Day 7

Nerd alert! The following post is awesome, if you are nerds like us.  You have been warned!  This is the follow up to the sick patient in the ER we saw on Saturday night.  Jeremy's late night text message said "I had to tap (lumbar puncture) that guy, lots of WBCs (white blood cells) but not enough fluid for GeneXpert (TB test)."  Basically, his LP showed meningitis.  His CT scan from that night did not have a mass or a bleed.  He did have bilateral pulmonary infiltrates (pneumonia or possibly fluid in the lungs) on his chest x-ray.   He did receive antibiotics in the ER, but there were not any anti-fungal or TB medications available to give him at the time.  When we woke up on Sunday morning, our only plan for the day was lunch with two NPs from the hospital who invited us out to a restaurant.  Little did we know we would be working all day.  We were literally, again, laying on the couches in the living room drinking coffee when Jeremy texted and asked us to go to the ICU and do another LP on the patient so that we could test for TB.  Neither of us like doing LPs (they are often difficult) but we figured we'd head over and get it done quickly, then come back to finish our coffee and breakfast.  When we arrived in the ICU, our patient was in the very last bed beneath the windows.  He had nearly no urine in his catheter bag from overnight, and what was there was brown.  He was breathing fast and deeply, a sign of his severe acidosis.  Jeremy was at his bedside, brow furrowed with concern.  He gave the family two options -- drive the patient to Addis Ababa immediately for hemodialysis or stay in Soddo and we would continue to try our best to save him.  His family could not afford the ambulance transport to Addis, and there was no way he would survive a car ride there by personal transport.  There is currently no option for dialysis in Soddo, but Jeremy has been researching how to do peritoneal dialysis in hopes of someday being able to offer at least some solution to patients in acute renal failure at his hospital.  Peritoneal dialysis (PD) was both our, and the patient's, last hope for survival.  Here's the catch -- none of us have ever done PD on a patient.  We've all taken care of PD patients in the ER, but we usually aren't responsible for placing a PD catheter (a catheter that inserts into a person's abdomen to allow fluid exchange) or for making the dialysate solution used in the exchanges.  Although we had basically zero experience, and the procedure has never been done at Soddo hospital, this patient was a great candidate and we had no other choice.  Jeremy sent us off to research how to best do PD in this setting (thank you Navy Emergency Medicine) and after about 30 minutes of googling, PubMed scrounging, and brainstorming we came up with a plan.  Jeremy had a recipe for the dialysate from a nephrologist friend, but it had to be made from scratch.  We quickly became mixologists -- a liter of saline, a little dextrose, two parts bicarbonate, a touch of calcium, a pinch of heparin and top it off with ceftriaxone (I promise, we were much more precise than this sounds) and we had homemade dialysis solution.  It sounds like a simple recipe, but nothing is straightforward here, not to mention we hardly ever mix medications (or even handle them for that matter).  Each component had to be purchased by the family and brought to the ICU.  So did every syringe.  Making the first 2 liters of solution took forever.  Next, we had to place a PD catheter.  We rummaged through the medical supply store room (an outdoor shed with donated supplies) and found 14 gauge single lumen central venous catheter, which seemed to be our best option. We placed the catheter into the peritoneal cavity at bedside using Seldinger technique.  Then our homemade fluid was instilled into the patient's abdomen through the catheter to begin the exchange. We repeated this process twice on Sunday, taking breaks only for half of the church service held in our guest house and a potluck dinner with other visitors to the hospital.  After dinner, we went back to the ICU one more time to check on our patient.  He was alive, looked slightly improved, but was still in very critical condition.  It is amazing how few resources we have here to practice critical care, but it was extremely rewarding to work together to do something brand new, to creatively make use of our scarce resources, and to try everything in our power to help a patient in extremis.

That was Sunday, our day "off."  Bring it on, Monday!

Also, we only brought a small amount of hand sanitizer...here is hoping it lasts the three weeks!