Sunday, January 5, 2014

Dangerous Side Effects

Last night as I was getting ready to leave the hospital, one of the nurse assistants told me there was a patient that needed review. An older woman who had been admitted to the ward with symptoms of potential heart burn was having trouble swallowing. From the outside, things looked OK. Her lips weren't swollen. And when she opened her mouth, her tongue looked normal. When we got a look at her soft palate, or the roof of her mouth towards the back of her throat, we could see a serious amount of swelling on both sides. This was coming on quickly, and we knew right away that she was potentially in serious trouble. If the swelling continued, the opening to her windpipe would swell shut and she would lose the ability to breathe. At this moment in the US, I would be on the phone with an anesthesiologist who would urgently come to her bedside and evaluate her. If he thought that she was going to lose her airway quickly, he would give her medicines to sedate her, and then use a fiber-optic scope to place a tube into her windpipe. She would then be placed on a ventilator machine and would stay on it until her swelling was improved and she could safely breathe on her own. Here, we didn't have that option. So we gathered what we had available to place a tube in her windpipe, and even materials to perform an emergency cricothyroidotomy if her throat was too swollen. This scary procedure involves trying to cut a hole in the front part of her neck down to her trachea, slip a breathing tube in, securing it to the skin, and then breathing for her by squeezing a bag for the next 12 hours or so. We gave her some emergency medications to try to stop the swelling, watched, and thankfully (so very thankfully), she remained stable over the next few hours. The swelling was not worsening. We reviewed her medications and found that she was on enalapril, a medicine for hypertension that is in the ACE inhibitor class. By her family member's report, it seems like she might have had a similar episode in the past. In case this reaction was caused by her medication, we stopped it and warned her never to take it again. Today, she remains stable. We are all very thankful.

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