Ins and Outs

14 Mar 2013

On the surgery rotation one of the medical students’ main duties and first orders of business of each day is to tally the ins and outs of their team’s patients.  The most important of these is urine output over the past 24 hours.  It is not an arduous task.  All it requires is simple math, the addition of numbers entered by the nursing staff into a nice spreadsheet format on the computer.  It takes 10-20 minutes, depending on how many patients the team has.

A surgery is a shock to your system.  Depending on the type, it may take the body some time to recover.  This is time during which the surgical team monitors the patient for complications. We watch urine output for many reasons.  It is an important indicator of fluid status, especially in a post-surgical patient who may have lost blood.  If someone is peeing less than they should it could mean that they are blood down from the surgery but still too weak to self-hydrated, so we should give them IV fluids.  If someone is peeing much less than they should, or not at all, it could suggest kidney damage – that while blood vessels were being pressed on or clamped during the operation the kidneys did not receive enough blood flow.  Or perhaps something else was damaged, accidentally “nicked” during the surgery – such as the urethra or both ureters.

In theory I understood the importance of checking urine output on a post-op patient.  But the practice simply became rote.  I did it every day, at 5am, for two months.  And I never had a single patient with a problem.

I was on a shift at the hospitalito when María, almost 50, had a hysterectomy.  She had her uterus removed because a huge fibroid was growing in it, down low close to her bladder.  The operation began at 8am and was over by 9:30.  When Jane, the doctor on call, and went to check on María.  It was just before 11am.  The first things we looked at were María’s vital signs and urine output.

As in the US, these values are measured and entered into the patient’s chart by the nursing staff.  Unlike the modern hospital in the US where I had my surgery rotation, the hospitalito charts are on paper.  Jane and I looked at the piece of paper that itemized María’s urine outputs in a long list.  We (thought we) saw that she had already made 200mL of urine after the surgery.  After checking on her – she had some pain but otherwise no complaints – we declared her to be fine.

At 3pm the nurse found us, worried about María because she had only made about 80cc of urine.  The measurement wasn’t exact because her foley had fallen out.  Thinking that she might be dehydrated, we gave her a liter of fluid.  An hour later the nurse said that she still hadn’t made any urine.  We put the foley back in, hoping that all she had was a below-the-bladder obstruction.  Nothing came out.  Now we were worried.

Looking back over María’s chart we found that we made a colossal mistake.  María had been admitted the day before her surgery, which is when the nurses began tracking her urine output.  She already had one and a half pages worth of urine output listed.  We thought that the second page, the 200mL, was all from after her surgery.  But it wasn’t.  It was from the early morning hours, before.

The gynecologist Antonio who performed the operation was in clinic.  We pulled him out to consult.  By this time it was close to 5pm, the end of the day at the hospitalito for everyone except the doctor and two nurses on the night shift.  The laboratory technicians were about to leave.  We couldn’t even check María’s kidney function and electrolytes.

Antonio was clearly concerned.  He stayed until 6:30, something the nurses later told me that he never does.  Jane and I thought that he would send the patient to Sololá, to the large national hospital that is our hospital of reference.  But it wasn’t.  He opted to keep the patient in our small hospital until 7am the next morning, when he would take her back to the OR and reopen her to find the problem.  As the surgeon, the patient and the decision were technically his.  At first Jane didn’t fight him on the decision.  He is permanent staff, she was a temporary volunteer.  He is Guatemalan, she is foreign.

But by 8pm, when María hadn’t made urine in over 12 hours, Jane felt she could no longer stand by the decision.  The kidneys are in charge of removing certain wastes from the body by placing them in the urine to be expelled.  They are also responsible for electrolyte balance – they reabsorb them from the urine when body levels are low, and place them in the urine when body levels are too high.  When someone isn’t making urine, the buildup of wastes and electrolytes can be very dangerous.  Even deadly.

Jane called Antonio at home to convince him to let her send María to Sololá.  Antonio was resistant.  He said that the surgeons in Sololá wouldn’t do anything until 7am either.  And perhaps he was worried about exposing his possible surgical mistake to others.  But Jane insisted, and Antonio said that he wouldn’t stop her.

As she filled out the reference paperwork Jane vented, “He said that Sololá wouldn’t do anything until 7am when the day staff arrives.  But I can’t believe that.”

I agreed.  Sololá has 24-hour surgical staff and does emergent surgeries.  What else could this be for if not a patient like María?

“And even if they don’t take her to the OR, at least they can do labs there at night.  And if her values are bad, they can do dialysis.”

Our ambulance left with María, and Jane and I both half-released the breaths we’d been holding.

Later we learned that Antonio was (mostly) right.  Nothing was done for María until the next morning.  They didn’t even check her labs.  But they did have urologist who repaired her two “nicked” ureters.

The principal new lesson for me:  In going to new places as a healthcare worker, I must adapt to different methods of record-keeping.  Especially in the developing world where charts may not be as organized, are often on paper and not laid out nicely on the computer, and could be in another language.

A lesson I’ve learned many times, reinforced in a new context by Jane:  Fight for the best care for your patients.  Even if you are the outsider.


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