Saturday, May 9, 2015

New patients

Forewarning, this is a fairly medically nerdy post...

Last night we were the admitting team and so we rounded this morning even though it is a Saturday…and it lasted about 6 hours. Being in the wards on the weekend was actually great (for me) because there was no intern and the Kenyan med students either didn’t come or left early so I was actually really helpful. Especially since we got 11 new patients overnight, two of whom were (are) really sick.

The first is a 14 year old boy who ingested an unknown herbicide yesterday afternoon. We later discovered it was D-amine 72% after telling the family they needed to go home to retrieve the bottle. When I first saw him he was breathing very fast, completely confused and not responsive, exhibited a mix of hypertonia and posturing, clearly in great distress. When we discovered what the chemical was we realized there was no antidote so all we could do was supportive care (which is true with most chemical ingestions). We got an arterial blood gas on him and discovered (unsurprisingly) that he had a bunch of metabolic derangements (see photo of his ABG below) including an extremely low calcium level. He actually had a positive Chvostek’s sign, which is the first time I’ve ever seen that. Apparently patients who ingest this chemical die of either severe hypotension or ventricular tachycardia so we basically need give him the closest thing to ICU level of care that we can.

The second sick patient was a 17 year old boy with known type 1 diabetes who was transferred from another hospital after having been treated for diabetic ketoacidosis and developed acute kidney injury requiring dialysis. He was the patient I picked up this morning and as soon as I saw him I knew something was clearly wrong. At home in the states he would immediately be intubated and sent to the ICU (as would many of these patients). He also was breathing very fast but had an okay oxygen saturation and was completely unresponsive. He had a fast heart rate and very low blood pressure (about 75/60 but it was so hard to measure because his breathing was so fast and labored that it made the BP dial jump all around). We later got a blood gas back on him (also see below) which showed a severe acidosis (pH 7.09), severe hypernatremia (163), and many other derangements. His blood gas is actually pretty interesting to try to puzzle out. He had a CXR which shows a possible pneumonia and he was quite hypothermic so we are basically resuscitating him and covering him for a variety of possible infections while we also arrange for dialysis. I have no idea what is ultimately wrong with him and he cannot speak for himself and we have not been able to talk to his relative so his story is still very unclear.

Patient 1's ABG


patient 2's ABG

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