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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