My first trip to Mogadishu (bless you) was to pick up a poor
chap in his 30s who had gone into complete
bowel obstruction. An abdomen full
of trapped gas is not something you want when you are ascending in a plane as it expands. He needed a lot of fluid resuscitation and a nasogastric tube on
the ground but apart from that transferred ok. As predicted the gas expansion
caused cramps and a further reduction in his lung capacity so he needed O2,
analgesia, buscopan and lots more fluid - something I’m discovering that health
care providers in this area of the world are rather stingy with. But my oh my
they love their Lasix (Frusemide, a diuretic – good if you are a boggy cardiac
patient with fluid backing up everywhere, but a disaster if you are already a
crisp.) In the end he had a ‘twisted sigmoid colon’ sorted laparoscopically. My
referral from where he was treated in Mogadishu had as it’s top, and only, differential diagnosis ‘psychosomatic pseudo-obstruction’. Poor chap, unless he was able to twist his colon with the power of his mind that was a rather unfair call. He’s making a good recovery now in Nairobi.
Then the next day I had a far more complex situation. One transport, three
patients; one a spinal fracture with unilateral leg weakness, one an epigastic
pain of unclear origin and the third was one of the sickest conscious patients
I’ve ever seen. A poor chap who had diabetes and had been on ARVs for about a
decade presented with chest pain after a 11K run the morning previously. He had
widespread changes on his ECG apparently (I did not get sent them so couldn’t
see) possibly ischeamic, possibly a more suspicious cardiomyopathy with a large
heart on CXR. It’s all a bit confusing but he got catheterised and was not
passing urine. Someone, somewhere obviously told these guys ‘if the patient has
a cardiac problem and doesn’t pee – he needs Lasix. Lots of Lasix.’ Which is
exactly what they did. Regardless of the fact that he had just run 11K in the
friggin desert! If you squeeze a dry sponge you will yield little water, but
you may well tear the sponge to bits.
The airframe equivalent of his kidneys |
So when got to him airside in Mogadishu (bless you) he was
alert, breathing four times the normal rate, chest clear with good saturations,
a crappy BP and a bizarre broad junctional bradycardia. Given our prior info about his renal failure, a stonking
potassium was my first bet so we threw the kitchen sink at him. Atropine,
bicarbonate, Calcium, insulin and filled up him with fluid as best we could.
For the medics reading this, his pH was 6.8! I’ve only ever seen corpses with
blood that acidic. His blood was so full of acid (probably a good mix of
uraemia, ketones and lactate) as his kidneys had packed in that his lungs were
the only thing keeping him alive by blowing off CO2. If he stopped breathing
for a nanosecond he was highly likely to crash as the acid took over. I was
asked about whether we needed to intubate and put him a ventilator. While his lungs were working so well the
resounding answer to that is ‘no’. If we stopped his breathing to get a tube
down his throat and ventilate, his acidosis would worsen to a level
incompatible with life. Patients like this have a cardiac arrest as you put
them to sleep.
No, what this man needed was to be attached to an artificial
kidney in Nairobi and everything else we were doing was just temporising the
situation but not for long. We managed to get him to call his wife for what I
strongly suspected would be the last time.
With a lot of hard work we got a more normal looking ECG
trace, a reasonable BP and his lungs kept doing a good job. We delivered him to
the emergency department with a glimmer of a chance of survival. That’s when we
had to leave him. Unfortunately getting a patient on a heamofiltration
apparently requires a specialist nephrologist consult and in the delay his time
ran out. He needed ventilation and had a cardiac arrest as they intubated. All
for the love of Lasix. Stupid drug.
Matt - loving these! Please write more & keep up the good work. Adela
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