By Dr. Tabu Robert
In the spirit of #civiceducation for our middleclass. One of the many reasons #LipaKamaTender is here with us.
*Case in point…
A 25 year old is rushed into the Emergency dept. He has loss of consciousness and was previously complaining of abdominal pains. The relatives tell you he is a diabetic on insulin. You do a random blood sugar test and it gives you a reading of HI(too high to give an exact figure). That is when you know you are done for.
The patient most likely has diabetic ketoacidosis (DKA). One of the acute complications of diabetes. The blood glucose levels go spuriously high to levels of 55. Take note a normal level should be teetering between 5and7.
You act with speed. You put in an intravenous line, take blood samples and start running fluids. Smooth so far. Fluids rarely miss in public hospitals. Even if it’s missing, a ward somewhere will have some lying around, a few barked orders here and there, and your going to forage for them will turn up what you need.
The algorithms for DKA management require insulin administration along with rehydration. Now pay close attention, here comes the tricky part.
Insulin will lower the blood sugar levels, but at the same time it will lower the potassium levels. The normal range of potassium is 3.5 to 5.5. Fall outside this range and your heart will beat in a manner more erratic than (morbid analogy alert) a beheaded chicken runs. Your fate and that of the beheaded chicken, chanda na pete.
Since the blood glucose levels are this high you need a lot of insulin. That means your potassium can easily fall low. One of the tests you need to do on the blood samples gives you the potassium levels. This test is not in the public hospitals. This test is supposed to be done (at least) 2 hrly while you are managing DKA. It will take a minimum of 24hrs to effectively manage DKA.
I can guarantee you that the average rural folk will have to hold a mini Harambee for the initial test. And then send someone to go look for a laboratory in town that is open (emergencies have a knack for showing up at night). You in the meantime need to start your insulin. So what do you do? You start insulin blindly, fingers crossed the potassium levels do not drop to below the critical level. Can you fathom the mental torture a doctor goes through knowing that the medication they are giving could be the straw that breaks their patient’s back?
The potassium levels have come back, they are at 4. Within the range, but with the insulin you are giving, you need to supplement it. Now if they managed to find a laboratory open at night, finding potassium chloride vials is like looking for a needle in a hay sack with no needle! Patients in the county I work in have to go to Nairobi to get them. Nairobi is 5 hrs away. This is a luxury the patient and the relatives definitely cannot afford. (A vial is probably 5000shs, they will need a number)
What if the potassium chloride vials are in the hospital? You don’t want to give so much that the levels go above 5.5, ergo the need for 2hourly tests. A test that will cost around 1400 a pop. One that if done in the hospital will be significantly cheaper (e.g. a certain test in the public hospital costs 120 vs 500 in private labs of the county I work in. Same test goes for 1500 in a private hospital in Nairobi)
So you are back to square one. Giving your hourly insulin as you hope and pray that arrhythmia (remember when I said the heart will beat erratically) doesn’t set in.
And if it does, you will toil to resuscitate that patient. When you finally decide that this chicken is running no more, your chickens will come home to roost. You will slump in your white but mostly blood and sweat stained lab coat.
The ordeal will goad you to give up altogether. What’s with working in a facility that has no basic lab tests? Basic drugs are not around. Patients sometimes having to buy their own insulin syringes. You realise that this particular life was so near(you are well trained in managing this condition) but so far.
Other emergencies need you, wallowing is for that corrupt politician who didn’t get a tender because his compadre in crime beat him to it.
The doctor’s strike is a call to responsibility by the government. The CBA asks for more than fair remuneration for doctors who have to go through this. The public has to firmly stand behind doctors. You have a right to QUALITY and AFFORDABLE healthcare. The government is supposed to provide this, not individuals who have been knee-capped by poor working conditions!
We shall ESCALATE till the ship is righted. Anyone bitter about this alambe sukari, at their own peril.
*Medical jargon reduced to a bare minimum.