Shanksteps #102
Wednesday, September 17th, 2008Shanksteps
The pediatric ward was full and I was just seeing my last patient. One of the grounds workers comes running up saying that there was an emergency in the ER. Greg was in surgery. I grabbed my medical bag and followed him into the Emergency Room. Before me was a young man, about 20 years old, breathing terribly, flailing from side to side. The room was full of his friends “trying to help”. I could not get a straight story from anyone so I decided to try to examine him. His breathing was labored
but with good breath sounds; Heart rate fast but regular; Extremities cool; Pupils, non-reactive; Blood sugar – 21! There was the cause of his agitation. His blood sugar should be at least 65. I always keep a ziplock of sugar in my bag. I place sugar under his tongue with a drop or two of water hoping that he will absorb it quickly. The ER nurse works on getting an IV in his arm to give him dextrose directly into his veins. Finally he starts to calm down and I know his sugar level is back
in fairly normal range. I check him again – 82. He’s now able to answer questions. Between him and his younger brother I find out that he’s been sick for about two months, worse for about two weeks, and in a coma since this morning. He has complained of headache, body aches, and especially abdominal pain. He has taken several unknown medications from the market, and I’m sure some traditional medications over the course of the past two months. In addition he’s a big bili-bili drinker (the local
millet wine). I examine him again to assure myself that he’s stable, place him on oxygen to make him more comfortable, and then go to write his orders. I ask the lab to check for malaria, typhoid, dysentery, and liver disease. By the time I leave the ER, he’s laying comfortably on his side making faces at the baby in the next bed.
I go to make rounds on the adult ward, but realize the one of the patients probably needs surgery so I go to find Greg. I find him in the ER with the young man who had come in earlier. He’s breathing terribly and somewhat delirious. Greg thinks he may have a pneumothorax because his breath sounds are diminished on one side. He inserts a needle, but no air escapes. He’s still receiving sugar in his IV so I worry less about hypoglycemia. He sits up and seems to breathe better, so Greg goes to
check on the woman who needs surgery. Several minutes later the patient sways and lays back on the ER bed. Now he sounds like he’s breathing through water. I listen again and his lungs are full of fluid. I give him Lasix to remove some of the fluid and turn him on his side. Greg returns to the ER and examines him. In the mean time look for a mask and ambu-bag in case he crashes and needs CPR. I find the bag but no mask. I look all over the ER, tearing through drawers and cabinets. Before
we left on vacation, there were at least 3 adult resuscitation masks there. Greg cuts a hole in a rubber glove to do somewhat protected mouth-to-mouth. I run to the stock room but to no avail. Fortunately someone had run all the way to the OR and grabbed a mask and bag and brought it back to the ER. By the time I made it back, Greg was bagging him. He had just vomited a full stomach of some type of alcohol mixed with blood. I listened for breath sounds and found no heartbeat. I started chest
compression while Greg bagged. Every couple of minutes I listened to his chest again, and each time I heard more fluid/less breath sounds. After about 15 minutes we decided to stop CPR. He was dead.
About 20 minutes later we get the results of his labs. Not much malaria, no typhoid, but his liver enzymes we so high they were above the range of our machines. The diagnosis: acute liver failure; probably due to hepatitis and possibly exacerbated by traditional medications. I go home that night to read about hepatic failure, complications and management. What I find out about the initial management is frustrating. My Medicine textbook says that he could have had kidney failure and I should
assess his volume status with invasive monitoring (NA -none available). He may have cerebral edema (swelling of the brain) that needs to be monitored if possible (not) and given mannitol to decrease the swelling (NA). He may have a GI bleed (which he did) that should be treated with antacids (none IV) and fresh frozen plasma (NA). He may have low oxygen due to fluid in his lungs (he did) that would require intubation with special ventilator settings (NA). He might have low blood pressure that
could be treated with special medications (pressors) (NA). He may have an underlying infection causing sepsis and blood cultures should be done (NA). He may be acidotic and should be given Bicarbonate. We have Bicarb, but no way to test if he is acidotic. He may have low blood sugar. This we did find and treat. He may have low potassium or low sodium. Thanks to World Wide Labs, we would have been able to test these, but didn’t. In the end, I read that even if he had been in the best of situations,
his chance of survival was only 10-40%; and the only treatment if it looks like he won’t recover from this attack is liver transplant.
We do the best with what we have available. And thanks to help from family and many friends we’ve been able to improve the quality of care here considerably. It’s still frustrating when we know that something could have been done for him had he been fortunate enough to have been born in a different country. It still amazes me though how many people here do survive, not because of what we do, but sometimes in spite of what we do. That is the powerful hand of God at work. He heals our patients
and protects US every day from harm and deadly disease. For those of you in the US and Western countries, never forget how blessed you are to have access to good health care. Â Please continue to pray that God helps us through in spite of our deficiencies.
In His Grip, Audrey (for the Cameroon Shanks)
