Friday, January 31, 2014

Practising the Ancient Art of Bloodletting in the Modern Era of Online Communication

Blood Letting in the "Olden Days"

I can remember as a child being fascinated by the apothecary shop. The shop was a Colonial era rendition of what a doctor-pharmacy habitation might have been like in the 1700s. As the aromas of dried herbs and potions wafted round the wooden timbers and layer of sawdust strategically spread over the floor beams, the historical enactor in petticoats and apron, held up a jar of live leeches. “These were used for those with a bit of blood congestion after a long winter.” One of the black slug-like critters swivelled his sleek body in a u-shape and smirked through the glass. I stepped closer for a better view.

“Over on this table you can see some of the knives that the Dr Hugh Mercer used to cut his patients who needed to lose more substantial quantities of blood. Different sizes were used depending on how much blood the doctor felt needed to come out.”  Several smallish metal contraptions with one or more lancets, including one with rolling cutting blades that resembled a primeval torture device, rested benignly on the table. Gruesome, spine chilling, and fascinating!

Fast forward to current time period. Haemoglobin levels are measured by handheld devices now. Too little blood or too much blood have fancy technical terms like anaemia and polycytosis. Physicians are much more prone to infuse blood into the body’s veins than let it drain out although there are a few instances where blood donation is beneficial such as Polycythemia vera.  I’ve never planned to practise the art of bloodletting though! Vampires don’t seem to run in my family heritage.
Nifty little cutter for making multiple cuts at once -- improving blood letting efficiency!

NN had already met with the young mother and father of the patient, a youngster of almost 2 years. AJ clung to his mummy with his little fingers grasping at her shirt while his mother patiently consoled him by breastfeeding.

“Doctor, they’re just from hospital X,” NN informed me as I joined her in the consultation room.

“Tell me what you’ve discussed already,” I requested and sat across from AJ, still clinging to his mother.

“He was admitted in hospital Y a few days ago. He had malaria and was given quinine drips and antibiotics. He also was given one bag of blood. Now he has no more fever but he’s weak.”

“So he is taking breast well? No vomiting? No fevers? Normal stools? Everything is fine except that he’s weak?” I turned to the parents.

They looked down at their baby and nodded together. “Yes, doctor,” they chorused.

“Ok…” I wondered if there was more to the story. “Let’s examine him. Bring him over to the table.”

Mom detached AJ from her breast in spite of his protests and placed him before me. He was not happy at this separation and made sure everyone understood such.

Crying. Good sign. I mentally catalogued the information as I noted his pink conjunctiva and fingertips with a brisk capillary refill. Certainly not a haemoglobin of 5.1 g/dl anymore! After stalling for time by doing an extra long examination of AJ, all I came up with were some rough sounding lung sounds and mild oedema of the fingers and feet.

“Doctor, let me explain something,” AJ’s auntie joined the conversation. “At the hospital they gave him too much blood. See.” She pointed out some figures and written orders in AJ’s medical booklet. From her description of what actually happened versus the orders in the book, it did appear that AJ might have received more than his fair share of blood.

Although he was not critical, he was not well. AJ’s parents’ observation that he was weak was accurate.

“Is he peeing fine?” I asked his mother.

“He pees too much, doctor. He drinks plenty water.”

“More than normal?”

She nodded.

I added this factoid to the assorted observations floating around in my head, trying to align themselves into a coherent diagnosis. “Let’s check an Hb (haemoglobin level) and blood sugar,” I suggested to my nurse.

NN nodded and headed off to prick baby AJ. I headed in the opposite direction to retrieve my pulse oximeter. We met up in the laboratory. Haemoglobin is 17.9 g/dl (normal is 12-14 g/dl).  The Pulse oximetre beeped red and angry. It spit out a reading of “82%”. I waited a bit for AJ to stop crying. Gradually the oxygen level in his blood climbed up to 90%. Still low.

“Doctor, the blood sugar machine isn’t working,” NN interrupted my concentration.

“Oh, let me see.”

She handed me the machine.  I fiddled with it. Hum? She’s correct. Definitely not working. I pause. “Ok. Let’s check a urine analysis. We can see if he is spilling glucose, or having ketones, or if there is protein. We’ll be able to check the specific gravity too.”

She nodded. AJ had already confirmed his mother’s assertions that he “pees plenty!” He’d urinated all over the exam table when I examined him earlier. It took less than an hour and AJ let off another fountain. His father expertly caught it in the cup provided. Plenty urine! Analysis revealed dilute urine without anything else of significance. “Kidneys are working,” I commented to NN.

In spite of their initial protests, AJ’s parents agreed to admission to the hospital for treatment. I wasn’t completely sure what to do. Diagnosis – iatrogenic erythrocytosis with secondary congestive heart failure and its sequela of pulmonary oedema?

Thankfully, one does not always have to have a diagnosis in order to begin treatment. When in doubt, one can at least treat the symptoms. “Put him on oxygen. Give him a little furosemide (diuretic medication) and monitor his breathing and oxygen saturations. Can you think of anything else?” I gave NN a chance to add any insights she might have picked up on.

She shook her head. “Doc, the blood level… it’s too high.”

“Yes. It’s too high.”  She went off to carry out my instructions – strategically placing our little youngster in the adult ward since the electrical sockets actually convey electricity in the adult ward unlike our paediatric ward. I meandered back home to finish supper and mull over the case and figure out if there was more I should be doing.

A fluttering of dark evil-eyed doubts and fears danced across my consciousness. I’d Never had a case like this? Haemoglobin of 17.9 g/dl? Can all the patient’s symptoms be explained by such a concentrated blood level? Is there something else underlying the child’s weakness? … and what about all those other unknowns – the creatinine, the electrolytes? The evil grins on my self-doubts spread wide and showed their gleaming razor teeth. Ouch!  I was inexperienced and blinded by lack of further laboratory data – stumbling in the dark was no fun.

When one is the only physician in a foreign mission hospital, it is incredibly helpful to have online consultants, colleagues who can dialogue with you through email, Facebook, Skype…  I sent out several “feelers” hoping someone would be available.

A couple emails and Facebook message later, I found one of my dear friends (and co-conspirator in African mission work) available. “I have this 2 yo male with…. “

She and I exchanged ideas and thoughts in between several additional check-ups on baby AJ in the hospital. “He’s not really getting better,” I complained. “He’s generally stable but even with oxygen his blood oxygen levels are not getting above 92%.”

The network expanded. My friend sent off a question to another colleague working in Africa. Within the same night, he’d sent back his advice, “partial blood exchange transfusion…”

“I’ve never done anything like that before, have you?”

“No,” my friend admitted. “Makes sense technically though.”

“So many unknowns though. I don’t have a lot of back up. What if it changes the hemodynamics of her circulatory system too much? What if her potassium or glucose levels change too much? What if…” Doubts and questions swivelled in my mind. “I’ll wait until the morning and see how she responds over night to the furosemide since she’s overall stable,” I replied.

Morning came. I couldn’t eat breakfast until I’d seen AJ. “How is she doing?” I asked the night nurse, NN.

“A bit better,” she smiled.

Small better. This is really not as positive a response as most English speakers might imagine. I grabbed my stethoscope and pulse oximeter. “How is she?” I woke up AJ’s mother.  “A bit stronger,” she answered after blinking awake.

I bent over the sleeping form of AJ. Still rather rapid respirations. Auscultation didn’t reassure me either, coarse rales in the lungs, same as yesterday. The saturation reading of oxygen in his blood was 85% initially. I waited and found it wavered between 85-92%. Still not good. Essentially unchanged. Crumbs!

I spent breakfast hunkered over my laptop looking up blood transfusion complications and updating my network of online colleagues about AJ’s condition. I received a reply from another colleague. “I’ve never had a case with such a concentrated haemoglobin.”

Hum? Should I feel special that such a unique patient resided in my hospital currently or might I instead freak out because now everything was going to be “experimental and theoretical”?

“I’ll ask another friend of mine,” she emailed back. My worldwide doctor network expanded again.

I’m afraid I wasn’t completely focused on the sermon in church that morning. So many different options and alternatives rolled around in my brain. I processed step-by-step how each might play out in real life – practical? Did we have the equipment? Would my nurse be capable of such? What would be the potential complications? Argghhh!

I anxiously checked AJ when I came back from service. No change. “A little stronger,” mother and father agreed. Basically that meant she wasn’t worse. She wasn’t getting better either. A recheck of her Hb was 18.9 g/dl.

More emails. More Facebook instant messaging. I received some great information. Options. Alternatives. Things to consider. Advice. And, most importantly, encouragement. One dear friend wrote, “I know you might be nervous about doing something like that, but you might be the best trained and equipped to do it.”  The phrase stuck in my head.

Patient consultations slowed down for the day. The labouring woman had given birth to her baby and was settled comfortably in the maternity ward. There was still no change in AJ’s status. “NT, let’s talk to the parents about removing some of AJ’s extra blood.” She helped me explain the procedure to the parents and auntie.

AJ’s father signed the consent form. He seemed rather relieved that the doctor was finally doing something that made sense – take away the extra blood his baby had received from his excessive blood transfusion.

Together then, the nurse and I gathered the materials. “Doctor, my heart, ee de fear. EE de shake inside,” NT admitted nervously.

“We’ll only remove twenty millilitres of blood at a time. We’ll go slow. It will be ok,” I consoled NT and myself.

Normal saline dripped slowly into the left ante-cubital vein on AJ. NT inserted a second IV catheter into the right arm. Mother calmed AJ by breastfeeding her. AJ was surprisingly placated with sucking. The 20 cc syringe seemed huge (4 teaspoons). AJ’s blood trickled through the tiny 24-gauge catheter and finally filled up the barrel. “One good thing about a small needle…won’t have to worry about rapid hemodynamic collapse,” I watched, amused.

Twenty millilitres of blood out; twenty millilitres of intravenous fluid in. The procedure was repeated. Over the next hour and a half, we aspirated 60 mL of blood.

“Ok, check the Hb.”

“14.2 g/dl” NT reported.

“We’ll stop the transfusion then.” She turned off the IV drip and removed the oxygen. We waited.

“How is AJ doing?” It had been about an hour. Did AJ need another dose of diuretic to help his body excrete the excess fluid on his lungs? Was he still urinating freely indicating good kidney function? Questions continued to flood my consciousness.

“He’s fine,” AJ’s mother smiled.

I checked AJ’s chest. His breathing was slower, steady. I listened to his lungs. Still a little rough but improved. His oxygen saturation even without supplemental oxygen was 92%. I smiled. He was improving. He really was better.

With joy I shared the good news with my online colleagues. Baby AJ continued to improve. The next morning he went home. At his check up he was doing perfectly. His doctor is extremely grateful to God for the healing He provides. She is also immensely indebted to her team of international physicians of various specialties who provided much needed advice, expertise, and encouragement to a lonely, anxious mission doctor practicing the ancient art of bloodletting for the first time.

Thank you!

“And my God will supply all your needs according to His riches in glory in Christ Jesus. Now to our God and Father be the glory forever and ever. Amen.” Philippians 4:19,20
Hum? Sign says "talk to your doctor"... !