Atypical organophosphate poisoning and a successful case of prolonged intubation in a low-resource newly developed intensive care unit in rural Zambia

Organophosphate poisoning is a common, under-reported cause of attempted and completed suicide worldwide. Following the resolution of the acute cholinergic syndrome, patients may develop respiratory muscle and proximal limb weakness, known as intermediate syndrome. A young man was brought to our rural hospital unconscious, in extremis, due to organophosphate pesticide poisoning. He developed atypical intermediate syndrome with global paralysis, persistent fasciculations and prolonged cholinergic symptoms, differing from the recognised presentation. He was intubated for fifteen days in our newly developed intensive care unit. Limited treatment options and the absence of blood gases, electrolyte testing, ECGs, invasive monitoring and imaging, in conjunction with regular disruptions to electricity and oxygen, and complications including seizures and pneumonia, all made this prolonged intubation an ambitious and challenging endeavour. We offer learning points for the acute physician and rural intensivist, and a summary of our reflections and hints for best care when adapting to a resource-limited setting.