If a Tree Fell in a Forest...
Friday, June 29, 2007
Sean Donahue, DO
When she came into the Emergency Department you can imagine her condition: she was disheveled, covered in feces, urine, and was mildly hypothermic. We examined her thoroughly from head to toe and discovered that, fortunately, she did not injure herself from the fall. Now it is bad enough to be severely malnourished, dehydrated, and cold (each of these topics could be their own essay), but the real and much more sinister threat to her health was what was occurring deep in her muscle tissues, blood, and kidneys. After cleaning her, changing her clothes, and giving her warm blankets, we inserted a catheter into her bladder to help her urinate. She was too week to walk to the bathroom. After the catheter was inserted we were surprised to see what came out - a thick viscous maple syrup-like sludge began oozing into the tubing. Her body had begun to break itself down. After lying on the ground for 5 days, Mrs. B had crushed her muscles under her own weight. Her muscle tissue began to disintegrate - flooding her blood stream with toxic levels of muscle by-products, and clogging her kidneys.
Rhabdomyolysis (Rhabdo for short) is the term for the breakdown of muscle tissue leading to acute renal failure, or the inability to produce urine. The main building blocks of muscle - creatinine kinase, and myoglobin flood the blood stream and literally clog the kidneys with sludge. This event most often occurs after crush-type injuries (such as lying on a hard floor for 5 days), strenuous exercise (yes, we have seen this condition in people who start a new exercise regimen), electrical burns, and ingestion of certain chemicals. Growing up in Colorado Springs near the Air Force Academy, my father would tell me stories of treating soldiers who would march 50-100 miles a day during basic training. Many would come to see him the day after with severe muscle pain and coca-cola colored urine. Excessive myoglobin from the muscle turns the urine a dark coke-like color. They called it March Myoglobinuria, another name for rhabdomyolysis.
The diagnosis of rhabdomyolysis can be made both clinically (by the history you obtain from the patient), and by laboratory analysis (checking blood levels of creatinine kinase, and the urine for myoglobin). A normal creatinine kinase level in an adult is 20-170 International Units/Liter of blood. Mrs. B’s level was 20,000! That is the highest level I have ever seen. Her urine was flooded with myoglobin accounting for its dark color. Her condition was no doubt worsened by her dehydration. When treating rhabdo, you want to protect the kidneys as much as possible. Anticipating such a condition, we immediately began giving her intravenous fluids. In order to help clear excess creatinine kinase and myoglobin from her blood stream we administered a drug called Sodium Bicarbonate. This drug is a very strong base, and helps to alkalinize the urine (make it more basic versus acidic), thus helping the kidneys to clear the toxins (who figured this stuff out?!).
After 3 liters of intravenous fluid, and Bicarbonate, Mrs. B’s urine began to lighten, and flow more freely. Surprisingly the rest of Mrs. B’s lab values were normal. We admitted her to the hospital for continued hydration, and physical therapy to help with building her strength. I am never ceased to be amazed at our ability to treat any person, with any type of condition, no matter how obscure, that comes into the Emergency Department and that we as humans have figured out how to treat it. What is more amazing is that for 5 days Mrs. B lay alone, cold, and in dire need of help and we had no idea.
8 Comments:
At Fri Jun 29, 02:54:00 PM 2007,
Anonymous said…
You mention a CK of 20,000 - in my third year internal medicine clerkship this past year, one of the patients I followed was a guy in his early 20s with McArdles disease (one of the glycogen storage diseases) who would kick himself off into rhabdo with any sort of moderately strenuous effort, and his *baseline* CK was around 8,000-10,000. After a brief (and highly ill-advised!) game of tug-of-war, he came to us and the lab reported his CK as 178,000 (no, that's not a typo). Apparently this was his worst episode ever, but he had a histoy of being admitted in rhabdo for a week of aggressive hydration with a CK in the neighborhood of 100,000 every year or so for the last few years. File that one in the "diseases I'm really glad I don't have" category...
Mike, brand-new MS4
At Sat Jun 30, 07:17:00 AM 2007,
mansoor ul haq said…
that was a very interresting case but as let me tell u this is nothing because u r working in the best of the healthcare facility and management with utmost patientcare protocols,i am medical officer of indian origin working in afghanistan the worst warhit country and beleive me patients with common medical problems come to me after travelling 3 days by foot,4 days by bus and because of the overload of the patients and just few indian doctors to serve they had to stay in inn for few days before they got to have an appointment.
anyway the best part is when these patients come for follow up with smiling faces inspite of all the labourous journey bringing with them almond,fruits and other rural speciality as a mark of respect and love for those who havehelped them to get well.i hope u will feel much batter that there are people who work in the worst scenarios and still feel much better than u.
dr mansoor ul haq
medical officer afghan apollo indian hospital,kabul,afghanistan
phone 0093799333759
email:dastgeeri@gmail.com
At Wed Jul 04, 10:23:00 PM 2007,
Sean Donahue, DO said…
Mike:
thanks for the story-very interesting-and I should have been more specific: you are right, intrinsic errors in metabolism have the potential to create VERY high CKs-I should have stated in my Blog that this was the highest from EXTERNAL forces (just lying around) that I had ever seen. Sounds like a great case none the less-keep track of them throughout your career-maybe you can write that one up!!
Thanks,
Sean
At Wed Jul 04, 10:28:00 PM 2007,
Sean Donahue, DO said…
Dr. Mansoor ul haq:
Thanks for the email. You are right-working in conditions like you are really gives you a new perspective about healthcare. I have done quite a bit of work in Africa, and this experience has really changed the way I practice here in the US. I applaud you for your efforts- I wish every doctor could experience the things you have.
Please keep in touch-would love to hear your stories.
Sean
At Thu Jul 05, 07:30:00 AM 2007,
Anonymous said…
You mentioned in your blog about sodium bacorbante making the body more alkaline. I know having a more acidic Ph is not good for the human body, but what are some non medical ways to keep a more alkaline Ph in the body.
At Fri Jul 06, 01:54:00 AM 2007,
Sean Donahue, DO said…
Anonymous:
Wow great question. The body does an amazing job on its own of maintaining a perfect pH (between 7.35-7.45). Any imperfections in this balance, either too acidic or basic, due to environmental facors, and the body can, to a point, counteract through either the lungs (breathing more or less), or the kidneys (making more or less bicarb). Obviously if someone is very ill, or has a harmful medical condition, we sometimes have to help the body correct the imbalance-as in the presented case. But usually, there really is not any benefit to disrupt-on purpose- the body's own way of doing things!
Sean
At Sun Aug 12, 08:32:00 PM 2007,
Anonymous said…
That case was reall amazing!!!
A survivor like her should be treated very well...
What she had suffered really tested her faith to our Lord...
I was really blessed on how our Lord God Almighty worked on her life... It is really a miracle...
It is true that with God, nothing is impossible!!!
At Sun Aug 12, 08:38:00 PM 2007,
Anonymous said…
Truly, dehydration is fatal, but with thorough medication and continuesly updating the patient can lessen its risk on our health.
That case proved what science and technology can do... without these, Mrs. B will surely not recover...
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