Shocking Saturday!

clostridium

It was spreading, his leg had become black above his knee too. A decision was in order. It wasn’t going to be an easy one. Operate right away and the Operation room (OR) would be unusable for 6 hours (for cleaning and fumigation-an essential process after operating on patients with transmissible infections such as HIV, Hepatitis B, Gas gangrene), risking a delay in treatment of all the wait-listed patients. Delay it and the patient would lose his life, let alone his limb. Being the junior most person in the unit, I just stood there, while the seniors discussed the options, slipping in a profanity here and there (not uncommon with surgeons) with voices loud enough to awaken all the patients on the floor from their deep slumber. It was after all midnight.

A decision was made. The patient was to be operated urgently. Saving a life took precedence over anything else.

The patient had Gas Gangrene. A wound over both his legs a few days back, coupled with inadequate care, both by the patient himself and the primary physician, led to this condition. The wound was infected with deadly organisms, which released toxins, causing rapidly spreading death of the muscles and the skin. The infection would continue to spread, unless his limbs were amputated.

A few hours back, Mr. Dattatray had come to the emergency ward, walking, on an otherwise uneventful Saturday evening, with complaints of mild discomfort in both his legs. He complained of a wound over both his legs, a consequence of overzealous farming 4 days ago. Within hours, his leg was turning black, with a sickly sweet door, an unmistakably characteristic feature of Gas Gangrene.

My job was to prepare the patient for surgery, to make sure he had a urinary catheter inserted before entering the OR, he was hydrated well and that the hair was shaved off (important part of every surgery). The patient was to receive anti-gas gangrene serum, which was essentially a cocktail of antibodies obtained from horse’s blood after injecting them with the causative toxins. The cost was immense (40,000 ) and beyond the means of his family. The serum would at least give him a fighting chance. Without the serum he’d die.

As with all public hospitals, KEM hospital too had provisions for concessions for poor patients, provided they’d give proof of the same, in the form of a ration card. The procedure was tedious. The first step was to fill out a form in the book provided to each unit with a signature of the junior most and senior most person on call. This was the easiest part. It then required the relatives of the patients to run across the breadth of the hospital to obtain signatures of 4 other administrative officials, who more often than not, couldn’t be found. Eventually, it took at least four hours for the relatives to come back with the required medicines.

We didn’t have the luxury of time. As doctors, we wouldn’t get involved in administrative hassles, letting them take their own course. But this was different. A matter of life and death. No sooner did the relatives return with the concession book empty handed (they’d been asked to try again the coming morning), did I dart towards the Casualty Medical Officer and in a arrogant, semi-aggressive manner asked her to sanction the concession for the Serum.

In my short time thus far at this hospital, I had come to realize that when patience and tolerance weren’t helpful, a sound clinical argument and aggression most definitely were. Raising my voice to prove my point wasn’t necessarily the best way of going about things, but it produced the desired results.

“Madam, why don’t you understand!! This patient will not live to see tomorrow morning if you don’t sanction this Serum right away,” I said, raising my voice, realizing that all heads turned in our direction. Adding that touch of drama helped. The Medical Officer, who clearly didn’t expect a junior resident to argue in such a manner was stunned. “I…. I’ll see what I can do,” she said. She dialed a couple of numbers, spoke to what seemed to be people higher up in the administrative hierarchy and finally relented. The importance of administering the serum before the surgery could be comprehended only by the operating surgeons.

Finally, the patient was ready, 4 hours after first arriving in the emergency ward and 2 hours after developing the gangrenous changes. The extent of surgery was to be decided in the OR. I shifted the patient into the OR, which lay adjacent to the emergency ward and was sent back to deal with the remaining patients.

That was the last I saw of Dattatray till 8 am the coming morning. “Last night’s Gas Gangrene patient has been shifted to SICU in an isolated room. Go and see him first,” Shrikant, my registrar told me hurriedly, while I was preparing to go to the ward to round the patients.

After exchanging customary greetings with the nursing staff and ward boys, on entering the ICU, I went towards the isolation room. I entered to see him, as expected, on ventilatory support and in deep sleep. I started with my rounds, examining him for any signs of dehydration, checking his vital parameters and ventilator settings. I sent his blood investigations and finally removed the bed sheet to check on his dressing. I was shocked.

The dressings were soaked with blood. The smell was unbearable for anyone without any experience in this hospital, but that wasn’t the reason for my shock.

Both his legs had been amputated. Yes, it was as expected, but a little more. Both his legs had been disarticulated from his hip joint, a procedure we commonly refer to as hind quarter amputation. All that was left of him was his upper body, i.e his head, neck, chest, abdomen and upper limbs. He had no lower limbs, not even a small trace. I was speechless.

My immediate senior, Sonal and I toiled everyday to dress him, our fixed time being 2 am, a time convenient not only for us, but also the patient as the sedation given to him would put him out for the night.

3 days post-op, the patient developed fever and his lower abdomen turned blackish-blue. The gangrene was spreading. He would need another surgery to remove the skin and soft tissues over the abdominal wall. And operate we did, leaving his abdomen exposed to the atmosphere, a catastrophe our unit chief, Dr. Gandhi had planned for in advance. An absorbable mesh was placed over his abdominal contents to prevent his intestines from coming into direct contact with the atmosphere with a light weight dressing placed on top of the mesh.

This was the epitome of suffering and all the available means to alleviate his suffering were attempted. None seemed to work. His ventilation tube (oral tube) was changed to a tracheotomy tube (by making a hole in the neck- a more permanent alternative) as time passed by. His dressings became more tedious, often taking us over an hour to complete. However, all this while, his close kin stood by him, providing the invaluable tender loving care, no doctor could provide.

Mr. Dattatray had a daughter, Prerna (Sanskrit for inspiration), a pretty 10 year old, who was adamant on meeting her father. During a routine counseling session with the family, his wife requested me to arrange for permission for her daughter to visit. As per hospital regulations, children younger than 14 years weren’t allowed to enter the wards, ICU’s and OR’s. However, no regulation was stringent enough for us residents to get around.

The little girl was whisked into the small isolation room, away from the prying eyes of the nurses and ward boys on a lazy Sunday afternoon. She’d almost let her emotions get the better of her, but somehow kept them under control. Dattatray, who up until now was generally unresponsive and inattentive, noticed her presence. He made an effort to sit up and patted her head. A writing pad lay nearby and Dattatray signaled for a pencil/pen. The first written words were the marathi equivalent of ‘I Love you’. Prerna picked up the writing pad, kissed it, held Dattatray’s hand and sat there for close to two hours. We held fort for the entire duration.

The weeks passed by and Dattatray was actually improving. His daughter had ‘inspired’ a miraculous recovery. He was being weaned off the ventilator and his wound, irrespective of its size had shown some signs of healing. Our efforts were paying off. He started conversing with his relatives and the doctors using a writing pad and a pencil, often expressing an intense desire to go home to his family. Notwithstanding this, his chances of survival were slim.

3 weeks after his surgeries, Dattatray was off the ventilator and was able to converse through written words and gestures(his voice impeded because of the tracheotomy tube). However, the condition was a morbid one and the improvement only transient.

Four weeks post-op, he suffered a sudden massive heart attack. Dattatray had slipped into a coma and was placed on ventilatory support again. To bring him back seemed almost impossible. A week and two more cardiac arrest’s later, Dattatray finally passed away.

It was the saddest day of my residency. Here was a 30 year old farmer, with a simple wound, which if managed better may not have led to such disastrous consequences. It wasn’t his fault. The primary medical care given in this country is at times farcical. Quacks abound in the rural areas, using their inadequate knowledge and age old practices to do more harm than good. This makes the job of tertiary care institutions a lot more difficult.

A simple wound lavage with application of an ordinary not-so-expensive antiseptic solution would have prevented this complication. A complication, that resulted in the death of an otherwise healthy 30 year old. If only the primary physician had the requisite competence…..

 

 

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A Tale of Two IBD’s- II

bowel

 

Second Case:

“You better admit this boy to your ICU, or else……..,” Vivek, my registrar said. A 25 year old boy lay on a stretcher outside the ICU door, gasping for breath, while the anaesthetists were squabbling with Vivek, citing lack of beds as a reason for refusing admission to the Anaesthesia ICU.  The anaethetists had only a 2-bedded ICU, which more often than not, was filled with post-operative patients. But, one bed lay empty, the ventilator was unoccupied and the reason for denial unjust.

Devayani, my co-resident was by the patients side, making sure he was oxygenated well enough to prevent him from tuning blue (cyanosis). We had tried all the other ICU’s without any luck. He’d die without a ventilator. The crushing need and the limited resources came to the fore at this very moment. But, what had caused this 25 year old boy to crash to this extent? The sequence of events was quite astonishing.

All our admissions are made on emergency day, whether routine or emergency. It’s the day when you can fill the ward and no one complaints. It’s the one day of the week when you are allowed to do whatever it takes to fit in the admissions (including allocating floor beds to non-emergency patients) and the patients tolerate it.

On one of those emergency days, just a few weeks after Arun (our first IBD patient) had been discharged, did we admit Mr. Vijay. A 25 year old Gujarati boy, fairly handsome, overweight, a cherubic face and a cheeky smile, I’d never forget. He was admitted with a sudden onset, mild, upper abdominal pain. He’d admitted to having an alcohol binge a couple of days back. We fit the equations together and diagnosed him with acute pancreatitis, a condition causing inflammation in the pancreas, which usually occurs due to chronic alcohol(or at times acute alcohol) consumption. The diagnosis seemed appropriate at that point. As per unit protocols, patients with acute pancreatitis undergo a CT scan only on the 3rd or 4th day of the attack. Hence, the patient was investigated as per routine, diagnosed as a mild attack of acute pancreatitis and admitted.

He improved on every follow up round thereof and was in fact on his feet and joking with the staff and other patients on the evening rounds the next day. We started planning a discharge at the behest of the family, aware that the patient was an educated individual who’d follow up for a CT scan in the next few days.

We discharged him the day after in the morning itself. He said he’d go to college and continue with his studies and promised that he’d give up alcohol. Neither the patient, nor the doctors knew what was in store!

3 days later, on a lazy Sunday afternoon, my colleague and I had finished all our work and were making plans to go out for a movie in the afternoon. Just as we were about to leave, the phone rang. “Hello,” I said. “Dude, you’ve got to come down to the ESR (emergency surgical room), one of your old patients is down here,” one of my colleagues from another unit informed me.

Every surgical patient belongs to the surgeon who has seen him first, be it elective or emergency. This is the norm in our institute. I had to oblige and see the patient. As I walked down, a million thoughts raced through my mind. Who was the patient? Why did he come to the emergency ward? Do we need to operate him? Is our Sunday outing ruined?

As I entered the emergency ward and scanned for familiar faces, I came across Vijay. He was back. Ah! I thought to myself. Must’ve had another binge, another attack of pancreatitis. It’ll be all right.

My colleague told me about his findings, that the CT scan was pending and that he thought it was something more than just a relapse of his pancreatitis. His vitals were a little unstable and he looked dehydrated. I rubbished his claims (dehydration is common with pancreatitis too), called my seniors to let them know about the patient and cancelled the afternoon plans, as one of us would have to be around.

I rushed the CT scan of the patient, which would give us a confirmation of the diagnosis and let us treat accordingly. After arranging for the relatives to make the payment, we wheeled him into the CT suite on a stretcher. Patients accompanied by doctors are always priority and this was no different. I sat in the console waiting for the CT to finish, making plans for the night to compensate for the failed afternoon outing. The scan was done. The radiology resident and I went through the CT scan. Nothing. A closer second look revealed ‘Gas under the diaphragm’. An ominous sign if you ask a surgeon! It points towards a hole in the intestines (perforated bowel).

An unexpected turn of events. This meant the patient needed surgery. No explanations could be offered. This finding had stumped us. All my plans were scuppered.

The patient was operated on a emergency basis a few hours later. The relatives had become anxious. This was a boy, who was discharged 3 days ago in an absolutely healthy state and here he was being taken up for surgery.

The end result of the surgery. An Ischaemic Bowel Disease.

Our second young patient with an illness that usually affects the older generation. A diagnostic error which we’d hoped wouldn’t cost the patient his life. Retrospectively, a CT scan on admission may or may not have led us to this diagnosis. We dont know. What we did know is we had to remove his small intestines too (as we did for Arun) but this time around the amount left behind was a lot more, 200 cm. This would make it easier to manage we presumed. We couldn’t have been more wrong.

We followed the same protocols established with the management of Mr. Arun, did a few things differently and hoped for the best. We started him on oral feeds much sooner than Arun, he didnt require the extensive course of TPN (parenteral nutrition- high concentration nutrients injected directly to the heart) & re-feeding. While his overall management was a lot simpler, Vijay had a plethora of other surgical complications.

As per protocols, we checked the surgical wounds of all patients on the 4th post-operative day. Vijay’s wound was checked too, on his fourth post-operative day, 15 minutes before our seniors would enter the ward on their morning rounds. As I rolled a piece of gauze over his wound, there were a few drops of pus which streaked out. We removed his sutures to drain all the pus. To our surprise, we found around 200 cc of pus accumulated underneath his wound. This was bad! We removed all his sutures and cleansed his wound thoroughly. All in the 15 minutes before the seniors would start their rounds! The patient had what is called a burst abdomen (all the skin and underlying structures protecting the intestines from the atmosphere had given way). He was put on a regular dressing schedule and we’d hoped his wound would heal, sooner rather than later.

Over the ensuing weeks, we faced different problems with Vijay’s management than we did with Arun’s. While Arun was not in a septic state at any point in time, Vijay was in sepsis (infected state) due to the pus in his abdominal wound. We’d tried higher antibiotics, blood transfusions, local remedies but to no avail. His WBC counts would always be higher than normal, he would always run a temperature sporadically and he’d never want to eat. What was going wrong?

2 weeks into his post-operative course, we got a CT scan done. Partly because he was still in the infected stage and partly because we were worried that we were missing something. And miss we did! Vijay had a collection in his abdomen which had caused his septic state. We got a drain placed into it, under the guidance of the ultrasound machine. He settled down.

A week later, Vijay was better, he was eating well, he wasn’t pale anymore, he was walking around and he’d gotten his smile back! We started planning his discharge again, the only difference being this would be after definitive treatment.

The evening before Vijay’s discharge he seemed happy. He was elated that he’d be going home. He wanted to play his videogames and go to college like any normal 25 year old. He slept off peacefully after my evening rounds. The ward looked stable, the work was done. 11 pm. Time to sleep (relatively early, as compared to any other day).

At 3 am, my colleague who was on SICU duty that night got a call from the ward sisters. Vijay was feeling breathless. She rushed to the ward to see Vijay gasping for breath. He had turned blue. His body was not receiving any oxygen from his lungs. She resuscitated him, called the registrar and after putting him on high flow oxygenation and making sure he’d turned pink, initiated the procedure to shift him to the ICU.

Vivek had already reached the ICU and was haggling for a bed. There are 3 ICU’s in our institution for surgical patients and while 2 of them are controlled by the surgeons, one is managed by the anaesthetists. Both the surgical ICU’s (SICU’s) had no empty beds. The only remaining option being the AICU.

“You better admit this boy to your ICU, or else……..,” Vivek, my registrar said to the anaethetists who were on call. While the haggling didn’t work, the threats did. We knew it may land us into some trouble, but all we were concerned about then was Vijay. Eventually, we got him admitted in the AICU, put him on a non-invasive ventilation (NIV- a procedure to ventilate the patient without putting a tube into his airway) and hoped for the best. This was a huge setback!

Just around then, we’d heard about Arun’s demise and our morale had dropped. The hard work we’d put in for Arun was, so to say, in vain and Vijay was also in such a serious condition. Nothing beats the high a surgeon experiences when his operated patients walk home. It also held true for the low morale the surgeons faced when their patients weren’t exactly recovering as they’d hoped.

A CT scan done for the patient revealed a clot in his lungs (Pulmonary Embolism) which travelled up stream from his legs, the leg clot forming because he’d been immobile. We managed him on NIV for 3 days, gradually weaning him off the ventilation after that. We also started him on medications to dissolve the clot at the same time. Gradually, Vijay was weaned off the ventilator and allowed to breathe on his own.

His recovery had faced a setback by 3 weeks, but the end result was favorable. Vijay was discharged, 2 months after he’d been operated. A pale shadow of his former self, but still alive and walking. Vijay and his relatives gave us a letter of appreciation when he was discharged praising the way we’d handled his case, notwithstanding the misdiagnosis.

Vijay went home and we continued with our work.

The 4 months that we’d spent managing Arun and Vijay, were undoubtedly, the most difficult months of my tenure. They’d taught us much, both surgically and otherwise, they’d given us an insight into the life of a surgeon (considering we were not even a year into our tenure) and they’d taught us how to take care of patients with love and compassion.

4 weeks later, we received news of Vijay’s death. Such is the nature of the disease……………………….

 

 

 

The Carnival of all Carnivals- The FIFA football World Cup!

2014-FIFA-World-Cup-Wallpaper

 

1-0.. Croatia had scored. At São Paulo. The crowd was silent. The handful of Croatian supporters broke into a frenzy. What a way to kick off the world cup, with an own goal. Marcelo being the culprit. Olic crossed, Jelavic miscued and Marcelo scored, inadvertently of course. Little did he know he’d go down in the history books as the scorer of the one and only Brazilian own-goal, to date in the World Cup Finals.

A couple of hours earlier, the World Cup kicked off with the customary opening ceremony, filled with glitz and glamour, enabling the viewers to soak in the natural beauty of the host country. And what better country to showcase its beauty and diversity than Brazil, the unofficial mecca of football. A country which has arguably tasted footballing success like none other. A country so crazed by football, that every small boy would buy his first playing ball before he even went to school!

Controversies abounded leading up to the world cup, with numerous construction related deaths, structural deficiencies, protests regarding the high costs, but all would be forgotten once the World Cup is underway! It’s Brazil after all, a country as crazy about football as India about cricket. Technical glitches notwithstanding, the opening ceremony managed to showcase Brazil as we all know it. The amazing greenery, the vast expanses of natural beauty (both terrains and otherwise). The crowd seemed to enjoy every moment of it! Up until Croatia scored!

Brazil has never lost the opening match of any World Cup and the fans expected no different this time around, no matter if the team doesn’t match upto the quality of the Brazilian teams of the yesteryears. The fans expected Brazil to win it. And when they went 1-0 down, the fans were distraught, almost angry. How could they, would’ve been the chants emanating from the stands. But they did. Brazil had just scored an own goal! To be fair to the players, they’d understood the kind of pressure they faced and went about their work as professionals. Discontentment was growing. The fans were getting agitated. The tension was almost palpable. Mr. Scolari, always so animated on the sidelines, was a picture of composure. It was almost as if he knew the goals would come. He knew the team he’d put out would not disappoint him. And disappoint they didn’t.

Neymar, who could consider himself lucky to stay on the pitch after a debatable offence on Luka Modric, scored. However, the true credit went to one Mr. Oscar. The man behind the scenes and for me and almost everyone I spoke to after the game, the player of the match. Oscar didn’t lose the ball inspite of being tackled and tackled and tackled. This wasn’t the first time. He wrestled control of the ball from the Croats, deployed a masterful pass to Neymar, who still had work to do. Neymar sprinted forward, in a manner only he could and without assessing any options, opted to go for goal himself. An accurate shot, low but accurate. Brazil had scored. Faith was restored! The crowd erupted with joy.

Half-time came and went by. The crowd now wanted a win. Almost half way into the second half, Brazil got an opening after wasting a plethora of chances. A penalty. Fred, the almost innocuous looking forward, who by and large was ineffective up unto this point, was fouled in the box by Lovren. Lovren was judged to have put his hand across Fred to bring him down. Controversial. But, Brazil didn’t care. Neymar stepped up, the crowd was silent. Neymar stumbled on his run-in to put the goalkeeper off and so he did. The goalkeeper put in a dive to the correct side but couldn’t do much. Neymar had suddenly transformed from a boy with big potential, to a man! That’s what football does, it makes and breaks heroes in seconds. That’s the game.

Brazil went onto score one more. The player of the match (unofficially) Oscar got a goal to show for his untiring efforts and sublime skills. A player to watch out for in this tournament, considering his phenomenal club form as well.

This was just the first game of the World Cup Finals, but each player celebrated as if it was the Cup Final. The pressure and expectations were huge and more than anything they managed to deliver.

An exciting start to the greatest Football Spectacle on this planet. Lots more to come. Stay tuned.

A Tale of Two IBD’s – I

bowelAsk any general or gastro-entero surgeon, what’s his failing! More often than not you’ll get a universal answer, ISCHAEMIC BOWEL DISEASE.

An ischaemic bowel disease is similar to a heart attack, the only difference being that it occurs in the intestines. The blood supply to the intestines is cut off and can lead to a spectrum of diseases ranging from abdominal angina (yes, angina the term most commonly used for heart diseases) to a full blown blockade, leading to an Intestine Attack (similar to a heart attack but in the intestines). While the heart has numerous nerves which refer the pain caused by an decreased blood flow to various parts of the upper half of the body (jaw, chin, shoulder, inner arm etc.), the intestines are less equipped to do so. Which makes this condition ominous, as it is not only difficult to diagnose, but once diagnosed it is usually in a very advanced stage. The intestines contain a large number of bacteria within their walls, but while they are beneficial in health, in disease they pour out into the blood to cause a picture of full blown sepsis in the body.

The First Case:

It was a busy day in the emergency ward. We had already finished 12 minor cases, 3 major ones and we had 6 major cases wait-listed. And it was only midnight. 8 more hours for the emergency shift to get over, but several more hours till the cases were operated upon. This was going to be one heck of an emergency duty!

At around 4 am, while my colleague and seniors were operating in the emergency OR attached to the emergency ward, a 30 something, portly man (one Mr.Arun) came in with severe pain in the abdomen and a file of the various doctors he’d been to for all sorts of treatment. My initial impression after examining the patient was that he had a perforated bowel (a hole in the bowel, which could be due to various causes). I followed the routine protocols for resuscitation as the patient appeared extremely dehydrated and sent him for an abdominal X-ray, once it was deemed fit. To my surprise, there was no evidence of perforation in the X-ray. What else could it be? An obstruction? A tumor?

An ultrasound wouldn’t reveal much, so we decided to go in for a CT scan directly. However, even the CT findings were unremarkable. At this point in time, my seniors came out of the OR having completed the surgeries. I presented the patient to them, with history, examination findings and investigations. They were flummoxed too. The patient however had very little relief in pain during this time and had started developing a fever. A decision was taken to operate.

The clock struck 8 and the emergency duty had just ended. As was the norm, one of us would stay back with the Lecturer to finish the backlog of cases, the other would round off the ward patients, which was no mean task! It was my turn to go back to the ward. I finished my work, we rounded off patients with the consultants, the pending decisions were made and the CT’s of the various admitted patients were reviewed. All this while, I wondered what happened to that 30 something man who was going to be operated upon!

2 pm the following day and I was finally done with all the work. It was time to break for lunch. A quick trip to the emergency OR would do no harm, I thought to myself. Leaning in to the OR, I saw my colleague scrubbed in, closing the abdomen of the patient (the final part of the surgery).

What did it turn out to be! Ischaemic Bowel Disease!

Retrospectively, the long duration of pain signified it was an abdominal angina, the paucity of findings on investigations out of proportion to the clinical findings pointed towards an ischaemic bowel disease. Yes! but in a 30-something. This is a disease of 60-somethings. Strange things happen in the human body! There’s always so much to appreciate and learn. If the decision wasn’t taken to operate, we would have lost the patient without a diagnosis. It was a bold decision nonetheless, one that would’ve been severely scrutinised had we not returned with any findings. Kudos to the Lecturers.

The patient underwent surgery. Almost all of his small bowel and a part of his large bowel were removed, as it was gangrenous and infected, leaving behind 100 cm of the upper part of the small bowel (thats very little considering the entire small bowel ranges from 600-1000 cm). His remaining bowel was brought out onto his abdominal wall as an opening (stoma) at both the ends. The small bowel plays a vital role in the absorption of nutrients, vitamins and minerals into the circulation, which are all necessary for holistic growth. Loss of this function meant the patient would be a nutritional cripple all his life. The large bowel, on the other hand has a limited role in the absorption of nutrients, but a greater role in absorbing water and minerals.

Our patient, Arun, had practically lost all of his small bowel with his large bowel intact, both the ends being open on the abdominal wall, at the tender age of 35. While the surgery went off well and the post operative recovery was good too, the main problem would be nutritional rehabilitation.

The patient was put on a regime of parenteral nutrition (injecting nutrients in a concentrated form straight to the heart) and re-feeding. To prevent the patient from losing his body fluids to the exterior, we collected all the fluid coming out through the opening on his abdominal wall, put it through a sieve and fed it to his large bowel also opened on his abdominal wall (re-feeding).

On our morning rounds, two weeks post-op, the patient and his relatives came to us with complaints of burning pain around the abdominal wall opening (stoma). We examined him only to notice severe excoriation of the skin. Due to the highly toxic and vicious nature of the billiary fluids coming out through his abdominal wall, the patient developed excoriation of the skin. While, this could be considered negligence for any other type of stoma, this was just an expected complication for this one. The skin surrounding the opening was red, thick and excoriated. We tried all the available methods but to no avail.

It was then, that the experts came to our help. A reputed company which manufactured bags to place around the stomas, provided us a bag with a special design (concave) which prevented the excoriation. We tried it. It worked. The skin healed and the stoma contents were manageable.

Arun, was ably supported by his family, un-educated but always willing to learn. His mother was his biggest support, his father always using all available resources to provide him with the best care and his extended family always chipped in with some money. Ours, being a public hospital, the costs were heavily subsidised. Even then, we didn’t have everything available and the patients often had to purchase some prescription articles, using their own money.

All said, we did have our own problems with his relatives. Not that we really complained about them. It seemed that one of his relatives was affiliated to a Member of the legislative assembly. They regularly got letters signed by the administrators asking us to take good care of the patient (as if we weren’t already!). They also went to the extent of lodging a complaint against my colleague and myself for rude behaviour (a totally baseless charge, which was later withdrawn at the behest of the patient himself). Yes, there were arguments, there were disagreements regarding the best course of action, at times there was arrogance (from the patients relatives), but there was never rude behaviour involved, nor was there ever admonishment for belonging to a certain class of society(another baseless charge levelled against my colleague and myself). We were chided, asked to mend our ways, be polite and courteous, but never appreciated for the work we put into getting the patient this far! It’s at times like this when u feel like you shouldn’t go out of your way to help patients recover, stay within the limits of whats right and do the bare minimum. It wasn’t the patients fault though, so we continued with our work in a professional manner, knowing that the uproar would die down, sooner rather than later.

4 weeks post-op and Arun had lost weight, 20 kg’s to be precise. His muscle mass had reduced and his cheeks had become hollow (a sure shot sign of malnutrition). His nutritional rehab regime was failing and we had no idea what to do. My colleague and I came up with an idea. Reading about patients in the ward was always advisable, but none of us followed through with that, considering the lack of time. But Arun was an exception. Both of us wanted him to be fit and healthy, ready to go home. After all, we had spent so many sleepless nights monitoring him to make sure he was ok. We came across the role of medium chain triglycerides in such patients and decided to try them. We also started him on oral feeds, reducing his need for parenteral nutrition. Slowly and surely, he started gaining weight, to our surprise he was even weaned off the parenteral nutrition and could resume all his feeds orally, the only rider being he had to empty his bag 4 times in a day and reefed the contents into the other opening.

With a promise that he would be taken care of well at home, we started planning a discharge. The discharge summary took my colleague and myself 2 days to write out. After all, Arun had been with us for 6 weeks now and had gone through numerous ups and downs. We captured every moment of his stay in the hospital in the discharge summary, got the mistakes rectified by our Seniors and finally sent it to the nurse to follow through with the discharge. The whole process took the nurse 2 hours, segregating his multiple files and reports.

Arun was finally ready to go home! 6 weeks, 2 surgeries and countless troughs later, he was all packed up. His family was in tears, of joy or sorrow, we couldn’t say. They had come to grow very fond of us, the hospital and the surroundings and treated it as their home. Going out of our way to help him stay afloat and eventually survive and rehabilitate was an enriching experience. I learnt more from this one patient, than I had so far in my surgical residency (8 months down). It was because of times like this, that I threw my previous notions out of the window (doing the bare minimum) and felt proud of the effort we had put in.

Arun was placed on a strict follow up schedule. We saw him twice in the OPD every month after that, measured his weight, got his lab reports, kept a tab on his stoma function and made sure he was never dehydrated. He followed up in the OPD for the following 2 months. After which he disappeared.

No phone calls, no visits for consults, no news of him! It had been a month since Arun had showed up and my colleague and I were getting a little worried. We recovered his contact number from the old patients list and contacted him. It was his mother who greeted us over the phone. We exchanged pleasantries. We asked about Arun. HE WAS DEAD! His mother told us that he had collapsed suddenly while resting one evening only to be declared dead on arrival to the local hospital.

Such is the nature of this disease! If it won’t kill you, it’ll make sure some other system is affected. In the long run, that will kill you. We tried and even succeeded partially, but failed in the long run. Arun lived for only 4 months after his surgery, but he taught my colleague, Dr. Devayani and myself more than what any book could ever teach us.