WPW - what patients want....

I think I should be clear that when I write these clinical blogs its not for sympathy nor out of despair, I write them so that people can have a clearer idea of what it is like trying to capacity build in health in Cambodia. If you find them too depressing or distressing then I suggest you stop reading this blog, because it is more of the same I am afraid.

For a fortnight I worked with a doctor from a famous US university hospital at my hospital. He is an emergency physician (like I used to be!) & it was good to have him inject some inspiration back into my work. After his departure I went on a study tour & when I came back I went to see if the woman with pericardial TB was improving (she is) & I saw Dr L with an ECG but when he saw me he scuttled off, hiding it from me. I didn't have the energy to pursue it.

The next day (Thursday) I stumbled across a very worrying looking ECG on the desk whilst looking for another patient's notes - it was the same ECG that Dr L had been concealing from me. B had conducted a 2 day ECG workshop whilst he was here but the doctors will not ask me for help reading ECGs. I am not sure if this is arrogance or shyness or hostility but it invariably makes my job of capacity building very difficult.

The ECG had been done 2 days before and showed a wide complexed tachycardia. I went to see the patient. She was a 17 year old girl who had been working illegally in Thailand until 2 weeks previously when she developed palpitations and then swelling in her legs (pitting oedema), breathlessness & felt 'exhausted' all the time. She came back to BTB where the doctor 2 days previously had failed to diagnose her as having a life threatening tachyarrythmia so had started her on Dopamine for her low blood pressure & Digoxin. Dopamine is a powerful drug that is used to make the heart beat stronger & faster, the reason this girl had a very low blood pressure was because she had a heart rate of over 200/min - the last thing she needed was her heart racing any faster. Digoxin is an anti-arrhythmic that can be fatal if used in certain kinds of tachyarrhythmia - in short she was being mismanaged.

Dr S, who is a 'specialist' in cardiology, was on the ward - not one of the usual ICU doctors but one who often covers the odd shift there. I showed him the 'interesting' ECG - he immediately asked to see the patient. He had been on duty for the last 24 hours but apparently a 17 year old girl with an extremely fast heart rate & respiratory rate and no palpable radial pulse wasn't cause for concern enough for any of the nurses to mention her to him. He, of course, could have rounded - there are only 12 patients on ICU.

He agreed with me that this patient needed a DC cardioversion (electrical shock) & failing that a chemical cardioversion with an IV drug. Neither were available. The defibrillator that the same doctor had tried to shock me with, 6 months ago, now had a flat battery, otherwise I would have DC cardioverted her myself right there & then - no discussion.

Instead he started her on an oral version of the ideal IV drug - less than ideal because when a patient is hypotensive the gastrointestinal tract is one of the first areas to get reduced blood flow which is re-directed to more vital organs. This means that oral medications are not absorbed very well, if at all. He stopped the digoxin but was reluctant to stop the Dopamine as Dr L had started it & he didn't want an "argument" with him. After much insistence from me he promised he would come back in the afternoon to check on the patient & discuss the case with Dr L.

I repeated the ECG - there was no change from 2 days previously. She had not had any bloods taken as she had 'difficult veins' so I offered to show the staff how to do a femoral stab. One MA came with me - the rest of the nurses & doctors sat in the staff room watching TV. The bloods showed that she had renal impairment - 2 weeks of having a heart rate of over 200/min will do that to you.

After we had left the ward L (my VA) told me that SP - the same nurse that we have previously had run ins with - had said to Dr S, when he asked for her to stop the digoxin, "Do what you like, I don't care, she can die for all I care, I am only interested in money". What patients want? That kind of attitude from the staff looking after them!

The following day she was still on Dopamine & no better, there were no doctors on the ward so I went straight to the deputy director, Dr ON. I showed him the ECGs & explained that dopamine was bad and we went to the ward together. Dr L was there but told me to write my recommendations in the notes, rather than talk directly to him, which I duly did. He wasn't interested in my explanation or clinical reasoning. Dr ON however was keen to understand how he could tell if shock was due to tachycardia or if shock was causing the tachycardia. There was another young girl with sepsis with a sinus tachycardia on ICU so I was able to show him the difference between a sinus tachycardia & a tachyarrhymia. At least someone wanted to learn.

I spoke to the Head nurse about the nursing staff's attitude on ICU. I said although their behaviour revealed that all they cared about was money & they didn't care if patients died, it was probably not very professional to voice this in a room with 4 student nurses, 3 trained nurses, 3 Cambodian doctors and a barang doctor with her very shocked VA.

I called the local NGO hospital to see if they had either IV Amiodarone or a defibrillator that worked - no such luck. No pharmacists in town stocked IV Amiodarone - it is only available in Phnom Penh. The only other option was for her to go to the cardiac centre in Phnom Penh but as a poor card holder only her transport would be paid for & her parents did not have the money to go with her. In Calmette she would need her family there to deliver her basic nursing care & would not receive treatment with out giving significant amounts of "tea money".

I decided to wait & see if stopping the dopamine & another 24 hours of oral Amiodarone would improve her condition. On Saturday I went to check on her - without the Dopamine her pulse was stronger but still rapid. Her mother told me that if her daughter survived she would 'give her' to me. This made me feel profoundly sad.

Then I lost my phone. I bought a new one & replaced my SIM.

I rang a doctor from another NGO for her advice. She suggested a NGO Children's hospital in Siem Reap but the girl was too old. We both knew that she needed DC cardioversion & IV Amiodarone but like most of Cambodia her & her family were too poor to afford the healthcare she really required.

On Sunday I went to the Pagoda with my Khmer teacher - I found myself praying to Buddha. When I checked on her at the hospital afterwards she was worse. Her urine production was low, her breathing faster. J noticed that the dose of Amiodarone was too low (being an idiot I had misread the prescription chart) so we spoke to the duty doctor & increased the oral dose. In my heart I knew it was hopeless.

On Monday J went down to Phnom Penh for meetings - I waited for a miracle, it didn't happen.

Tuesday we had planned for J to buy 8 ampoules of Amiodarone ($40) & send them up by Taxi. The girl had been in a wide complexed tachycardia for 3 weeks by now.

I went to the ward first thing to find that the girl's parents had been told to take her home to die, as she was a hopeless case. I explained to the mother that we were arranging for medicine to be sent up & if she stayed in hospital we could give it to her daughter that evening. I went to tell the staff not to send her home & 'the lovely nurse' (as my VA now calls her) was there & shouted that she had been told to go home & that's what should happen. I tried to explain that we were buying the medicine she needed but SP's malignant presence meant my words fell on deaf ears.

I wrote in the notes a prescription for IV Amiodarone & tried to explain to the nursing staff how to give. SP shouted at me to just go & talk to pharmacy, she wouldn't do anything as she did not trust my translator's translation. I calmly & assertively told her it was none of her business - she wasn't on duty.

L & I went to cool down & have a coffee, when we came back to the ward. SP AKA 'the lovely nurse'  had left & suddenly every nurse was very receptive to learn how to deliver a loading dose & then maintenance infusion of Amiodarone. Dr L was the doctor on duty - I tried to explain to him that giving IV Amiodarone in a shocked patient was less than ideal but she was going to die if we didn't try. He wasn't particularly interested in listening to anything I had to say.

I waited for the package from Phnom Penh to arrive.

At 5 30 pm my VA picked up the package & I met her at the hospital (interrupting my khmer lesson with S). We gave the 8 ampoules to the nurse on the ward & I called J who with was in a meeting with the head nurse who in turn called the ward to check that they would give as I had prescribed.

Out of courtesy & concern I called Dr L to inform him that the Amiodarone had arrived. His response - "I am busy" (at his private clinic) "You do" (I had taken a history, examined her, diagnosed the patient, taken bloods, repeated an ECG, stopped the life threatening drugs he had prescribed, checked on her everyday, rang around trying to get the right treatment for her, arranged for IV Amiodarone to be sent up, stopped her from being sent home to die as a hopeless case - WHAT EXACTLY DID HE WANT ME TO DO?!) and then finally the one that really felt like a punch in the solar plexus "Why are you telling me, it is not my problem - it is not my responsibility" (He is the head of service for ICU medicine and was the doctor on duty that night).

That night I woke with a start after a vivid dream where the girl died because of the Amiodarone loading dose. It was 4 am. As I was drifting back to sleep my phone rang. S - my khmer teacher - was calling me but in my semiconscious state it felt like I was back in the UK on call & I knew the call was about the girl. S was agitated - she was insisting I went to the hospital to check on the patient, she couldn't sleep, GO NOW she kept imploring me. I looked at the clock - it was 4 20 am. I whatsappe'd J to tell her what happened & that I was a little freaked out, fully expecting her not to get the message until the morning. She responded immediately that she couldn't sleep either & had also been thinking about the girl. I was even more freaked out.

I waited for a reasonable hour to go to the hospital. I reminded myself that this is why I chose emergency medicine over ward medicine.

I went at 6 30 am to the hospital. She was still alive, I considered converting to Buddhism.

The nurses were agitated & looked worried - they were telling me that she had reacted badly to the medicine. Not surprisingly the Amiodarone had reduced her blood pressure further before it had converted her back to a normal sinus rhythm. Whilst J, S & I had fretted & tossed & turned all night, the patient had her first decent nights sleep in 3 weeks in normal sinus rhythm. The mother looked like a different woman - she had slept well too & when I told her we hadn't slept as we were so worried, she just laughed & gave me a big hug.

I repeated the ECG and this showed that the patient had Wolf-Parkinson-White Syndrome - WPW. I explained to the patient & her relatives what was wrong, what she could do if it happened again & what needed to happen next. The mother didn't want me to leave (she had seen me come to the hospital with a rucksack) and asked what would happen without me to be her daughters advocate. I explained that the staff had told her to go home to die as they did not have the knowledge & skills to know any better -  that's why I am here, its my job to capacity build them. It was a minor epiphany.

Dr S came to check on her. He had been to the hospital technical committee meeting the afternoon before to say that drugs like IV Amiodarone are necessary & if a 'poor card' patient needs them they should be bought my the hospital & not by Barangs. He thought it was best if the patient was transferred to his medical ward for further management now she had a blood pressure & a palpable pulse. This gave me hope.

I then had to go to Phnom Penh later that day but the next day L emailed me;

"This morning i visited the young patient in POP. She is getting better. She is on Glucose IV now.
Her abdomen is less swollen, and her breathing is better. She has appetite to food and drink.
I can say she looks better.  Oh! her mom asked me to say" thanks you! how are you?" to you.
She said you save her daughter life and thanks for your kindness.She is very thankful to you.

I will let you know if there is anything wrong."

And I so here I wait, wondering what else can go wrong & really hoping it doesn't.

Pitting oedema

'Bad' ECG

After chemical cardioversion, 'better' ECG revealed the diagnosis of WPW

IV Amiodarone - eventually!