Monday, October 18, 2010

A middle-aged man with flank pain

A moderately obese middle-aged man with a history of treatment for kidney stones presented to our Indonesian village clinic with a history of severe left-sided flank pain for several days. He was febrile, and writhing with what appeared to be classic renal colic. Though we didn't detect blood in his urine, given his history and presentation, we still suspected he had developed another stone. Given the fever, we also wondered if the kidney was infected (pyelonephritis). More worrisome still was the possibility that he had both an infected kidney and an obstructing stone. That's a surgical emergency and beyond our capacity to care for at the clinic.

We began aggressive fluids, antibiotics, and antiemetics, and gave him the pain meds we have--Tramadol, paracetamol (Tylenol), and ibuprofen. Then we took a look at his kidneys with the portable ultrasound, hoping it would help determine whether we needed to worry about obstruction or whether this was just pyelo. The news was grim. The left kidney showed clear evidence of blockage in the form of hydronephrosis, while the right kidney looked normal. It looked like he did have pyelo and an obstructing stone. We discussed transfer options with the family.

They happened to be relatively wealthy, and they decided to take him to the city where he'd been treated for stones before. The five-hour speedboat ride was arranged to take place the following morning. We were worried about the delay, but it appeared to be the soonest they could arrange for.

Just after midnight, my colleagues and I were called to his bedside. He had become tachycardic, hypotensive in the 70s, and delirious. He had developed snoring respirations as well, though his lungs didn't sound fluid-overloaded. In short, he had developed septic shock, and his life was in immediate danger.

We stepped up our supportive care, but were now faced with several hard decisions. Do we attempt to get this patient to the city sooner than his scheduled 7 AM departure? Does the family have the money to make this happen? Is he stable enough to ride in a bouncing speedboat for hours on end? What about a plane flight? The planes that leave the nearest airport (about two hours away by car) don't have a first-class section, and the aisles are only two seats wide--that's not enough to lie down across a row of seats. In any case, it was hard to imagine putting this man into a wheelchair, let alone manually lifting that chair up the steep flight of stairs from the tarmac into the airplane cabin. And once he finally arrives at the hospital, is there a urologist there and an ICU bed?

Worst of all, if his breathing deteriorated, should we place a breathing tube? This is no small matter even in the highest-resource setting, because once you place a breathing tube you are committed to "bagging" the patient by hand, giving breaths, until he is connected to a respirator. Giving breaths manually is far from ideal--it is much too easy to give them too fast, too slow, or at the wrong volume. There are no respirators here, nor anywhere nearby.

Faced with these problems, the family swiftly chartered a boat to leave at 4 AM. They expected to be treated there by the same urologist he'd seen in the past. As we discussed treatment options, they told us they were prepared for the worst, but asked us to give "the best care" in the meantime.

What is the best care in this instance? Does it include placing a breathing tube if he goes into respiratory failure? That would generally be the right choice in a high-resource setting in a previously relatively healthy man like this. But here? Is it the best care to intubate someone out in a village, with no X-ray to confirm correct placement, no continuous monitoring available, no respirator to regulate the depth and volume of breaths? What if someone overinflates a lung during the journey and it collapses? What about the lack of easily-titrated sedative and pain medications to keep the patient comfortable? And, given that we are trying to save both lives and livelihoods out here (a trip to the city can completely ruin a family's finances), are we sending these people on a futile errand? Sometimes our job here is to advise against escalating care.

In this case, the family had the means to travel. And we were spared the intubation decision, as the patient's blood pressure improved with increased fluids and his breathing didn't worsen. Soon he and his family had sped away in the clinic's small ambulance, headed for the docks, an Indonesian doctor at his side with a bag full of fluid bottles and extra medications. And a bag to provide temporary breaths, just in case. We wait to hear how he did.

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