There aren’t many clinical scenarios which alarm me. Maybe it’s because I’ve seen so many critically high blood pressures and blood sugars, and I’ve seen how quickly infectious diseases around here can take a turn for the worse. So when one of my patients left a message for me on my way to work, saying that his mom was sick with an upset stomach and that he was bringing her in to see me, I thought I knew what to expect. I expected her to be weak and dehydrated and for her heartrate to be fast. It was easy to give fluids for that and make someone feel better. I was surprised when her blood pressure was high, twice as high as normal. I diagnosed her with high blood pressure almost a year ago, and had yet to figure out why she only took her medications for a few days at a time. But I’d never seen a pressure so high in a patient suffering from low blood volume. And there were more surprises to come.
Her heartrate was fast – 110, but every fifth beat felt unusual, like it was skipped. I could feel it in her pulse and hear it with my stethoscope. Then I found that her oxygen was low, 82% and dropping. The nurse helped her get on oxygen right away, and her oxygen came back up to 98% where it should be. But it wasn’t long before her heart was skipping every third beat. I asked the nurse to get blood tests as quickly as possible. I chose the most important ones – electrolytes, measurement for heart function, and a full blood count to look for infection. Each additional lab I ordered would increase the time that the results came back, so I followed the blood sample to the lab to explain that all these labs were urgent. I asked the nurse to check a tracing of the patient’s heart and I sat in my office with the patient’s son and husband, entering urgent orders in our new computer system and explaining to the family why they were seeing me move faster than they ever had in the six years I’d been providing care to their family.
The heart tracing came back – no signs of heart attack or electrical problem in the heart. At least, not one which I understood. I could see the skipped beat every so often, but I couldn’t match what to call it or why it was there. I checked with my colleague in the hallway, Dr. Malemia. He often performs the heart tracings himself, and I figured he would have ways of reading them beyond my scope. He didn’t have much to add for the tracing interpretation, but when I told him about the case, he assured me that it was OK to start giving the patient fluids. I told him how, based on my training, I would not usually give more fluids to a patient with such high blood pressure, in fear that the pressure could get worse. He told me that he had seen cases like this before, and people at Malawi’s Central Hospital improve with fluids. He even cautioned against blood pressure medication at first.
I’ve never seen a patient with low fluid and such high blood pressure, and the combination of irregular heartbeat and low oxygen to go with it. But I got the labs back, and didn’t see any other problems, so I prescribed a fluid to slowly resuscitate her, and I watched her closely and prayed a lot. I praise God for the nurse who kept a close eye on her in our treatment room, and even mixed the oral rehydration solution herself to give the patient. I have never seen our lab return tests so quickly, I was so thankful for that. I was thankful for the family members who stayed by her side, checking oxygen continuously until my device was running low on batteries, then got a device from a friend so that the patient could have one at home. And my colleague Dr. Malemia, I was so thankful for his reassurance and advice. I thought I had seen everything after all these years, but in some ways, I think I was still biased by my Western education and the way I was trained to address cases like this.
I stayed with the patient until the color came back to her face and her oxygen stayed stable even as I slowly decreased the amount she was receiving. When I was leaving the hospital that night, she was on track to leave a few minutes after me. I kept an eye on my phone. In cases like this, I wouldn’t have been surprised if she had to come back, and I would have dreaded if things got worse. With the condition of her heart and her pressure and her oxygen, I even feared something could still threaten her life.
But the patient continued to improve. In the end, I didn’t do much for her, just slowly gave her about a half-gallon of fluids and made sure her heart was stable through it all. I worked with the family to plan how she might be able to commit to the blood pressure medication daily, and how to reduce stress at home. I thought this would be a simple case, but instead it was a terrifying close call - she could have died today. Instead, I sent her home after praying with the family for health, healing, and wholeness in the future.
This month, pleas pray for Greg as he starts a new session teaching pastors in Mphewa and as we think through plans for holidays and days off.
Thank you for your prayers and support, Christina + Greg
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