A lot of what we do here is reactionary. Bad things happen and we do our best to deal with the problem. There is no question that it is better to prevent the problem in the first place. As good as the trauma care in the developed world is compared to the developing world, the greatest contributor to outcomes has been in prevention. Americans, for instance, are often unaware of the blessings they have in the all the injuries that never happen because of good public health measures. It makes me pause and thank God for all the merciful and good gifts He has given me of which I am completely unaware, including the unknown good things given and the unknown bad things averted.

But knowing that prevention is good and actually making it happen are two very different things. There is a saying about being too busy fighting the alligators to drain the swamp. It is a real dilemma and there are no easy answers.

We have been blessed to participate in a little swamp draining in the last few weeks. Some of the most terrifying situations we encounter here are aspirated foreign bodies in children. Sometimes it is a coffee bean or a peanut or a piece of corn or a toy piece, but it is always terrifying. You have to get the thing out, or the child is very likely to spiral and die. But getting it out involves manipulation of an often very small airway in an already sick kid. And if oxygenation goes south, you often have only moments before the child goes into cardiopulmonary arrest and dies.

For the last several years we have been greatly blessed to have the proper tool to get these things out – a rigid bronchoscope. Wayne Koch, a visiting surgeon who has repeatedly come to Soddo, graciously provided it. It enables us to grab the offending item under direct vision from the inside of the airway without having to cut the neck open. Before receiving the bronchoscope, we had to do just that – cut an opening in the trachea and try to fish it out. Barbaric though it was, God was gracious to us during the pre-rigid scope days and we were able to successfully treat the kids that came in. God was further gracious in his timing of the rigid scope, however.

Since receiving the scope, a new culprit has proven increasingly common at our hospital. There is a cheaply made party toy widely available on the market that has caused a lot of problems. It is produced in a fairly populated country to the far east of here… It is a party noisemaker toy that consists of a tube with a balloon attached to one end. Inside the end of the tube with the balloon is a hollow plastic piece with a small tongue-shaped rubber diaphragm. The intended (I assume) concept is that someone blows into the opposite end of the tube, inflating the balloon. Then the balloon deflates, blowing air back down the tube, through the plastic piece and over the diaphragm, making a frankly annoying sound. The cost-benefit analysis of this thing utterly astounds me.

 

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Anyway, here is the unintended (I assume) concept. The kid blows down the tube and partially inflates the balloon. Then, in an attempt to amp up the fun, he/she then sucks in a big breath with the tube still in his/her mouth to get a second blow into the balloon. Having not personally observed the event, I assume it goes something like this: this works for a few times, maybe a bunch; but eventually whatever adhesives are holding the plastic piece in place weakens. Then, when the kid is in maximal inspiration for that second awesome breath, and the vocal cords are maximally open, the positive pressure from the deflating balloon knocks the plastic piece loose. Between the positive pressure from the balloon and negative pressure from the child, the piece rockets down and through the vocal cords into the airway.

We have now cared for at least nine such children here at Soddo Christian Hospital. The last two cases have been particularly heart-rending in that the thing was stuck just below their vocal cords, so that it made the intended noise with every gasping breath. The timing of the rigid bronchoscope is such a blessing because I’m not sure how successful we would have been trying to get these out through a blind hole in the trachea. Because they are designed to pass air through them, the pieces often lodge down in the airways to one of the lungs (usually the right) and coughing doesn’t necessarily knock them up into the main airway. Thankfully, we have been able to get them all out thus far, with healthy children at the end.

The last one (two days ago) was a beating. I always come home and tell Becca that each of these cases takes around six months off my lifespan. It is a weird emotional response each time. I start the case with a deep sense of trepidation and fear, praying fervently for God’s help. By God’s grace, I am able to keep focused on the situation while we’re doing it. But once the foreign body comes out, I get light-headed and tachycardic (racing heart beat) and develop a temporary tremor in my hands. Major adrenaline rush – but not the fun skydiving kind.

The last one however took about six years off my lifespan. It was a small, four-year-old little boy. His cords were so small I have no idea how he managed to fire it down there. He must have huffing up for a mammoth breath. I could barely get the rigid scope through. It was a dicey several moments, but I finally got a hold of it and tried to pull it out. But it literally would not fit back through the cords. The piece popped off the graspers and back into the airway. Unfortunately, I couldn’t get the scope back into his airway and his oxygen level began to plummet. We always have a tracheostomy set open and available for this possibility. So I grabbed a knife and slashed in. Emergency airways are absolutely terrifying. I remember it being described in residency as ‘operating with Elvis’ because when you’re leaning over trying to get it in, you usually have most of your weight on one foot – and the other one is spasmodically bouncing up and down in a frantic version of the King’s trademark move. Anyway, Elvis and I got into the airway OK and we were able to get his oxygen back up. Several more moments of improvisation ensued and we were able to confirm that the thing wasn’t downstream, in the lower airways. So it must be above the tracheostomy tube. By putting enough blankets under his shoulders to really hang his head back and aggressively tilting the bed down, I was able to peak upstream through the hole in his airway after removing the tracheostomy tube. Sure enough, it was there and I was able to grab it with a clamp and remove it. At this rate, I figure I’ve only got about 12 more years of life…

One of our residents has now written up an abstract on this situation for presentation at the Surgical Society of Ethiopia and has drafted and submitted a formal letter to the Zonal Health Department to seek official action on this toy. I don’t know what will come of it. But we pray that the importation of this toy will be stopped and that public announcements on mass media will help deter people from buying and using this toy. Please pray for a resolution to this serious problem. I don’t know if there are any other hospitals in the country that have a rigid bronchoscope for this problem. By God’s grace, we have had good outcomes for the kids who have been brought here. But I have no idea how many children have died because of this toy. Lord knows, there are plenty of problems at baseline around here. Please pray that this pointless one would go away.

Paul

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