Monday, March 24, 2003
Another email from Chuen-Yen, my friend in Malawi. This is a heartbreaking story about trying to treat pericardial tamponade without resources or equipment.
Thrusting a needle into someone�s heart is rarely a good idea. It is an especially bad proposition when requisite tools are unavailable and neither you, nor anyone around, have experience doing it. Nonetheless, circumstances occasionally necessitate such perilous undertakings.
While dissecting through an infant�s leg, I was called about a fifteen year-old girl suffering shortness of breath. I couldn�t see her immediately. So, the consulting general practitioner offered a tad of information. Lekelani had been admitted for chest pain three days prior. She was increasingly dyspneic. Chest x-rays and electrocardiograms had been done, but were reportedly uninterpretable.
Actually, a massive heart was conspicuous on the radiographs. And, though muted in amplitude, EKG strips clearly showed alternating large and small waveforms. Lekelani was in tamponade. I requested a cardiac ultrasound while finishing with the baby. Due to equipment issues, the patient was sent across town for the study and returned hours later.
By the time I received Lekelani, she was gasping for air, confused and dropping her blood pressure. Ultrasound had confirmed a massive pericardial effusion, which needed immediate removal. Our surgeon refused to attempt such a high-risk procedure. The only person known to have done one previously was in Geneva. Fortunately, pericardiocentesis instructions are on my computer.
Since no semblance of the recommended needle was available, we improvised as usual. I inserted an angiocatheter under the ribs and successfully withdrew a liter of fluid in twenty ml increments. (BAH�s largest syringes are 20 ml.) After evacuation of the first deciliter, Lekelani started to converse. She laughed, said she was studying to be a secretary and even ridiculed her condition. Everyone was delighted.
Later, I was called to see Lekelani for recurrence of her symptoms. This time she didn�t recover. Might the outcome have differed with better facilities and experienced physicians? Probably.
On a daily basis I do what is considered malpractice in the developed world but exceeds Malawi�s standard of care. Such shenanigans, which are tremendous experience to me, make the difference between life and death for the locals. It sucks to be sick in Malawi.