cyanotic and struggling for each breath. Our ENT, who had again been out at surrounding facilities performing surgeries, had just come back to Mbingo about 10 hours prior, and was called to take him back to the OR at 4am. This time, he found what we were looking for - numerous pieces of groundnut in both mainstem bronchi. Once the pieces were out, his respiratory status stabilized, and the patient rapidly recovered.

We did everything we could for this patient: we treated him as best we were able given the history and the clinical presentation, but despite our efforts, he didn't improve. Even though we knew the underlying problem, we were helpless to effectively intervene. Then when the patient was seemingly making small steps towards improvement, he acutely decompensated and almost died. When all else failed, however, God came through. It was no coincidence that our ENT had just come back from working at outside facilities in time to rush him to the OR. And even though the vocal cords were too edematous to pass previously, Dr. Acha now had clear passage to remove the pieces of groundnut. Princewill is alive now not because of what we did, but because God decided to intervene and saved his life. When all else fails, God comes through. Thanks be to God that despite our limitations and bumblings, He is able to bring healing when there is seemingly no solution.

Princewill - post the third bronchoscopy and removal of the groundnuts