Organophosphates are compounds originally synthesized as
pesticides, and later used as nerve gasses and biological weapons. Several of these compounds have been outlawed
in the United States due to their extreme toxicity, but here in Uganda and in
many third world countries they are still used.
They are used mostly for farming and killing pests, but too often they
are also used as an agent with which to commit suicide.
In humans, OPs inhibit acetylcholinesterase, increasing the
levels of this chemical in the body.
This sends messages to certain cells in the body to form a “cholinergic”
response, which is the opposite of the “fight or flight” response. Pupils constrict and it’s hard to see, eyes
water, noses run, saliva streams from the mouth. You get very sweaty and your lungs fill with
fluid. Basically your body will drown in
its own secretions. It can be accidentally
inhaled or absorbed through the skin – and in the rare cases we see toxicity
from this at home it’s in these settings usually in rural farm towns. Since I’ve been here in Mbarara I’ve seen at least
5-6 cases of men turning up bottles of the stuff.
This weekend on “attending-less” rounds I was seeing some
patients in the male ward when I happened upon a gentleman who was unresponsive
and whose clothes were soaking wet. At
first I thought his IV pole had leaked on him, but it turns out it was just
sweat. Before looking in the chart I saw
his pupils were pinpoint and I knew what he had done. Interestingly in America where we hardly ever
see OP poisoning, we have very strict guidelines on how to deal with it. You intubate and ventilate a patient, and
keep them on a lot of the antidote called Atropine. It is pretty much against medical law to “pump
the stomach” because this increases the risk that the chemicals might come up
and go into the lung. You just support
them through the effects of the drug. Again
as I’ve said, ventilators are a luxury here, and since OPs can stay in the
system for days, you have to do what you have to do. So every patient here gets their stomach
pumped and gets activated charcoal. For
whatever reason this gentleman didn’t get pumped/charcoaled properly before
getting shipped from the emergency ward to the regular medicine wards. He had originally gotten better when he came
in, but also as I’ve mentioned there are such few staff here that no one had
checked on him until I came around and found him covered in sweat
(interestingly that doing exactly the opposite of what we advise in America
would have been the most beneficial thing for the patient here…).
I rubbed on his sternum and shook him unfortunately with no
response. He had snot coming from his
nose and the few breaths he was taking each minute were labored and
fluid-filled. He hadn’t gotten Atropine
(which you can give every 5 minutes) in about 12 hours. I ran over to the emergency department, grabbed
a box of Atropine vials, and ran back to the ward. After donning some gloves I started breaking
open the vials and injecting them in his IV, meanwhile finding the transporter
to take him back to the emergency ward where he could get more monitoring. Unfortunately right as he got over there, he
died.
In light of all the residents’ stories I’ve shared, I have a
couple of thoughts on this. On one hand,
it’s hard for me to imagine surviving Idi Amin’s rule and Joseph Kony’s terror,
just to go on and try to kill myself with poison. On the other hand, perhaps after seeing all
those things it’s just too hard to go on.
Interestingly it’s only men I’ve seen taking these OPs – and it usually
seems to be after something somewhat insignificant – like having an argument
with their wife or having a bad day at work.
With cases like that sometimes it’s hard to feel like you
make a difference. There were so many
muzungus here at first I couldn’t participate in patient care as much as I’d
like, but then ultimately I don’t have a license here and don’t speak one of
the 52 languages of the locals. There’re
so many patients dying that even the residents can’t help a lot of them. It’s frustrating.
But the other weekend I was rounding with on attending-less
rounds. We were seeing patients in the
female ward this time and there was a girl (I say girl because she was younger
than me) who was having a hard time. She
had just been diagnosed HIV+ at admission (called NYY here to reduce the
stigma) when she came in with cough, fever, and shortness of breath. We had no idea what her CD4 count was, which
is what you measure to see how suppressed the immune system is in HIV. She had been started on medications for
pneumonia, but was too poor to afford a blood count or a chest X-ray. She had been in the hospital 3 days by the
time I saw her with Sam. She was sitting
straight up on her mat (on the floor as there wasn’t an available bed), bug-eyed,
breathing around 60 times per minute (you should give it a try to see how fast
that really is), and looked like crap.
She was scared and I was scared for her because she was going downhill
fast. We checked her oxygen level and it
was so low that it didn’t register on the machine. We moved her to the emergency room so she
could get some oxygen if it was available, and I told Sam maybe we should treat
her for this disease called PCP Pneumonia.
People with HIV (or immunosuppression) get this, but we couldn’t
actually do a test to see if she had it for sure. So we blindly started the medicine and hoped
for the best.
Every day after that she still looked the same. I rounded on her about 4 days after the new
antibiotic, but then realized that because of lack of staff and lack of
knowledge on the family’s behalf, the patient actually HADN’T EVER received the
antibiotic! I tried to keep myself from
having a hissy fit, and eventually got the medication to the patient. The next day, she was sitting up in bed
eating some lunch, and only breathing 40 times per minute. She still looked bad, but over the next few
days her vital signs got better, and about a week ago she packed up her bed
sheets and walked out of this hospital back to her family.
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