Monday, February 15, 2010

Kidney Failure

In the large grassy yards of the hospital, women and children (patients and caretakers, usually) sit outside during the day. Sometimes the children have IV lines in their arm - or in their head, in the case of severe malnutrition in which a vein cannot be located. The presence of the patients outside creates a kind of pleasant social scene, and it's nice that the kids aren't trapped in the depressing cage-like wards all day.

I am walking past the Pediatrics Ward when I notice all of the mothers in the yard outside Peds leap up and sprint toward the window of the Peds Ward. I wonder if something crazy is going on inside - maybe someone has collapsed? - so I walk over to see if I can help. As it turns out, the charts are being handed out before rounds, and the mothers are just collecting them. The nurse who tells me this then says "Doctor, I want you to come and see this child. He is very sick."

I don't know anything about children, and have negative interest. They're cute and all, but Pediatrics was my most painful rotation in medical school. Which is why I am always glad when Pediatricians are around - it means I don't have to do it. (I know most doctors feel that way about Gynecology). I try to defer by saying I am a Women's doctor, but she persists, saying he is very ill. "I'll take a look at him, and maybe I can call the other doctors in my clinic," I say.

She calls the mother over, who comes walking with her little boy, and immediately I see what is wrong. He is 5 years old, and his abdomen is huge with ascites (fluid in the abdomen), his legs are edematous (swollen), and even his eyes are puffy with fluid. He is reaching up to hold his mother's hand as they walk with difficulty across the yard, and as he reaches, his red shirt pulls up above his waist. He is not wearing pants or underwear, and almost gasp when I see his scrotum - it is hugely swollen, to the size of a newborn baby's head. The penis is swollen too, the skin taut.

As the mother walks him inside the door, he realizes that they are walking toward me (the scary mzungu) and he starts to cry. She keeps walking, and then he screams bloody murder. He tries to run, to fight, but she is holding his arm and he lunges toward her leg in fear of me. Of course I am not offended (I'm very used to this), and it's almost funny except that he looks so sick. I feel badly for making him so afraid, but I need to examine him. The nurse chastises him for screaming so wildly, and they pretty much have to drag him into the examination room.

Trapped in the room with me (and his mother and the nurse), he starts to almost lose his mind screaming. He doesn't stop. I decide to review him quickly without touching him and go get the Ugandan doctors I work with, who know much more about kids anyway. I notice that the penis is so swollen that the foreskin, which is swollen to the size of a finger, is constricting around the head of the penis, choking off any possible urination. Ugh. How awful. When I even lift a finger to point at something to ask the nurse, the boy screams even louder. The poor kid is so terrified.

I call Gloria, one of the doctors I work with, and she tells me to have the nurse bring the child to the clinic so they can look at him. By the time I get back to clinic they are already examining him in a room. He is upset but not crying. They are discussing what to do. Most likely, this is some kind of kidney failure, but what kind and why, we don't know. We decide to send off some labs using our Poor Patient Fund, and to attempt diuresis with Lasix. We discuss the constriction of the penis, which is the most pressing issue. He hasn't urinated in 3 days, and unless we can drain his bladder, the Lasix will just cause the kidneys to fill the bladder and he'll be in even more pain.

Victor touches the penis to examine the constriction. The child whimpers and then cries loudly when Victor does this. Victor lets go. I reach out a hand to point at his abdomen (about 3 feet away), and the boy starts to scream his head off until I back out of the room. Fear beats pain.

We need to put in a catheter. We think that a suprapubic catheter - one that goes in the abdomen just above the pubic bone - is the best option. He also needs some kind of incision on the foreskin to protect the penile shaft from constriction. In an adult, we could do this easily with local anesthesia, but a 5-year-old boy will never tolerate this. But how can we give him anesthesia when it looks like his kidneys are failing? What kind of sedative can he metabolize? Will he end up toxic and need a respirator, which doesn't exist here? We need to speak to the anesthetist.

I run off to find the anesthetist. It is about 4pm already. I try to call but his phone is off. He is not in theatre. Someone in theatre tells me he is in the big staff meeting that is happening just next door to our clinic. I tiptoe up to the meeting and ask a nurse I know for the anesthetist. "He is inside," she says.
I creep around to the side of the building, but the side door is locked. I peer through the window, and I see him sitting there, bored and not listening to the meeting. I wave for him to come outside.

Gloria and I explain the situation. He offers to do the case tomorrow. Gloria insists that it needs to be now - this could get rapidly worse, the urine could back up into his kidneys and destroy them even more. Plus, he is in pain. "Ok," he says, "We go. Bring him."

While I dash back to Labor Ward to deal with some patients there who need ultrasound, Gloria and Victor organize getting him to theatre. While I am scanning, I get a call from the anesthetist, telling me that Gloria and Victor have requested that I bring the ultrasound. I race over there.

When I arrive, Gloria and Victor are in scrubs, already operating on the boy. The anesthetist has given him Ketamine for sedation. They attempted to place the catheter suprapubically, but couldn't find the bladder through the incision they made. Now they are trying to free the penile shaft. They have made an incision on the foreskin, and the glans is easily visible. They place the catheter in the urethra, and 100cc of urine drains immediately. We discuss what to do about the foreskin. Removing it is the best thing for him - who knows when this edema will resolve - but is it ok to do a circumcision without express permission? Victor, who had spoken with the mother, knew that she was aware that we would probably be cutting the foreskin, and although we hadn't called it a circumcision, there was no doubt it was medically necessary. We went ahead with it.

I have done hundred of circumcisions in residency, but this is more challenging because the anatomy is distorted by all of the swelling, and because children and adults bleed more than newborns, so often stitching is required, whereas it is almost never needed in newborns. Victor does an excellent job. As we are stitching gently to stop the bleeding, the boy starts to wake up. The anesthetist already gave him more Ketamine earlier, but now he has stepped out of the room and there is none left in the syringe. The boy is still groggy, but he starts to wake more and more, crying out for his mother, then crying out in pain and reaching his hands downward. The nurse holds his arms, and Victor works quickly and skillfully under pressure. We finish before he opens his eyes. Meanwhile, I start dodging out of his line of vision, because if he is crying now, he will really lose it if he sees the scary mzungu standing there.

We call his family in and they come and carry him back to the ward. We explain what we did, but it's hard to know how much they understand.

The next day, I stop by the Peds Ward to see him. He looks a little worse - his feet are even more swollen. He cries loudly again when he sees me, screeching and twisting away from me. I realize he isn't getting the Lasix we wanted. I order a pediatric dose (which Gloria had reviewed for me) and ask the nurse to give it, and she does.

Over the weekend, he misses 1 of the Lasix doses, but does get 3 doses total. When I see him today, Monday, he looks even worse. Now the eye puffiness is gone, but his entire face is swollen. The nurse helps me ask if the mother agrees with my observation, and she does. His legs look the same, and his scrotum is the same or maybe better, I can't tell. His abdomen looks bigger to me. And now, because of the catheter, he stays in bed, not walking around.

The nurse notices the soiled sheets and tells the mother that she needs to change them. (Patients bring their own colored cloths to use as sheets, blankets, cleaning rags, etc. Nothing is provided by the hospital, and patients usually bring a stock of these cloths.) The mother replies that she had only brought 2, and has no one with her to send home for more. No one from her village has come to check on her. Her husband died years ago, so she is alone.

My heart breaks for this child and this woman. Gloria had told me before that the woman noticed symptoms in the boy over the last year, but has been using "herbal medicine" to treat him. It's hard to know when he got this bad, but the whole situation is tragic. I don't know what is causing the kidney failure - some causes are reversible or temporary, but require aggressive care until the problem resolves. Other causes are permanent. Any cause could be deadly for this little boy, who is getting very little care. I look at the woman and the little boy looking up at me. Today, he cried a little when I arrived, but stopped quickly. He lets me listen to his heart and his lungs without a peep. I touch his swollen legs and talk with the nurse for a long time. He doesn't cry at all. This might be a good thing - maybe he is getting used to me. But it could be a very ominous sign - he might be too weak to scream the way he did before. My time in Uganda has taught me that a loud child is a healthy child.

I don't know what else to do right now. There is 200cc of urine in the bad with a little sediment. Has the bag been changed since we operated? If not, he has put out 100cc of urine in 5 days - that's 20cc per day, which is close to nothing. I found out today that Gloria had wanted him to get some IV steroids, but he hasn't been getting it, so I am going back to the ward now to ask them to give it. The labs we sent are still pending - they should come back today. If we refer him to a hospital in Mbale or Kampala, his mother will still needs money for medications and tests, which she doesn't have. Gloria knows about a program in Kampala that sometimes takes very poor, very sick kids and gives them acute care. It might be his only hope.


nate said...

that anesthetist needs a visit from B.A. Baracus…

danengber said...

for christ's sake, I can't stop thinking about how that boy was put under, and then gradually came out of anesthesia only to discover that he was in the middle of getting circumcised. It's like waking up in a UFO while the aliens are performing invasive experiments on you. Also, why are children afraid of mzungu? Just because you look different? Or are there stories of what mzungu do to children? In South America, there are lots of rumors of white doctors stealing children to harvest their organs. Is it the same in Uganda?

Veronica said...

Dan - It's unlikely that he remembers it because the ketamine gives some amnesia. Plus he had local anesthesia (Lidocaine). It was upsetting, but not as bad as it sounds.
Children are scared of mzungus because we have freakishly white skin and weird hair. But also, many of the mothers tell the children to be good/stop crying "or the mzungu will take you away and eat you." It's grounded in some reality (ie. slavery) just as many of the fears in Latin America arise from the thousands of illegal "adoptions" of Central American children that happened in the past. And now we have genius missionaries kidnapping Haitian children and calling it god's work. Go team.
Anyway, once the kids are 4 or so, they lose the fear and just find us incredibly fascinating and hilarious.