It was a really hard day on the Emergency Ward today. I walked in to find a man vomiting blood and bleeding to death. We were not sure if he was bleeding from varices secondary to portal hypertension (he had a big spleen) or if he was bleeding from an ulcer. Aggressive fluid resuscitation was started and the family were cross matched for blood. The surgeons were contacted. However, by the time I got back from theatres he had died. We were too late.
We have two patients in coma’s at the moment and are not entirely sure why. They both had positive blood films for malaria and we have treated them for cerebral malaria. We have also given antibiotics for meningitis. That and regular dextrose for hypoglycaemia sorts most of our patients out. However, these two have not recovered. In the UK we would have done about 30 blood tests, a lumbar puncture and a CT head. Here, a CT is prohibitively expensive and so is an LP (total of about £200). If the family pay for this then they can’t afford the treatment. Let me give you one scenario. Let us suppose they have encephalitis. The CT/LP would be £200 and a course of IV acyclovir (the definitive treatment) would be 500 Sudanese pounds (about £100) per dose! The dosing is 4 times a day for 15 days.
So it’s “think on your feet time.” There are a few helminths (worms), fungi, and viruses that can cause this sort of picture. If they have HIV, the differential is wider. The other thing to factor in is that the drugs we are giving are of low quality (we will never know this). Myself a Consultant American Physician called Matthew and a few Sudanese colleagues thought about this and our patients are now on a combination of oral acyclovir (much, much cheaper), anti-helminth drugs, and a few antibiotics. We decided that even though they were in a coma and a nasogastric tube (or NGT- a tube that goes through your nose and into the stomach) may cause secretions to go into the lungs, if we do nothing, then they will almost certainly die. So we thought that it would be best to pass an NGT and put the oral medications down this. We also checked for HIV.
My saddest story is a 17 year old boy who was admitted with cerebral malaria and improved but sadly developed an aspiration pneumonitis. I have spent most of the day with him and his family. He was aggressively fluid resuscitated and antibiotics were commenced. For the first time in 3 years our cardiac monitor appeared out of the cupboard. The readings were thus:
- Pulse 130 (not good)
- Blood pressure 130/65 (acceptable)
- Respiratory rate 35 (barely compatible with life)
- Oxygen levels 81% on air (not compatible with life).
After a long hunt, we found 1 oxygen cylinder which contained a 6 hour supply of oxygen. We hooked it up and his oxygen levels improved to 90% (compatible with life). They would have gone higher but I needed to conserve our precious, life-giving gas. The nurses were brilliant. They created a high care bed and started keeping observations and urine output charts.
After another long hunt and no further oxygen was found I turned around to the family and said “I can’t find any more oxygen. The tank will run out in 3 hours time. After this his oxygen levels will fall and there is nothing we can do.”
I asked the family to phone any relatives. I left the ward listenning to them praying and singing hymns.
For six hours today, we had a hospital bed that was almost functioning at the level of a standard UK hospital bed. It was not long enough.