This is a confronting piece for us to write and share. This is a full disclosure post. All of our mistakes outlined, what we’ve learnt and how you might avoid a similar situation. If this post helps just one family avoid the situation we were faced with it will be worth reliving the heartache. We are not medically trained, all we have is our lived experience to share.
Mid January 2019 our family of 5 left Australia for Sri Lanka to commence a planned year of travelling through South East Asia. With 3 daughters under 5, we had taken the time to have extensive consultations with a specialised travel doctor (Thanks Dr Tse @TMVC) to ensure that we were vaccinated, had a well stocked medical kit and were informed of some of the likely challenges we would face. We knew that illnesses would arise on our journey, just as they would at home in Australia. What we were not prepared for was how early in our trip it would occur and how confronting it would be.
*Please do not comment if you only have negative things to say. This is a post to inform those who may be faced with a similar situation as to how we would have changed our actions*
We arrived in Colombo, Sri Lanka on a Tuesday and took things slowly, allowing the girls to adjust to “new time”. There were lots of naps, park plays and swims in the local school swimming pool. Evie, our youngest, took her first steps and had her first tuk tuk ride all before she turned 1 just 4 days later. Her 1st birthday “party” was celebrated at a cafe with cake, party hats and a candle and all in all was a relatively non-eventful day. Evie is a typical third child, curious about everything and wanting to be a part of everything her sisters are doing and exploring her surrounds (on all 4s). This is most likely how she contracted her viral gastroenteritis.
Mistake number 1: Considering her condition as “mild”
Evie appeared to have a relatively mild (or so we thought) bug. She had 1-2 episodes of diarrhoea a day over 2-3 days and a similar amount of vomiting. We had the added complication of having changed formula on arriving in Sri Lanka and considered this as a contributing factor. By Monday morning after 2 days of symptoms we were worried enough to take Evie to a private hospital in Colombo to be assessed by a Doctor to see if;
- She needed antibiotics
- She needed assistance with hydration
- If antiemetics (to stop her vomiting) would be beneficial
Mistake number 2: Being unaware of the cultural differences in developing medical care plans.
Culturally Sri Lankans are very respectful and do not question a Doctor’s treatment plan. Always clarify what treatment they would prefer you/your child to receive.
Coming from working in the Australian hospital system I am used to thorough discussions of treatment plans including conservative and invasive options as well as the pros and cons. This was our second mistake. With the added benefit of hindsight (and the 20-20 vision of the alternate journey for Evie) I wonder if the fact that the knowledge of doctors that we had onward travel plans influenced the treatment we received at the hospital. (i.e. not wanting to upset us and our all important places)
We received prompt and I would say thorough treatment. On arriving to the ETU the Doctor suggested admitting for IV fluids. I mentioned that “if she needed admission I would need to let our driver know” and subsequently a Paediatrician was called down to review Evie and an alternative treatment plan commenced. She was given an anti-emetic (anti nausea suppository) and oral anti-emetics as well as a local hydralyte (Jeevenee) and pro-biotics. After 2 hours of observation and with no vomiting we were discharged with instructions to keep her hydrated, ideally with the Jevenee 500-1000ml in 24 hours. Reassured that she was on the improve we continued with our onward journey to Hiriketiya Beach a 3 hour drive from Colombo.
Mistake number 3: That Evie sleeping was evidence of her improvement.
Evie slept most of the way, very unlike her and was quite docile and easily distracted. We thought she was sleeping to recover as most of us do when ill. All in all she seemed to be OK. She was interacting with her sisters albeit a little more frustrated than usual.
Mistake number 4: That hydrating Evie with water only was better than nothing or the risk of vomiting.
Throughout the day she continued to refuse to take anything orally other than to sip on plain water. At 7pm, after a bottle of formula, she vomited again – the first time since 3-4am that morning. With her refusing the hydralyte and vomiting the formula we resorted to a bottle of plain water and she went off to sleep as usual. She woke 1-2 times overnight, and at both times, rather than risk her vomiting – we filled her bottle with water rather than ORS or formula.
The morning of the hospital admission
We woke as normal to a chatting Evie. Our 2 other daughters were awake and the normal chaos of the breakfast routine of a family with 3 children under 5 commenced. We cooked toast and made a coffee. Within 30 minutes of Evie waking things took a dramatic and frightening turn. She started closing her eyes and drifting off to sleep in our arms. She was having difficulty focusing and her head was what I can only describe as lolling around. She was relatively limp. It was obvious that she was seriously unwell and we needed to get her medical attention URGENTLY.
So, with our minds in overdrive with concern we remained calm (for the sake of her siblings). I do not remember either of us raising our voices, crying or anything dramatic. We seemed to shift into action. I called our airBNB host who happened to be an expat Australian and explained our situation and the urgency. He responded with generosity and care and by the time we had gathered our passports, immunisation records, money, phone charger and nappies he was waiting to take Evie and I to his trusted local Dr. With Adam staying at our accomodation with our 2 daughters, I was left to make some big decisions in an unfamiliar environment alone.
8am. Stop 1.
The local Doctors’ clinic appeared open – it was 8am and the waiting room was buzzing. The receptionist informed us the Doctor would arrive at “maybe 8.30”?.
8.20am. Stop 2.
Emergency Treatment Unit at the local Dikwella hospital. A very basic hospital. Very Basic! The Doctor spoke great English and her treatment plan was clear. IV fluids for 4 hours, if no improvement we will transfer her the 45 minutes to the larger regional Matara Hospital. I accepted – I had a sick, listless, limp child that needed urgent treatment. I followed the non-english speaking nurse, past the dogs, into the children’s ward. A large open-aired room with 15-20 metal cots without sheets. Empty. With one nurse. The nurse asked me if I had a sheet? No, I replied. She then proceeded to take a sheet off another bed and offer it to me to smell for cleanliness. I felt uneasy. Concerned. Unsure. Alone.
8.30am. I decided to bypass this hospital and take Evie to Matara ourselves. It turns out this was a good decision, but at the time, turning my back on immediate care with only the unknown ahead was heart wrenching.
9am. Stop 3. Asiri Private Hospital Matara
We arrived, with Evie still barely rouseable, to the ETU at a private hospital in Matara. We were seen promptly. A paediatrician was consulted over the phone and a treatment plan was proposed. IV fluids with glucose and in addition anti-emetics, zinc (for gut health) and pro-biotics.
9.30am. Moved to a ward. No IV as yet.
1st attempt to get an IV into Evie’s foot failed. She was too dehydrated. This is when I realised that my decision to bypass the local hospital without a resident Anaesthetist was a good move. Had we stayed we would have been delayed potentially another hour.
9.50am. Anaesthetist arrives to cannulate Evie successfully into her right hand. It is splinted and bandaged so that she cannot remove it. At this point in time she has no interest whatsoever in it.
10am. IV fluids commenced. Evie asleep. Mum relieved.
In Australia the best practice guidlelines for rehydration is via a Nasogastric tube, however in “SHOCKED” children, which I believe was Evie’s case IV fluid “resuscitation” is indicated.
Over the next 24 hours, Evie received a total of 19 hours of IV fluids. She received a suppository in her bottom containing anti neausea (Ondansetron) medication and did not vomit. She had one large episode of diarrhoea, no fever and no vomits. Her wet nappies improved significantly, to the extent that it was only then that I realised how much her “wet nappies” had dropped off. This is an EARLY SIGN of dehydration of which we were asked about in Colombo and I could not answer accurately.
Be persistent and pedantic about oral rehydration!
According to the Royal Children’s Hospital (RCH) fact sheet, our first step for treatment should have been:
First 12 hours replace formula bottle with an Oral Rehydration Solution (ORS) at 20mls per hour. Evie was fussy and refusing ORS, we persisted with formula bottles.
Give it by syringe, icypole/iceblock (not available in chemists) – we could have frozen iceblocks and would do this next time. Be creative and don’t be complacent, small children become dehydrated very quickly. Try alternative flavours – we have since found a lemonade flavour as opposed to the orange that Evie prefers.
Be patient and be clear that you want the best treatment regardless of travel plans!
Use clear language. Cancel onward plans, or do not mention them until a treatment plan is confirmed. Time can be very fluid in Sri Lanka and most developing countries, be patient and don’t ask for a timeline. In Australia you would always expect up to 4 hours in an Emergency Department situation.
A change in your child’s energy levels, combined with reduced oral intake and in conjunction with diarrhoea should be considered as URGENT!
If this happens, seek medical attention right away. Do not assume your child is recovering. Do not persist for 12-24 more hours at home without follow up. PLEASE trust your parental instincts, you are not a hassle and your child’s small body may need help recovering.
Using plain water diluted Evie’s body of the electrolytes needed for her system to function correctly!
In basic terms, we flooded Evie’s body which made it difficult for her vital organs to function. This is why ORS exists, the formulation contains the right electrolytes at the right concentration when made according to directions. Which goes back to LESSON 1.
Keep track of wet nappies!
Information is key to medical professionals and assessing a patients level of dehydration relies on knowing their urine output. Count them over a 24 hour period, feel the weight of the nappy, check the colour. All of this information is important.
We have learnt so much from this experience and are lucky that Evie recovered so quickly.
Have we missed anything? And…more importantly have you learnt anything from reading this? If you feel this has been helpful or would benefit other travelling families, please feel free to share this.