12 hours, 16 mops and 5 blood transfusions later, the surgery was finally over. It’d started at 9:00 am, the ampulla was opened at 10:00 am, the decision to perform the ampullo-jejunostomy (anastomosing the ampulla to the small intestine) was taken at 10:30 am and the procedure was formally completed at 9:00 pm.
Akshay was wheeled out of the OR, with a tube in his throat and a bag (AMBU) attached to it, being pressed manually to ventilate him (an accepted method to shift ventilator dependent patients). The Surgical ICU (SICU) was prepared in anticipation. The first bed was emptied for him and the most sophisticated gadgets available in the ICU were set up to monitor him.
The immediate post-operative period is the most critical for the survival of patients undergoing major procedures. Fluid imbalances, clotting disturbances and hypothermia (a decrease in the core body temperature) being the major culprits in early post-operative period. An intensive care unit (ICU) with the physical presence of a doctor to monitor the patient is the bare minimum requirement for such patients.
I stayed in the SICU all night monitoring Akshay, who was drowsy and unresponsive at the time of shifting. In a few hours, Akshay was awake and fighting the tube in his throat and the restraints that had tied down his hands and legs. A mild sedative knocked him out again. Fluids were managed judiciously as per his urine output and ventilatory settings were changed as needed all night. Besides a mild drop in his blood pressure (owing to under-hydration) Akshay survived the night without any major mishaps. His chances had just increased manifold.
Over the course of the next few days, Akshay was weaned off the ventilator, without rushing him into anything. The recovery seemed promising. A feeding tube placed directly into his small bowel had allowed us to resume his feeding, avoiding the more dangerous parenteral nutrition (high concentrations of nutrients injected directly to the heart through a catheter placed in the neck).
Akshay, however had become reticent. He spoke only when addressed and did not take an interest in the surroundings. All of us were so consumed in making him better, that we’d overlooked his fragile emotional state.
Post-operative day 5. Morning rounds.
The previous nights wound dressing over the abdomen was soaked. It smelt and had a greenish tinge. Nothing in the drains, but something from the abdominal surgical site? On opening the dressing, a litre of bile drained out onto the sterile gauze pieces.
Every surgeon has only one enemy. Not the physician, not even the anaesthetist, but PANIC. A part of every surgeons training is to avoid panicking in tricky situations. And we held our own, that fateful morning.
Akshay had developed a fistula (a communication between the intestines and the skin), a known complication of such procedures. The bile draining into his abdominal surgical site had to be addressed soon, as devastating complications could’ve followed. Such fistula’s were known to close spontaneously as long as the causative factors were taken care of.
We came up with a novel idea for Akshay. A home made closed suction dressing. In simpler terms, a dressing that would drain the fluid out of his abdominal cavity and at the same time facilitate healing. A simple rubber catheter was places as an atraumatic tube into his abdominal cavity. The other end of this tube was connected to the suction apparatus available in the SICU. A sterile plastic adhesive film was placed over the partially open abdominal wound containing the rubber catheter, to create a vacuum, which would allow the suction to take effect. Utmost care was taken to avoid spillage of the vicious bile over to the surrounding normal skin, to prevent it from damage.
The dressing had to be changed every time there was even a hint of fluid spilling over to the surrounding skin, which would range anywhere from a few hours to a few days. It took 2 residents, a staff nurse, a ward boy and a relative to complete every dressing.
As time passed by, the amount of bile draining through the wound decreased. Akshay would go on for hours without the suction attached to his dressing. Yet the amount was not so insignificant that we could wean him off the suction completely. However, this decrease in drainage from his abdominal wound drew our attention to another reality.
The environment of the ICU was taking a toll on Akshay. Akshay was depressed. He hadn’t interacted with us in days. His parents too complained of the same thing. His face bore the same melancholic look as when he’d first come to us. A complete recovery from surgery meant physical, mental and social well-being. Akshay was recovering physically, but his mental health was on a downward slide.
We increased the time we spent by Akshay’s bedside everyday. We cracked jokes around him, involved him in our stupid banter while sitting in the ICU and allowed his parents to visit him more often in the ICU. Unfortunately, Akshay couldn’t be shifted outside the ICU as the suction apparatus in the wards were non-functional. He was shielded from seeing patients die in the ICU by strategically using the curtains provided. We even arranged for a small laptop with a collection of the latest Bollywood films for him, procuring special permission from the sister-in-charge and the doctor-in-charge.
Slowly, but steadily Akshay recovered, both physically as well as mentally. The surgical wound over his abdomen had begun to heal, contracting in size. Owing to the fistula, Akshay was still not permitted to take anything orally. Feeding through the tube, however accounted for his nutrition. A brief period of feeding him the bile sucked out through the surgical wound also helped in improving his nutritional state.
3 months after first entering the hospital, Akshay was en route to a complete recovery. The fistula had closed partially and the wound was contracting at a rabbit’s pace. He had finally been weaned off the suction dressing.
On our morning rounds on one of the days, we urged Akshay to take something orally. The smile that followed was the broadest smile I’d ever seen. It was the first time in 3 months that Akshay had smiled. His mother got ‘khichdi’ (porridge) and fed it to him in front of all of us. Mr. Yashwant and Mrs. Nita (Akshay’s mother) were in tears. My eyes welled up too. Crying, however, would seem unprofessional and I held back.
“I want some chocolate,” Akshay demanded as he looked towards us. Our boss nodded. Chocolate was immediately arranged for and fed to him. His impish smile and childlike enthusiasm caused immense joy amongst us. We realised this was something special. Every human being has an instinct to survive. Akshay not only had the instinct to survive but the will to fight against all odds and emerge victorious. I was honoured to bear witness to this amazing exhibition of will power and courage.
Akshay was discharged, 3 months and 10 kilos of lost weight later. My unit and ward switched, weeks after Akshay was discharged and I hadn’t seen him in a while.
A year later.
I ran down the corridor wheeling my patient into the SICU. Ganesh had aspirated and needed an urgent intubation. I saw a familiar face as I hurried down the corridor, but didn’t pay much attention to him. Ganesh was shifted to a bed in the SICU, intubated, his bronchial tree was suctioned dry and he was put on ventilatory support. After giving the SICU Registrar the relevant instructions I walked back towards the ward. The same familiar face was still standing there.
“Sir,” he said as he embraced me. It was Mr. Yashwant, Akshay’s father.
“I’d touch your feet today, but you had asked me not to when we came here first. Thank you for everything.”
Behind him stood Akshay, unrecognisable from his past form. He’d transformed into a plump teenager with a rotund face, with the same impish smile. He hadn’t let the 3 months spent in the hospital hamper his subsequent growth.
I couldn’t keep up with my normally stoic demeanour. Emotions got the better of me. I cried…………..