Sunday, 14 November 2010

Matters of the heart

Sunday last week was quite a call.  After rounds, the day was unusually quiet.  Things began rolling around 5:30 PM when I received a call from the nurse in the ER.  A young woman was just brought in who had swelling of the abdomen and legs, and she was really sick.  Could I come see her?  I grabbed my stethoscope and my bilum of doctor tools, headed out the door to the hospital.

I picked up the skel buk (a portable medical record) and scanned the brief history.  There were no previous entries, which suggested that this was her first visit to a doctor.  The patient was too sick to speak so I gathered further information from her family members.  Apparently Salome had been ill for about 5 months... weakness, shortness of breath, fevers, swelling of her lower legs and then her abdomen.  I looked at her and shook my head.  She had been sick for 5 months, and today might just be too late.  Why it took so long for the family to bring her to the hospital was never really clear.

I pulled my pulseox from my bag and the saturation read 90%.  Her pulse was palpable, but weak and thready.  Heart sounds were distant, and I couldn't hear nay air moving in her left lung.  Her abdomen was swollen with ascites and her legs edematous.  Ultrasound confirmed a 5-6 cm pericardial effusion, or fluid around her heart.  There was barely enough room for her heart to fill and contract.  No wonder her pulse was weak and thready!  I could also see that the left side of her chest was completely filled with fluid from a plerual effusion.

Pericardial effusion is not an uncommon finding or diagnosis at Kudjip.  The most common cause, we suspect, is tuberculosis pericarditis.  (TB does all sorts of weird stuff.)  Infection from viruses or bacteria is another cause.  And cancer would also be at the top of our list.  Well, we can't do anything about cancer.  We treat what we can.  I admitted Salome to medical ward and started her on antibiotics and TB treatment.  I asked the nurse to call me with any change of her condition.

Before Salome went off to the ward, I took a few minutes to talk with her.  You are very sick, I said.  We will do our best to take care of you, but I am afraid your illness will win.  Sickness of the body is one thing; the condition of your soul is the most important.  Salome said that she had been a Christian but had fallen away from her faith.  We prayed together, and she gave her life back to Jesus.

Around 10:00 PM I received another call.  There was a chop chop in the ER.  I evaluated the patient, looked at the wound and decided that the almost amputated hand was a little too much for me to handle.  Our volunteer surgeon came up to help stop the bleeding.

While working on the chop, the ER had filled up with patients.  I looked through the skel buks that were lined up on the counter.  The patient in bed #3 had a heart rate of 220.  He was the first priority.  Unlike my first patient, he had been to Kudjip before.  Notes from the other doctors documented a liver mass that was suspicious for cancer.  He had been doing fairly well until this evening when his heart suddenly started to race.  I did a quick exam and confirmed the tachycardia.

Back home in the Sates, a patient like this would have been immediately hooked up to a cardiac monitor.  An EKG would be on the chart before the doctor even made it to the bed side.  Things don't work that way here.  We have one EKG machine.  It lives in the lab and EKGs are done by a lab tech, if the tech knows how.  Thankfully our on call lab person was already working on a CBC for the chop.  Since the phones are out, I sent the nurse with an urgent request for EKG.  

Meanwhile, I was concerned that my patient would become unstable.  The heart can only beat that fast for so long before giving out.  I searched through the crash cart and found an amp of adenosine.  The nurse quickly inserted an IV.  I placed my left hand on the patient's chest to monitor his heart rate and pushed the medication with my right hand.  I felt the heart rate slow and become irregular.  The lab tech arrived with the EKG machine.  The read out confirmed my now suspected diagnosis of a-fib with RVR.  I returned to the crash cart and searched through the vials.  I hoped that digoxin would control the patient's heart rate because it was my only option.  The patient was loaded with dig and taken to the ward.  I sped through the last of the waiting patients and headed home with the hope of getting a little more shut eye.

And hour or so later, I was awaked from a restless sleep by the ringing of my cell phone.  Salome, the patient with pericardial effusion, had no pulse or blood pressure.  I pulled on my scrubs, jumped into Herbie, and sped up the road to the hospital.  Salome was still conscious, but neither could I feel a pulse or get a blood pressure.  I did a quick sono and found that the fluid around her heart was no longer allowing it to fill with blood.  Cardiac tamponade!  This was a true emergency.  Pericardiocentesis is a dangerous procedure, but it was the only thing that would save her life.  I explained to the patient and her watch meri that I needed to stick a needle into her heart.  It could kill her.  But if I didn't try, she would surely die.

I had only ever seen one pericardiocentesis months before, so I called in Dr. Bill.  He has seen and done just about everything.  We set up for the procedure and had a word of prayer.  I got the first try.  I pointed the needle into Salome's chest and slowly advanced it toward the heart.  The syringe began to fill with blood tinged fluid.  A slight readjustment stopped the flow.  I rechecked her vitals... pulse was slightly stronger but still no blood pressure.  Dr. Bill tried a second and a third time.  We never got a continuous return, but the 300cc we took off was enough for the time being.  Salome's pulse was stronger, her heart rate had slowed form the 160s to 90s.  And she looked better.

As I headed out of medical ward, I walked by the bed of the patient with a-fib.  He was now complaining of severe shortness of breath.  I suspected that he may have through a PE, a blood clot to the lungs.  The nurse tried to start oxygen.  He was too distressed and pulled it away.  She prayed for him, that God would bring peace and comfort.

I stumbled back to my bed, this time for another hour or two of sleep.  It was waaaay too early when my alarm went off.  I got ready and headed to work, making a detour through medical ward to check on my patients.  Salome was sitting up, still alive and looking a little better.  We got her through the first night, but whatever was making her sick was too big and too bad.  She died the following day.  I am confident that she is in a better place.

I paused at the bed of my second patient.  He was no longer conscious and his breathing labored.  He was also not long for this world, and died just a few hours later.  I grieve that I did not take time out of my busy night to pray with him.  I am thankful that the nurse did.

"But in your hearts revere Christ as Lord.  Always be prepared to give an answer to everyone who asks you to give the reason for the hope you have.  But do this with gentleness and respect."
~ 1 Peter 3:15

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