Trips to the Moge - part 2 - For the love of Lasix

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.