Letting Go

     LETTING GO

Patricia is 30 y.o. women I was asked to see. She had a thick chart from previous admissions and when I visited she was extremely weak, getting worse and looked like she was going to die. She carried a diagnosis of chronic Congestive Heart Failure (CHF) on her chart felt to be from Mitral Valve Regurgitation. If that were true then some of the blood entering her left ventricle would go backwards into the left atrium when her left ventricle contracted or squeezed.  As things got worse and the valve got more leaky or more regurgitant some of the blood going back to her left atrium would go farther backwards into her lungs. In time, Patricia’s lungs would get overloaded with blood, the blood pressure in her lungs would increase and fluid would be pushed into her lung tissues and the air sacks in her lungs. When severe, her lungs would fill up full of fluid, as if she was drowning and she would be very short of breath. If you listened with a stethoscope you would hear all that fluid in her lungs.  This is called left heart failure because the defect, in this case, mitral valve regurgitation, was on the left side of her heart.

  But when I examined Patricia, her lungs sounded fine, not wet or full of fluid. She was a little short of breath but I think that was from her being anemic and just her general deconditioning after being sick for so long. Looking at Patricia and examining her it was obvious that she was full of fluid but the fluid was not in her lungs, it was in her abdomen and her whole lower body. Her legs were like elephant legs. Her belly was gigantic and when I palpated her liver it was huge, probably full of fluid. Blood was trying to get into her heart but couldn’t. It’s like trying to get onto the interstate in Los Angeles; traffic was all backed up at the entrance.  In contrast to left heart failure where fluid backs up in your lungs Patricia had right heart failure because of some defect on the right side of the heart. When I listened to her heart she had a big murmur. It sounded like her Tricuspid valve was where the leak was, not her mitral valve. When I examined her neck the neck veins were distended, full of blood, even when she was sitting straight up. The traffic (blood) was backing up all over Los Angeles, like at rush hour. There’s a reason they call Congestive heart failure.

    Because of gravity, most of the blood settled in her lower extremities, then her belly, then in her liver. If she stood on her head it would back up into her brain.  It was impossible to tell with out an echocardiogram, if indeed the problem was her Tricuspid Valve or some congenital defect. But what I did know was that we had the wrong diagnosis.  Patricia had right heart failure not left heart failure. She was not receiving the right medications and to be honest: none of this made any difference.  The right treatment does not exist here and even if it did Patricia and the hospital couldn’t afford it.

    But, we could make her more comfortable and maybe, if we all got lucky, she could get home.  We used 1970’s technology, I gave her big doses of diuretics, and over several days we drained 4 liters of fluid from her abdomen by placing a plastic needle through her abdominal wall. This is somewhat dangerous and of questionable value but she improved over a period of a week. I even thought about using rotating tourniquets, you’ll have to Google that one but it was desperate clinical maneuver from the 1960’s. But I’m not sure that has ever been proven to work. I calculated Patricia needed to lose at least 15 kg. (33 lbs.) to get near to her  ideal weight of about 55 kg.  We checked her weight daily (a big deal here).  Slowly over 10 days, as her weight dropped, she got moderately better.  Then she disappeared.

     She and her family (her bedside assistants) “ absconded” one night, probably to home.  This is how it is here. The family not the doctor, not the nurses, decide when to leave, and it’s often at night. The decision is economic. Maybe they had run out of money. Maybe it was time to go home and plant crops, a time when every able body person is needed to work the fields cut out of the jungle. Her family had to choose. Stay here and help Patricia or go home and plant crops so the family doesn’t starve and maybe even make money selling the crops. And it really is about the numbers. Stay and help Patricia and we all may starve in 4 months. Let her go and the family lives. Its the law of the herd, on a human scale.  

    I don’t know where they lived but it was far away in the bush. There is no follow up appointment, no letter to a local clinic or practioner.  Worst case scenario:Patricia will run out of meds, get worse and die… Best case:  she might come back here…..if the economics are right.

   So, here’s point. The practice of medicine here is acute care medicine. Get Malaria, have a baby, get bit by a snake. We can do that. But if you have a chronic condition that requires long-term medication, as in life long, you may be outta luck. In the best situation (the developed world) Patricia would need daily medications, follow up and ongoing management. Optimally, she might benefit from surgery.  Here that is impossible. In the developed world most medical care is chronic care medicine. Our medical industrial complex thrives on diseases we can’t cure but instead are treatable with long term care. Renal failure with dialysis, diabetes and its complications rheumatoid arthritis, heart disease and maybe someday cancer are all chronic care, common and often very profitable diseases in the developed world. Here, it is simply out of reach. Patricia’s family knows that, maybe not in so many words, but they know enough to make the decision they made. That is real world decision making and there is nothing more real then the developing world, where the good of the many always trumps the benefit of the few.