Tuesday, December 9, 2014

Overly Sweet

It’s 3AM. Danae and I are both awake and have been all day. One or the other of us have been in the hospital all day. She just had two C-sections. And I’ve been bouncing to the hospital and back repeatedly to check on a patient. Our kids are likely to wake up in less than three hours. So why not write something?

This morning at our morning report, I learned a diabetic came in comatose around midnight with a blood sugar near 600. The nurses knew he required aggressive fluid resuscitation, so they gave him a whole liter of fluids (sarcasm, one liter is not much, but nobody ever gets more than a half liter every six hours, so he was ahead of the curve) by 7AM. We’ve been over this before: Diabetics in comas needs lots of fluids. Oh, and they also crushed up a metformin and stuck it in his mouth. Awesome.

So I went to see the patient and I ordered fluids. Lots of IV fluids. And I kept cycling back throughout the day to keep hanging fresh bottles of IV fluids to replace the empty ones.

Now you may think my job is hard and HHNK (Hyperosmolar Hyperglycemic NonKetotic Acidosis, used to be HONK, which was an exceedingly cooler acronym) is difficult to treat. But Bere Adventist Hospital makes it simple. You see, my only blood test is a blood sugar. And I can only get that about every twelve hours.

Typically, DKA and HHNK patients have normal-appearing potassium levels, even though they’re quite potassium-depleted. They’re just so viciously volume-depleted that it looks more normal than it is. So as you start replacing their volume with IV fluids, the potassium level goes down. It’s fun to treat elevated blood sugars with insulin, but the thing is, insulin drives potassium into the cells and out of the blood stream. Then the heart starts receiving lots of blood without potassium. Then the heart stops. And I learned in residency that cessation of cardiac activity is rarely a desired outcome.

And being unable to check a potassium level, I was left to guess. I gave my patient lots of Lactated Ringer’s, which is an IV fluid with a little bit of potassium. So I figured (prayed) the patient had enough potassium to support a whiff of insulin without his heart stopping. Normally, I’d give this guy 7 units of insulin per hour, but I had no way of knowing his potassium level and I had no IV pump. I’m just running in half liter bottles as fast as I can. So I don’t really get excited about the prospect of giving him a 7 unit IV push blind.

So I wimp out and give him 10 subcutaneously, which may not help, but is unlikely to hurt, which I think is an oath I took at med school graduation. Maybe. Then I give 20 units. Then I give 20 more. Every few hours. Blind.

Oh, and his blood pressure has been 60/40.

And there’s the pesky question of why he got so out of control in the first place. He apparently stopped his meds a few weeks ago. He felt lousy the last couple days and started treating himself with unknown IV fluids at home, because he thought he had malaria.

So now I have him on ceftriaxone (for ?typhoid, ?UTI, ?pneumonia, ?meningitis, who knows!?!!? Don’t judge me, I have no xray, no… well, let’s just say I have very little) and quinine IM, which I’ve never given before. Quinine decreases the blood sugar and is the world’s greatest anti-malarial, and can be given IM, although it frequently causes painful muscle necrosis. I could give it IV, but I want to give fluids quickly. And I don’t want to bolus quinine, or else I’ll stretch out the patient’s QT interval and push him into torsades de points (which also ceases cardiac activity, see above under ‘undesirable result’).

I would ask for intense nursing care, but his current nurse has over 20 hospitalized patients, all receiving cardioactive IV drips and is also in charge of consulting all new patients coming in overnight. And busy season is picking up, so we usually consult at least 60 new patients each day, many at night as well.

I was just in the hospital and the patient has been here over 24 hours. And he JUST now peed. And he has received 13 liters of fluids. That’s 26 half-liter bottles of IV fluids. Thirteen liters. That’s three and a half gallons of IV fluids. That’s twice somebody’s normal blood volume. And 11 of those liters were given in about 17 hours. Three and a half gallons and he just now peed. Try this for fun: Drink three and half gallons of any liquid. Then don’t pee for a day.

Anyway, his tongue is not quite as dry as it was and he’s starting to move around a bit and open his eyes and make some noises and localize pain (which is medico-speak for ‘pinch him and see if he tries to push your hand away’). His blood pressure is up to 110/60, although he’s still not talking or filling out the Sudoku I left at his bedside. I probably should have started with an easier puzzle.

Anyway, just praying he survives, as HHNK carries up to a 25% mortality rate, even in the states.

olen and danae


Olen Tigo: +235 91 91 60 32
Danae Tigo: +235 90 19 30 38

Olen et Danae Netteburg
Hopital Adventiste de Bere
52 Boite Postale
Kelo, Tchad

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1 comment:

  1. Basically everything in this post is unintelligible to me, lol. But I'm thankful for a God who continues to watch over you and protect you. He knows exactly what you need, and His wisdom will never fail you. "Be strong and of good courage, do not be afraid or discouraged, for the Lord your God is with you wherever you go." (No matter what you find when you walk into the hospital.) :)