- Written by Ethan Abbott
The following is a post from Duc Tran, PGY-4 and 2019 recipient of the Yale/Stanford Johnson and Johnson Global Health Scholarship to travel to Uganda
Hello again from Uganda,
I’m still alive over here and doing well. I wrote a little something about one of my experiences here last week, and I wanted to share it with you all.
A 17 year old girl brought in by her mother for altered mental status that started today, and was preceded by a few days of generalized weakness. You see in front of you a young skinny female laying listless in a stretcher, minimally responsive to strong sternal rub. She has labored breathing, rapid pulse, diaphoretic skin, and normal pupillary response to light. No vitals are done as of yet. As any good ED physician, you know altered mental status automatically means you get a CBG. You were lucky enough to have CBG strips available. The CBG on this girl showed “HI”.
Here in Uganda, when people see you standing next to a patient, they come crowding over, looking to see what is going on and how they can join. The ED team is now mobilized. Nurses check vitals; it shows BP is 60s systolic, HR is 140s, and Oxygenation is high 90s. Concerned about brain perfusion, you drop the head of the bed down, and prop pillows below her feet. Two IV lines are now inserted in the patient, and she is receiving two 500 cc (there is no 1 liter fluids here) cartons of normal saline run wide open into her. After 4 Liters are in; BP is now 70s systolic, but overall still too low of a MAP for adequate brain perfusion. You make your dirty epinephrine drip (this and dopamine are the only vasoactive agent you have available). You take 0.5 mg of the code cart epinephrine (To save the rest for later, you simply tape over the top of the vial containing the rest of the 0.5 mg of epinephrine) and inject it into the 500 cc of normal saline. Since there is obviously no infusion pump, you titrate your dirty epi to affect. You’ve now reached a respectable MAP of 65, minimum MAP required for brain profusion. Patient has been successfully resuscitated.
It takes a couple hours for labs to come back. Your suspicion for DKA is high based on your history and physical; obtunded, young skinny girl, with reports of generalized weakness, elevated blood sugar, with Kussmal breathing, low blood pressure, and tachycardia. Although you would like to have labs confirm your diagnosis, you are better off treating the girl now if you suspect DKA, as her PH is likely less than 7.0, and she will likely go into cardiac arrest soon if you don’t. You bolus her 10 units (0.1 units/kg, assuming a weight of 100 kg) of regular insulin and start insulin infusion (0.1 units/kg/hr). To make an insulin infusion for 100 kg patient, you take 10 mg (0.1 units/kg) of regular insulin, inject it into 500 cc of normal saline, and make sure the drip rate will finish in one hour, giving you effectively a 0.1 units/kg/hr infusion rate. How do you do this? Dr. Google says there is approximately 20 drips in a milliliter. You want the entire 500 cc volume to finish within one hour. So there is 10,000 drips in a 500 cc container. Rate equals 166 drips/ min, which equals 2.77 drips/ sec. Now you take your wrist watch with a seconds hand, put it up in view with the drip, and titrate the drip to have 2-3 drips go in after 1 second has gone by on your watch. That gives you a 10 units/hour drip.
Labs come back a few hours later. NA = 150, K = 4.5, CL = 100. Where is the bicarb? Oh thats right, there is no reagent for the bicarb in this lab. So no bicarb for you. Also no ketones or a PH. So what do you do? How do you follow an anion gap when you can’t calculate an anion gap? Well first off, this is pretty much the only set of labs your gonna get for a while for this patient. Remember, family members are the upfront payers of healthcare here. Each chemistry costs 10,000 shillings (a little more than 2 USD); however, this is a lot for many of the patients that come through the hospital doors. 10,000 schillings is fine once, but 10,000 schillings every 4 hours until the anion gap closes is often burdensome for the family. As with this case, the patient’s who are in DKA, are in florid DKA. Often times, when patient’s present with DKA, they are altered, acidotic, and hypotensive; so you can expect the labs to represent this severity. If they are in florid DKA, taking the sodium, and subtracting the chloride and 30 (upper limit of normal for bicarb), you will still get an elevated anion gap (i.e 150-100-30 = 20 = still DKA!). Again we are using the upper limit of normal for bicarb, anion gap is likely significantly higher, as we expect the bicarb to be much lower in subacute presentations of DKA. You can assume ketones are positive from the patient’s history; assume low PH from altered mental status, poor perfusion, and Kussmal breathing. Voila! You’ve Diagnosed DKA, from part history, part physical exam, and part labs.
Your plan will be to continue IV hydration, continuous insulin infusion, monitor and give respiratory support (putting her onto her side so if she vomits, she will vomit onto her bed instead of her right bronchus) when needed. When the glucose goes below 250, switch normal saline to 5% dextrose and continue the insulin infusion, as you would in the U.S. Regarding potassium, add 10 meq of potassium chloride every once in a while (I know, not an exact science) to your IV fluids – better to under do this then over do it. How do you know her DKA has resolved? The best thing really is hope her mental status improves, which we would expect to happen once the ketones and the lactic acid resolves.
In the unfortunate case her mental status doesn’t go back to normal, ask the family members if you can repeat labs, and if the labs show a resolution of DKA, she may have something else going, and you may have to ask the family members to pay for a CT brain scan for the continued altered mental status. Here they cost 300,000 schillings (~ 80 USD).
For this specific patient, by the end of the night, she was fully talking!
Obviously, I can’t take much of the management I practice here back to the US. But what it has taught me was an understanding of illnesses and its course. Here, I won’t have labs, drips, etc, at my disposal. I won’t have numbers to follow, but I will have the same sick patient. For this case, we resuscitated her, then we gave her insulin — which is what her body was lacking, and hoped that was enough for her body to heal itself. I certainly don’t want to give the impression that with a little bit of ingenuity and close attention, many of diseases can be managed successfully here, and that Uganda’s, and Africa’s health problems can be fixed with simply an understanding of pathophysiology and pharmacology. There’s a lot of the same problems that we face in healthcare in the U.S here, but it is compounded many times over by limited resources.
Although I conveniently painted a neatly done resuscitation, and management, the reality was far from it. The girl in this case actually did get better, was talking, but overnight the limitations of the ED had caught up to her. It appears that overnight she did not get her insulin, and she went straight back into DKA. When the team saw her the next morning, she was again altered and now she could not move the right side of her body. CT scan done later showed significant cerebral edema.
Last week, I attended the resident’s lecture on DKA. Most of what they were taught is from our management of DKA, which is highly dependent on laboratory values, and fine titrations of drips. It was hard to listen in, as many seemed underwhelmed after realizing that they cannot do what is considered standard of care for what is a very common ED presentation. They were learning about following anion gaps, not starting insulin until the potassium is known, and EKG changes on hyper/hypokalemia. Nonetheless, in such a true resource limited setting, they will have to create their own protocols, as those in the western textbooks don’t suite them. They not only have to know what I was expected to know, but they must adapt what they learn to work for them. Their road will be difficult; they are paving their own path, and possibly unbeknownst to them, they will likely be the next pioneers of emergency medicine.