Dying on Rounds

It’s frustrating to have a patient die while under your care and know that there was more you could do.

We had a 27 year old female come in the day before for hypertension with a history of chronic kidney disease. There was no known cause of either her hypertension or her chronic kidney disease, and no way of knowing if one led to the other based on the tests we had available. For whatever reason, even though she had been admitted there had been no baseline labs drawn (you can get a creatinine level, an indication of kidney function, for free) since admission. Unfortunately, since Monday night at 6:00 PM she stopped making urine, a bad sign that the kidneys are failing. Also unfortunately, despite an attempted trial of lasix, a medication used to make the kidneys produce more urine, she was still anuric (without urine output), and no one acted on this until this morning. When I arrived for early morning rounds yesterday, I went over to talk with the medical student caring for her and noticed that while her eyes were open, she was clearly not awake and not interactive, breathing in large gusts of air and occasionally twitching her arms and legs. Her facial muscles were also fasciculating, clenching and unclenching spasmodically. Her eyes were open and dry, occasionally rolling back into her head. She was not responding to me, even with the painful stimulation of pressing her fingernails. When listening to her heart I now clearly heard a pericardial rub, a sound of friction between the two layers of tissue surrounding the heart. These findings, in combination with her known kidney disease made concerned that her renal failure had worsened. Since there is no way to scan her bladder to see if she is indeed making any urine, we decided to place a catheter and drain her bladder. There was only a minimal amount of urine after we placed the catheter. She had no intravenous access, and when I checked her blood pressure it was in the 90’s systolic- very low. I called over the other residents on the team and we started working on her, attempting to place intravenous access and getting medications like insulin, dextrose and calcium drawn up. The calcium gluconate in the drug closet had expired in December 2007, so I wasn’t sure if it would do more harm than good by administering it. We had no access to an EKG machine to check to see whether her kidney failure had caused her potassium levels in her blood to build to dangerous levels, but her heart rate was quite slow at 50 beats per minute. Despite our efforts, her breathing and heartbeat swiftly ceased. The family and the attendants were by her side for the entire time, and were surprisingly accepting when we discussed with them how sick she was.

One of the things that I like about being a doctor is seeing when something is going wrong and knowing and being able to intervene. It’s frustrating to know that in the US we would have done things very differently, and she might have survived. Now, whether that survival is to a life of dialysis isn’t clear. Furthermore, long term hem dialysis is difficult in Uganda, and there are no options in Mbarara yet. I enjoy the role of being the one that knows what to do when patients are getting ill. I forget sometimes that my other role is to be there for and with the patient and family, even and especially if there isn’t much we can do medically. All too important here, where patients are all quite ill and it’s not always clear what illness they have.