God Slaps part deux

Holy jeez was there a lot of fluid in there. I probably drained off 2 liters today, which is several 7-11 Big Gulps more than you are supposed to. (I will address the logic behind my uncharacteristic deviation from S.O.P. in a moment.)

The gentleman arrived early in the morning, excited about having this pain taken away. I have to admit my heart started beating faster when I saw him. But not in the good way.

I took him into the empty "isolation room," which in theory is supposed to house TB patients but somehow never does. The guy took off his shirt and sat on the edge of the bed facing the wall. I went to the other side of the bed with all my equipment. I examined his back and percussed between every rib again, for the fourteen millionth time.

I've already given a pretty intricate description of sticking needles in body cavities in a prior post, so I won't repeat all of that.

But let me just say that these two procedures (draining fluid from the belly and from the lung) should be more different than they are in Kisoro. In the U.S. they have entirely different kits, but here I basically did the same procedure.

They don’t have the superfine needles we would use to give anesthetic, so I had to numb him up with a big ole 18 gauge. Stuck it right on the periosteum of the rib --- forgot how close beneath the surface that is. Then I shifted the needle up, no tilting, just lifted it and kept it horizontal. I pulled back and injected, pulled back and injected. Once I was over the rib I literally pushed the needle forward in millimeter increments.

Why so cautious? Lung + needle = puncture. Pull back, inject. Pull back, inject. Pull back, and suddenly there's yellow fluid in the syringe.

I squirted a little lidocaine into the pleural space, and then slowly removed the needle, keeping my thumb on the spot where the needle had gone in deepest. I compared the depth of the needle to the length of the longest IV catheter I had. It was about 1.5 inches, just barely long enough.

So then I inserted my IV catheter in exactly the same position as the lidocaine injection. And I repeated exactly the same process, except without injecting anything. I just pulled back on the catheter at each step of the way, and when I got the yellow flashback I removed the needle and screwed the syringe directly onto the catheter.

The dangerous part was over. There was a soft plastic tube in his lung, no sharp needles, no risk at all of a puncture.

But here was a problem: there were no large syringes in Kisoro hospital. Literally none larger than 5 mL. So I had to keep sucking out fluid in little 5mL increments, and in case you’re not so good with the metric system that’s about a tablespoon each time. They finally found me a 10mL syringe, and then things went a little faster.

But that was a minor issue. The real trouble was something I hadn't thought of: air. When you do a thoracentesis with one of those fancy American kits, the fluid goes straight from the lung, through the tube, into a bag. The entire system is sealed, air can’t leak in anywhere. But with my hodge-podge arrangement, every time I unscrewed the syringe I let air in.

When I started the procedure air wasn’t a problem. He had buckets of fluid packed inside his chest, so the pressure was pushing out, not in. When I unscrewed the syringe the fluid kept flowing out briskly.

Then I heard a weird noise. It was after I'd drained over a liter of fluid from his back (again, this is not what you're supposed to do, and I promise I'm going to explain why, just be patient for a second), and suddenly there was this scratchy sound, kind of clicky.

At first I didn’t think it could be coming from the catheter because it sounded too mechanical. Then I noticed that fluid wasn’t dripping out anymore. In fact, when I looked at the place where the fluid had been flowing out, it was completely empty. Not even a little drop sitting at the opening. And when I listened to the sound again, I realized it was similar to what you hear when you finish a milkshake with a straw.

So something was sucking the fluid back into his pleural cavity. I had to stop and think for a minute about why that might be happening.

I had drained out nearly 2 liters of fluid (for a good reason, wait for it now), and what was filling the space where the fluid had been? Ideally, his lung. And eventually, one day soon, it would be his lung, but right at this moment --- not his lung. He’d had this effusion for months. His lung was squashed down small, and it would take a while to expand.

Which meant that when I drained out 2 liters of fluid, I was creating a 2 liter vacuum inside his chest. And now, every time I unscrewed the syringe, that vacuum sucked a little bit of air into his pleural space.

So I started covering the IV catheter with my thumb. But even in the half second between taking off the syringe and sticking on my thumb, the fluid was getting drawn quickly back into his chest.

This was a little scary. Because I wasn’t going to stand around all day covering this hole. Eventually I was going to take the catheter out, leaving a hole directly from his pleural space to the outside world. This guy was a set-up for a pneumothorax (fancy word for air in the pleural space).

So why was I doing all this? Why was I removing 2 liters of fluid when the guidelines suggested a maximum of 400 to 500 mL? You've been waiting patiently for the answer, and here it is.

This gentleman was not staying. He didn't live near Kisoro, and he had to go home. If I could take away some pain he'd be grateful, but he had a life to live. He wasn't sitting around in the hospital for two weeks while I removed a little mayonnaise jar of fluid each day. He'd stated clearly he was leaving tomorrow.

Which meant that this was my only shot.

There was another reason to do this all at once. Under these conditions the procedure is not all that sterile. Every time you stick a guy with a needle you're risking giving him an infection. And this is a patient with HIV, so reducing the risk of infection is pretty important. Even if I could do six taps in six days, that would not be best thing for him.

(BTW, this is the same reason we usually give 2 units of blood when we transfuse someone. Why give one unit and then a second unit the next day? It's double the risk of a lab error.)

So there I was, torn between two competing instincts. On the one hand, drain as much fluid as possible since this was the only chance. On the other hand, the more you drain out, the higher the chance of a pneumothorax.

I ended up sitting around for a while, shooting the shit with the med students with my thumb on the syringe. I thought maybe that would give the lung a chance to expand. Sure enough, fifteen minutes later when I unscrewed the syringe, the fluid just sat where it was, it didn’t trickle out or get sucked back in.

So that was it. I pulled the needle out and held some pressure on the area for a few minutes. It didn't bleed, and he wasn't coughing or short of breath. I knocked on wood a few times and sent him to the Male Medical Ward for the night. I can assure you he'll be the first patient I check on in the morning....

(update several weeks later: next morning he was fine. The pain was better but not gone, and since I'd actually done him some good he agreed to stick around for another day. I did another tap and took out 1.5 liters. Yes, that's a total of 3.5 liters -- sitting in his chest. If your jaw hasn't dropped yet, picture it in Coke bottles. He went home very happy with no pain. I gave him oral antibiotics which he probably didn't take and saved to give his children the next time they get sick.)