Juliet Okoroh, Class of 2014 UCSD SOM
My patient was a 72-year-old-male with hypertension who was five days post-op from an epigastric hernia repair.
An exploratory laparotomy was performed because the hernia was strangulated and there was concern for viability of the bowel.
Intra-operatively, the surgeons found malignant ascitis, a cirrhotic liver and some metastasis in the mesentery of unknown origin.
The patient did well, was extubated immediately after the case and met his post-operative milestones.
This morning, he appeared well, was walking around, his only complaint that his compression stockings (prophylaxis for deep vein thrombosis) were too tight.
In the afternoon, one of the exchange residents from the Democratic Republic of Congo noticed that the patient had a bout of emesis and started to have “anxiety” afterwards.
I came see the patient. He was tachycardic and tachypneic: acutely ill-appearing, but mentating well.
His lung sounds were unremarkable except for some upper-airway wheezing, he denied any chest pain but endorsed feeling short of breath.
On cardiovascular exam, he was tachycardic but regular, and he felt cool and clammy on his extremities.
His abdomen appeared a bit distended but his incision was clean, dry and intact.
My differential for this patient on post-operative day 5 with acute deterioration of clinical course included a pulmonary embolism or myocardial infarction.
The last vitals were reported as afebrile, hypertensive to 160s/90s, heart rate of 110, and respiratory rate of 40.“Let’s get a pulse oximeter on him if we can find it.”
“Ok let’s get him some oxygen, I will go and find a pulse oximeter in the hospital.”
I went to the ICU and borrowed a pulse oximeter from an ICU anesthesiologist. By the time I came back another resident from the team had joined in.
“I think we should get cardiac markers, EKG, arterial blood gas (ABG), start treatment with high doses of aspirin, oxygen, nitroglycerin, and morphine.
He was previously on prophylactic heparin, but we should give a therapeutic dose now.
A D-dimer will not help us because he is post-op and high risk and I know we can’t get a CT-scan now.
Cardiac markers and ABG will take some time to come back.
EKG — we have to call someone to do it.
Aspirin, nitroglycerin, morphine, additional heparin — we have to send the son to go buy some.”
About an hour later, the patient was able to receive some aspirin and heparin that the son had to go buy.
The EKG tech arrived and the EKG showed some ST depressions in leads II, III, and AVF. There was no right bundle branch block or evidence of strain.
“Can we transfer this patient to the ICU? He needs to be intubated since he probably will tire out.”
“We have no beds available. He can go to the intermediate unit and we have no available ventilators in the intermediate unit.”
My patient continued to be in significant respiratory distress. He became hypotensive in the 90s/50s with no evidence of bleeding. We supported him with fluids.
“I think we are probably going to have to start pressures on him. He is going into shock. We need a central line and some more labs.”
We had to send his son to go buy dopamine and the central line.
Three hours later, we were still calling every pharmacy available to find dopamine (dobutamine is first-line but almost impossible to get). We finally found some at the 37 Military Hospital. The pharmacy there was kind enough to send someone in traffic to bring it to our hospital.
“This is the problem with Ghana,” said my chief resident. “Even if I was in this condition, the same thing would happen to me.”
Now the patient was on 20mg epinephrine to maintain his pressures while we were obtaining the dopamine. His urine output was dropping. His mean arterial pressures were in the 30s, he was still in respiratory distress, and he was not intubated because we had no ventilators available.
We could not even give him blood, because he was a Jehovah’s witness.
We placed a central line. An anesthesiologist showed me how to estimate central venous pressure when a transducer is not available using a column method. He was intravascularly low either due to third spacing or hypovolemia. We continued to hang bags of fluids. MAPs improved with dopamine although they were still in the 40s-50s — with kidney failure and impending doom from respiratory compromise.
The following day I walked into the hospital. The patient’s son was smiling at me and I thought to myself, Maybe he survived.My chief resident told me that our patient expired despite our best efforts with the limited resources we had. He had expired thirty minutes after I had left the hospital the day before.
The family had a meeting with my team, thanking us vehemently for our help even though deep inside, I felt this man could have still potentially been alive if we had more resources. I guess for a region of the world whose life expectancy on average is in the 50s, living till 72 is considered good, and families expect a grave prognosis after surgeries. The fact that the man was alive five days after his procedure had given the family enough comfort.
As we develop the future of robotic surgery in high-income countries, we are widening the inequities in health, so that people continue to die due to disease states that are preventable.
Out-of-pocket payments and lack of medicine and supplies continue to threaten the health systems of low and middle income countries.