A Hospital Story

I walked into rounds and there was a crowd of medical students around one of my patients.  Never a good sign.  She’s a 40 year old lady with 6 children at home, and she has terrible heart failure.  We’re unsure of the etiology, but interestingly there are a lot of young people here in Uganda that have heart failure – a specific kind called dilated cardiomyopathy.

Anyway, the day before she didn’t look very well.  Her arms and legs were cool to the touch (meaning her heart wasn’t beating well enough to send blood down there) and she was standing up and leaning on the bed to try and support her breaths.  Anyone in America like that would go to the ICU and be on really aggressive medications, but not the case for her.  It was more like the opposite.  She was supposed to get several doses of Lasix (a diuretic) daily, but since there are so few nurses for so many patients she had missed the last three doses.  Consequently she hadn’t urinated, and so fluid was consistently building up and making it harder on her heart to pump.

The reason she attracted all the med students was that she blacked out on her way to the bathroom a few hours before our arrival to the wards.  She didn’t have an attendant to help her, so another patients’ attendant helped her back to the bed.  No doctor or nurse was called.  The patient became progressively confused, and started screaming nonsense words across the ward by the time we arrived, likely due to the fact that her brain wasn’t getting oxygen.  This time her arms and legs were ice cold, she was breathing about 50 times per minute in between her groans, and I could barely feel a pulse.  She had no blood pressure that was measurable.  Her abdomen was distended with fluid so that she looked pregnant, and her legs were so swollen she could barely move them. 

There was some report in the record that she had an echocardiogram a few months prior (not repeated this admission for lack of money), and someone thought she might have had some fluid around her heart.  If there’s a lot of fluid around the heart, the heart can’t pump against it and that can cause severe heart failure like this lady had.  I grabbed one of the Ugandan residents and we rushed to the locked cabinet where the handheld ultrasound was.  Luckily it was charged, and I brought it over to her (while all the other patients were watching) and found her heart with the ultrasound probe.  Unfortunately there was no fluid (otherwise we were planning to stick a needle in her chest and drain it off to help her), and her heart was barely squeezing.

We realized then there was really nothing we could do for this dying woman.  Ideally she’d be on a constant infusion of medicine to help her heart pump and support her blood pressure, and also probably a constant infusion of medicine to pull fluid off of her.  She’d be in the ICU with big IVs and machines constantly monitoring her and probably be on a ventilator.  But here, we only had 1 vial of the medication to help her heart and blood pressure – we had to mix it ourselves to make a constant infusion that unfortunately only lasted about 30 minutes.  Then the fluid medicine we just gave as we thought appropriate and tried to not drop her blood pressure further and kill her.  At one point I asked the resident, “Should I do CPR if she dies”?  The answer was “no”.  In America I probably could be fired for telling someone to not do CPR.  But doing CPR implies that if (IF) you get the patient back, you then must support them on a ventilator, with constant aggressive medications, and in an ICU.  Then perhaps in this patient’s case you could keep her stable until she could have a device implanted in her heart to help it pump.  But those things won’t happen here.  The patient has to pay for her own medication which is on short supply already, there are only a few ventilators in the hospital and they are rationed, and even if we got her back – what would we do then?  She’d be right back in the same situation in a day or so.

Of course there are a lot of questions that go along with this.  Why can’t we get better local government or international funding in our resource limited settings like Uganda to help poor patients like this one (which is a particularly interesting question in Uganda where currently the Ugandan government is spending money trying to outlaw homosexuality)?  In a place when you don’t have much to offer, how do you decide who gets scarce resources and who doesn’t?  More controversially does this change my opinion about what we offer our patients with end stage chronic diseases in the US – when an insane percentage of our health care dollars are spent within the last 6 months of life?

There definitely aren’t easy answers to those questions, and there’s not an easy answer for this woman – and most of the other women lying around her in the ward here and in hospitals in resource-limited settings across the globe.