Belly Juice

A woman came in last week with a big distended belly. She had lots of ascites (fancy medical word for fluid that’s not pus or blood). At first I assumed she had cirrhosis, which is the most common cause in the U.S. But in her case it was heart failure so bad that the fluid had backed up through the liver into the abdomen.

She was in a lot of pain, and I considered doing a paracentesis immediately (draining fluid directly from the abdomen using a needle). But then she told me that she had stopped taking her meds two weeks ago. And that meant that I should try putting her back on her meds before poking around with sharp objects.

A day later I saw her again and she wasn’t better. Her big belly was firmer than before, meaning more fluid had collected inside. The hospital was out of IV lasix, which would be my medicine of choice, and the oral lasix wasn’t getting the job done. So I decided that a paracentesis was, after all, necessary. Plus she said she was having trouble breathing. (Any compromise of the vital signs seals the deal.)

In the U.S. we have these nice kits with the word “Saf-T-Centesis” printed in big letters on them. You tear the package open with a satisfying ‘rrrrrrrrrrrrtttttttch” and everything is nicely laid out inside. One of my many fears before coming to Uganda was having to do a procedure --- any procedure --- without the comfort of a kit.

Now, I don’t want to alarm anybody who’s coming to Uganda soon. But yes, the technology is different. They don’t have fancy sterile kits, and that means you have to learn how to use some new equipment. How are you going to learn this new equipment? By inserting it, your first time ever, into a real live human being (who by the way is very sick so you can’t screw it up).

So yes, you have to be willing to get your hands dirty. And by dirty, I mean literally. Like covered in amber belly juice.

But I’m getting ahead of myself.

It seemed so straightforward when I mapped it out in my mind: take an IV, stick it in the belly where the fluid was collecting, remove the needle, let the fluid drain through the catheter and tubing into the bucket. All I needed was an IV, some tubing, and some iodine to sterilize. Simple.

I found an IV in the nurses station and played with it for a few minutes. Needle. Catheter. Plastic bits. Cool.

Next I pulled out a length of IV tubing and inspected it. One end was easy, it was designed to attach to the IV. The other end was supposed to go into a bag of saline or Ringer’s, and had a sharp plastic prong on it for said purpose. I hunted for a pair of scissors for about three seconds, and then just yanked the prong off by hand.

I was ready to go. Or so I thought.

I had by now collected two medical students to assist, and they reminded me that we would need a place to put all the ascites. (Good job Jen, you are so getting honors.) I knew there would be a lot of fluid, so we needed a big container.

Of course the hospital had nothing useful, but the impoverished patient did. Like everyone admitted to Kisoro District Hospital, she’d brought a wide plastic basin with her.

(Why, you ask? Standard patient behavior at KDH is to keep one’s basin beside one’s bed, and lean over at intervals to spit into it. I never object to this behavior, because it eliminates the question “what color is the mucus you are spitting up?”)

We were ready to go. I sterilized the area, and inserted the needle using proper Z-technique (don’t worry, I just threw that in for medical-legal reasons.) Nothing came back through the IV. I pushed and pushed, until I started getting worried that I was going too deep. There was, after all, an intestine in there somewhere, with a thin wall easily punctured. On a whim, I pulled out the needle, leaving the catheter in place.

Suddenly clear amber fluid started spurting from the IV, dripping on the bedsheets and all over my fingers. I fumble with the tubing, trying to screw it onto the IV, but it won’t go. Why won’t it go? I stub them against each other, but they’re not designed to interlock. Oh shit! I’m trying to attach two female ends together. Stub stub stub. Everyone’s watching, shit!

Then I see it. There’s some kind of plastic doohickey attached to the IV, a tiny clear nub getting in the way. I twist at it, still under the wide-eyed gaze of the patient, her family members, all the patients in neighboring beds, and the two medical students. Everyone’s fascinated by this, it’s a flaming car wreck, they can’t turn away.

The nub is still there. Why is there a nub and why won’t it come off? Why would anyone design a product like this? Its sole purpose is to humiliate and destroy well-intentioned doctors like myself. The fluid keeps pouring out of the IV, and my hands are getting slippery. Do I deserve this? I came here to help people, for God’s sake, not cover myself in abdominal juices!

Finally the nub comes off, and now the tubing fits neatly onto the end of the IV. I screw them together tightly and watch the fluid drip down into the basin which is resting on the floor.

That’s it for the exciting part. We didn’t have vacuum bottles to suck the ascites forcefully from the abdomen, so we had to sit and let it trickle out by the force of gravity. Took about half an hour.

I squatted, holding the tubing and staring at the bottom of the patient’s basin. It was forest green, with a snowman pictured over the words Merry Christmas. I wondered, since most people in Kisoro have never seen snow, if my patient understood who this rotund white figure was, and what he represented.

We drained out about six liters of clear yellow fluid. The patient’s belly got less swollen and she felt better. That’s it.

Probably the grossest three seconds of my entire month in Uganda was when I had to carry the full basin of off-yellow fluid into the smelly squatter bathroom and dump it.

Please give thanks, to whatever Lords you may have, for the great great gift of Purell hand sanitizer.