Sunday, December 05, 2010
Vengeance on Dark Souls
These are a few anecdotes and statistics that I have jotted down during the last few days. They are all related to each other in some obtuse fashion.
I examined a 60 year old lady in the Cholera Treatment Center (CTC) a couple of mornings ago. She had no pulse that I could feel at her right radial or brachial areas. I could feel a slight pulse at her right femoral artery which meant that she had a blood pressure of at least 40 mm Hg. I was not able to take her blood pressure in her arm at all.
After my exam I was staring down at her on her cart and she looked at me and thanked me even though her brain was not getting a "full head of steam" with her low blood pressure. I had no idea how she could even talk let alone thank someone.
Two lines were started in her left wrist and her right saphenous vein by the ankle and she perked up in an hour. However, she was febrile with her new circulatory status and had a tender abdomen, so I transferred her out of the CTC. I had bad feelings about her...like more was going on than "just cholera".
We had an 18 month old boy with pretty severe cholera. He also had an hour of seizures off and on, which is called status epilepticus. The CTC where I work has no medication at all except Ringer's Lactate IV fluid. People with cholera, especially children, can become hypoglycemic with cholera. Their sugar can become so low that they seize. So we started some Dextrose solution along with the Ringer's Lactate and his seizures stopped, he woke up, and started eating. Hypoglycemia is a poor prognostic indicator but he sure looked good the next day.
One of the Haitian nurses I work with lives in a tent. She has lived there with her family every since their house collapsed in the earthquake. She comes to work everday to the CTC in immaculate condition. Her clothes are pristine and she has a smile on her face. What about that?
The definition of cholera that we use here is greater than or equal to three liquid stools within 24 hours with or without vomiting. We use no lab tests to diagnose it and draw no other labs. We treat as fast as we can, especially the severe cases with IV fluids running wide open.
I had a middle age man a couple of days ago who was completely out of it with tenting of skin and he had a heart rate of 144. He had been sick for about 18 hours. Fluids were run in quickly through two lines and he woke up and waved both arms in the air as Haitians do thanking God.
Some rough statistics re cholera:
About 80% of people with cholera are asymptomatic. That leaves 20% symptomatic. Of the symptomatic 20%, approximately 80% of them can be treated with oral rehydration solution (ORS). Only the remaining 20% need IV fluids.
For a CTC of 200 beds, about 160 employees are needed.
One should never run out of supplies in a CTC. Ringer's Lactate is life saving and so are good nurses. I worry about Haiti and lack of IV solution.
Each bad cholera patient needs about 60 liters of potable water per day.
Start cholera patients drinking with IV still in. And a severe cholera patient can lose his entire body weight in fluids in several days!!
I saw this on the back of a guy's tee shirt outside the CTC the other day: "Vengeance on Dark Souls".
"Je we, bouch pe." (What the eyes see, the mouth is afraid to say.)
Reporting systems are poorest in countries like Haiti, where cholera is highest.
"Lajan vire loloj." (Money twists the mind.)
I have noticed that my patients with cholera breathe fast. I think this is due to the fact that they have a metabolic acidosis and are "blowing off their carbon dioxide" to compensate for their acidosis.
Patients may present after only a few hours of illness with massive volume loss of between 500 and 1000 mL per hour, and rapidly can lose more than 10 percent of their body weight. In patients treated with proper rehydration, diarrhea is most severe during the first two days and then ends after four to six days.
The mortality of cholera in untreated patients may reach 50 to 70 percent. In areas endemic for cholera, the mortality risk is increased in children (ten times greater than that in adults) and in pregnant women, who also have a 50 percent risk of fetal death during the third trimester. Patients can die within two to three hours of the first signs of illness, although death in untreated patients usually occurs after 18 hours to several days.