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……………………….

 

 

 

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