A Stitch in time saves Nine- I

DU perf suturingWhat would a doctor in a public hospital do when a 19 year old boy is wheeled into the casualty with 2 tubes exiting his abdomen and a bulky dressing over his belly?
Try to send him elsewhere.
But what would the same doctor do if his family was made to run from pillar to post and not accepted in any other public hospital?

That was the story of nineteen year old Akshay, who’d been operated in a private hospital and had developed complications after the surgery.

Akshay had an ulcer in the duodenum (the part of the small intestine just beyond the stomach), the kind most of us have had and attribute to ‘acidity’. The only heinous aspect of the ulcer was that it had perforated. The ulcer had penetrated the wall of the duodenum and exposed its interior to the abdominal cavity.
The entire gastrointestinal tract is sealed off from the body, with the only two openings being the mouth and the anus. Millions of organisms thrive in the gastrointestinal tract serving many purposes. Any breach in this tract would lead to contamination of the body with these organisms, which underlies the importance of sealing the gastrointestinal tract from the inside of our body.
Intestinal juices (bile) were pouring out through the perforated ulcer into the sterile abdominal cavity, hence contaminating it. Any doctor, in his right mind, would’ve advised surgery at this point in time. And so did Akshay’s physician.

Any Indian who can afford private medical care prefers a private hospital to a public hospital. Due to a lack of interest in healthcare, shown by the ruling class since Independence, the infrastructure in the public hospitals is poor. The wards and corridors are dirty and infested with various kinds of insects and animals (citizens must take the blame too, what with spitting and open air defecation rampant in the premises of these ‘premier institutes’). The operating rooms have cobwebs and leaking roofs and the wards have an unusual stench, one which is unbearable if one isnt used to it.

It’s only once the underbelly of the private medical centres is exposed by these complicated cases, does the common man turn to the public hospitals to salvage the situation.

Akshay was operated on an emergency basis in a private set-up not too far from the public hospital we were training at. Simple sutures were taken to seal of the perforation and standard practices were followed for post-operative care.
Three days after the surgical intervention, however, the drains placed during the surgery (to suck out any residual fluid) showed a change in colour. Green colour, in a drain, is an alarm bell for a gastrointestinal surgeon. The tubes were draining bile, implying a give way of the sutures placed over the perforation.
Duodenal perforations aren’t notorious to leak, but there are always exceptions to the rule.
Akshay was managed in the private set up for a few days, before his parents ran out of money and patience and took the decision to shift him to a public hospital. Without prior intimation by the private hospital, the patient was paraded to the various public hospitals around the city, with each of them providing novel reasons to refuse admission. After all, this wasn’t an easy case to manage.

Facing rejection from the other three public hospitals in the city, Akshay’s parents turned to our institute as a last resort.

Akshay was wheeled into the ward accompanied by his family. Akshay’s father came up to me, as I was in charge of the emergency ward at that time, folded his hands and was readying himself to touch my feet.

“Please save my boy’s life,” he stuttered, as tears rolled down his eyes, along the side of his nose.

The chaos of the emergency ward blurred itself out for the next ten minutes as Akshay’s father, Mr. Yashwant narrated his story to me. His mother, who looked more like his sister, stood by his side, stroking his hair as if to tell him that he’d be all right soon.
The chaperone accompanying him seemed least bothered, ready to dump him in that mess of an emergency ward and run away. That was all his duty demanded of him, after all.

Akshay sat there motionless, least bothered by the surroundings. He was stationed on a wheel chair, outside the door of the emergency ward, mildly breathless, with a grim expression on his face. A dressing was placed over his belly, the size of which was twice his body circumference. Two tubes were placed on either side of his abdomen, connected to bags draining greenish fluid (bile), and the skin around the draining tubes was excoriated due to the irritant action of bile. He’d already been through enough at that tender age of nineteen. Sitting on the wheel chair outside the emergency ward and watching patients die/gasp for breath/vomit blood seemed trivial to him.

Akshay and his parents had suffered enough. After due consultation with the seniors in the unit, Akshay was admitted, stabilised and shifted for a CT scan. Akshay had to be operated and was prepared accordingly.
Operating him was not as difficult as anticipated. The cause of the leak was identified during the surgery. The sutures that had been placed to secure the ulcer, had given way leading to leakage of the intestinal juices into the abdominal cavity.
The ulcer was re-sutured and Akshay’s abdomen was closed. We were all glad it went off well and counselled Akshay’s parents about the procedure with guarded optimism. Akshay was shifted to the ward after the surgery, not requiring either intensive care or ventilatory support.

Re-operations are always tricky. As the body heals from the stress of surgery, the immune system forms fibrous bands in the abdominal cavity, as a part of the healing process. The easy access to Akshay’s abdomen worked in our favour, as did his age. Younger patients always heal better and faster than older ones.

First post-operative day- Evening rounds.
All five residents of the unit were on rounds that day. The wards were full and work was pending. On reaching Akshay, the junior resident pointed out, “Check his drain Sir, it looks like bile.”
The senior residents and I immediately turned our gaze to the drain. It was indeed bile. Akshay had leaked again. Akshay required surgery again. What the hell was wrong with his luck?
The same routine of preparing the patient for surgery was followed.

Akshay and his parents were distraught. They didn’t know how to react. Their boy, who was in his last year of his teen hood, was to be subjected to a third surgery in a week. The initial reaction was to transfer him to a private hospital, cursing the public hospital system and the lack of care thereof. Better sense prevailed, however and his parents consented to the surgery.

Akshay was operated again the following day, i.e. two days after his second surgery. The sutures had given way again. His plight had left everyone dumbfounded. The access this time around was a lot more tricky than it had been two days ago.
The human body is a mystery. Inspite of the extensive research performed on it, no one seems to have a conclusive answer to the plethora of problems faced by doctors regularly. There was no logical explanation to justify the difficult access to Akshay’s abdomen just a couple of days after the same operating surgeons had a relatively easier access.
The surgery this time around was a lot more complicated than it had been previously. Due to the adhesions and scarring around the stomach and the intestines, an unfortunate complication arose.
The pancreas and liver connect to the duodenum via ducts opening at the ‘Ampulla of Vater’, which is surgically defined as a ‘no touch zone’, except for procedures involving the pancreas. Due to the extensive scarring, identification of the ampulla proved to be difficult and while operating, the ampulla opened up inadvertently.

This was neither expected, nor anticipated. Akshay’s problems had now travelled a full circle, starting from a simple leak to a failed re-surgery to the most dreaded complications of all. Pro’s and con’s of various procedures to repair the ampulla were discussed hurriedly amongst anyone who would be brave enough to provide an opinion.

The most amazing thing about surgeons is their decisiveness. No matter how good or bad a decision maybe, the decision is made in a split second. The surgeons are always brash. The quintessential Alpha’s of their field (whether male or female). The physicians are always behind the surgeons in this aspect (and maybe in this aspect only), as they dilly-dally with every decision that has to be made. A physician will always ponder over his decisions before putting them into effect, sometimes losing valuable time in the process. If a patient is critically ill requiring urgent attention, I’d bet a surgeon would do a better job than a physician as far as the primary management is concerned.

A decision to anastomose the Ampulla to the small intestines (jejunum) was taken after a short discussion. The procedure was underway. 3 surgeons and 2 residents were scrubbed in for the surgery, one which took a total of 9 hours to complete. No tea breaks. No bathroom breaks. Adrenaline was flowing through the veins of every doctor in the OR.

The Operating Room is a social set-up where various cultures interact and work in harmony to provide quality care to the patients. Chattering, gossiping, music in the back ground are some of the various characteristics of every OR. As opposed to popular perception, a lot of friendly and unfriendly banter takes place in the OR. It is far from the silence one expects in the hospital.

Silence in the OR was an ominous sign. And while Akshay was being operated, one could’ve heard even a pin drop. The silence was eerie. The jovial atmosphere had transformed to a grim one. It seemed like the silence had galvanised all present in the OR to perform efficiently and in perfect harmony. After all, the life of a nineteen year old was at stake!

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4 thoughts on “A Stitch in time saves Nine- I

  1. Wow, Harsh, I generally don’t read up loooonnnggg articles on FB..
    But this one was worth it so far!!! [except the physician v/s surgeon part- on which one is better!! 😉 ]

    and yes.. you write really well..

    Waiting for Part 2 on this one & Hoping for Akshay’s speedy recovery!!!

    • Thank you, Khushnuma.. Part 2 is on its way.. working on it! Maybe by tomorrow morning..
      And I have the utmost respect for physicians.. Thats why I mentioned, ‘The physicians are always behind the surgeons in this aspect (read:decisiveness) (and maybe in this aspect only)’.. A surgeon is trained to make quick decisions, whether right or wrong..
      No matter how good a surgeon you are, you are stranded without the help of a good physician.. Cheers to all the Docs, whether surgeons, physicians or otherwise.. 🙂

  2. I don’t agree at all on the decision to operate on him again. Bile leak on day 1 should have been managed expectantly. It would have stopped by itself. What repair had you done? Your ampulla jejunostomy didn’t work anyways. The only reason to reoperate on him would have been peritonitis. If it was a contained leak, nothing should have been done.

    • We always have different opinions regarding such decisions. I respect yours, as long as you respect that of the treating doctors (and not enforce them by saying “nothing should have been done”). If the cause of the leak is surely a leaked duodenal perf and that too on day one, very few surgeons would manage it expectantly and wait for it to heal.
      If you’re one of them, kudos. I admire your courageous decisions.
      The blog was not meant to illustrate surgical decisions or glorify the surgeons, it was purely meant to bring to the forefront exactly what most of us doctors forget, while bickering about decisions and who’s better than the other. THE PATIENT AND HIS FAMILY!
      Additionally, I have no idea regarding your identity. Would be nice if you could reveal it especially when posting such a strong message.

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