48 Hours!

(Names and certain events have been modified in order to protect identities)

Two resident doctors, 48 hours, and unforeseen complications, resulting in triumph, failure and revival of the blame game that plagues every government organisation in this country.

The New Year was being celebrated with the kind of zest and pompous show that only our countrymen are capable of. Diwali was drawing to a close and it would be back to some serious work, better still, an emergency duty awaited me on the very next day. Little did I know that the sleepless nights would begin on the new year day itself.

At 9 Pm on New Years day, a 3rd year resident, Dr. Nilesh from the Department of General Surgery was found lying unconscious outside his hostel room by one of his colleagues, Surya. Nilesh had suffered an injury to the side of his head, a contused lacerated wound, one that would require suturing. But that was the least of Surya’s concern. Surya, an astute clinician in his own right, realised that something wasn’t quite right when he turned Nilesh around, only to find him unconscious and unresponsive. Never one to panic, Surya gathered some help and rushed Nilesh to the casualty initially and the CT suite and ICU eventually.

Inspite of the initial efforts at resuscitation, Nilesh remained unresponsive and a call was made to place him on ventilatory support. The Neurosurgeons, who were informed about the patient in the meanwhile, reviewed the CT scan of the brain and reported it to be normal, just as the Anaesthesiologists attempted an intubation of his airway. Nilesh coughed out as soon as the intubation was attempted, precluding any plans to put him on ventilatory support. The CT findings provided further encouragement to manage him off any ventilatory support. Nilesh was placed on supportive care and routine analysis for toxins in his body were sent to the various labs, in addition to the blood investigations.

The physicians, neurologists, neurosurgeons were all involved in his management and a call was taken to perform a MRI scan in the morning. Nilesh was started on antibiotics and other supportive medication. As the hours passed by, his consciousness improved manifold, albeit not to the expected level and the worry lines on everyones face seemed to relax just a little bit.

As Nilesh was being shifted for the MRI, the next morning, to investigate him further, we received an urgent reference from the physicians for another patient in their ICU, i.e the Medical ICU (MICU). A 2nd year Anaesthesia resident, Dr. Swati, who had been diagnosed with Dengue, had been admitted to the medicine wards three days ago. Her recovery hadn’t gone on as hoped. Her platelet counts showed a downward trend (as is the norm in Dengue) and her general health appeared to deteriorate.

In order to avoid any mishaps, Swati had been admitted to the MICU on New Years day. As the day progressed, Swati developed one complication after the other. Her breathing had become laboured due to ARDS (Adult Respiratory Distress Syndrome), a condition which caused inadequate oxygenation of the blood passing through the lungs. Gradually, she was shifted onto Non-Invasive Ventilation (NIV) and eventually was intubated and put on full ventilatory support. She was managed on the ventilator overnight, while Nilesh had just about managed to avoid the ventilator.

Around the time Nilesh was undergoing the MRI, Swati’s health was on a downward spiral. The dengue virus had spread throughout her body and was causing a Polyserositis, a condition where the membranes in the body secreted a large amount of fluid into the body cavities. Fluid was accumulating in her lungs and her abdomen, leading to further difficulty in breathing inspite of the ventilatory support. Despite the low platelet count, Swati wasn’t bleeding from anywhere. This was a positive sign, notwithstanding all the other complications.

When we assessed Swati, she had some abdominal distension due to accumulated fluid. However, her intra-abdominal pressure seemed to be maintained and hence the fluid was just tapped with a needle with a hope that it would not re-accumulate.

Nilesh, in the meanwhile underwent the MRI of his brain which turned out to be absolutely normal. There was no cause that could be ascertained for his fall. He had been complaining of headache since the past month, a finding that could’ve been correlated with any abnormality picked up on imaging. However, all the imaging modalities turned out to be normal. After brainstorming with the neurologists, it was decided to go ahead with a Spinal Tap, i.e insert a needle in his spine to remove some cerebra-spinal fluid for analysis. Performing this investigation would effectively rule out all causes of a secondary headache.

An hour after tapping her abdominal fluid, we received a call from the MICU doctors that Swati’s intra-abdominal pressure had risen. On re-checking the same, it was found to be over 30 cm of water, a sure shot sign of an Abdominal Compartment Syndrome, a condition where the pressure in the abdomen had increased to a drastic level requiring decompression. Such high pressures would lead to a decreased urine output, strain on the heart and further strain on her already weakened lungs. She would require an emergency procedure to drain the fluid from her abdomen and release the pressure. There were two options available to us, one was to insert an abdominal drain under the guidance of an ultrasound and the other was to make an incision in her abdomen to release the fluid and cover the open abdomen with a bag. Either procedure would increase her morbidity, let alone run the risk of killing her due to the accompanying fall in blood pressure. Any procedural delay would surely lead to her death.

A decision was taken to place a drain under ultrasound guidance. Swati was on four infusions to maintain her blood pressure. Inspite of that, her blood pressure was still suboptimal and her overall condition very poor. Prior to the procedure, the anaesthesiologists pushed drugs and fluids into her blood through the central line to elevate her dropping blood pressure.

The ultrasonologist marked out the site for the drain placement and the procedure was underway. As soon as the abdomen was opened, fluid gushed out and Swati’s blood pressure, which had held its own so far, dropped again. The drain was fixed and a dressing was applied, while the physicians and intensivists worked hard to revive her falling blood pressure. Eventually, her blood pressure stabilised and we moved out of the MICU to look at how our boy was doing.

There wasn’t a blemish on Nilesh’s reports so far. The neurologists were stumped. A Spinal tap was planned for to rule out any further causes, following which he would be subjected to a Video EEG (electro-encephalogram), a procedure to study the brain waves and co-relate with the patients behaviour. Using all the requisite precautions, the spinal tap (lumbar puncture) was done, following which Nilesh was shifted for the Video EEG.

As soon as Nilesh was shifted for the EEG, we went back to see Swati. Her blood pressure and oxygen saturation had stabilised by then and her drain was draining fluid from her abdomen. However, her urine output was still low and the abdomen still distended. The intra-abdominal pressure was still in the higher twenties, indicating that inspite of draining the fluid, she still suffered from an abdominal compartment syndrome. Her bowel wall was swelling up leading to this eventuality, one which we could do very little about. Our work with Swati was done. All we could offer her now were our prayers. The intesivists had worked up a list of residents on call at her bedside, through the night.

Soon after we saw Swati, Nilesh’s reports came back. The CSF reports and the video EEG were both normal, just like every other test performed on him. His diagnosis had left everyone stumped. Eventually, we settled at a diagnosis of a post-trauma concussion injury and decided to observe him through the night. Even though it was our emergency duty, all our efforts were focussed on the two residents admitted in the two separate ICU’s. We paid Nilesh an hourly visit in the night to monitor his progress and rule out any further complications.

Nilesh was getting better. His consciousness was improving and he started verbalising for the first time, almost 36 hours after his injury, i.e. the morning after emergency day.

However, Swati wasn’t doing so well. Her intra abdominal pressure continued to rise, even though her vital parameters remained stable. She hadn’t passed much urine since the previous night, indicating her kidneys were shutting down. Her pupils weren’t reacting to any light stimulus, indicating some brain damage due to the persistent lack of oxygen. No path had been spared by the intensivists to salvage her. After all, the life of a 25 year old doctor was at stake. By morning, her parents decided to shift her out of the government setup to a private hospital. Swati was shifted to a private setup, managed there till the evening of the same day, when she breathed her last.

Nilesh, on the other hand was showing a slow but steady improvement in his condition, one which offered all of us hope.

Swati was a victim of the apathy of the officials of the public hospital. Breeding sites for mosquitos abound in the hospital campus, which led to the spike in the number of dengue cases. Normally, dengue doesn’t manifest in such severe forms, but for every 100 cases of dengue, one would always present with such complications. Swati was unfortunate to be that one.

A young resident doctor at a premier institute in the country died of a disease, which has been propagated by the sheer negligence of the very patients & their relatives, that this young doctor had selflessly treated. Patients and their relatives spit in the corridors of the hospital, throw garbage on the floor of the hospital leading to development of breeding sites for mosquitos, spread of tuberculosis and various other diseases. The authorities are also apathetic to the breeding sites for mosquitos all over the public hospitals.

A massive clean up drive was initiated in response to the residents death, to identify and fumigate breeding sites in the Girl’s hostel. Albeit laudable, it came a bit too late. It couldn’t save the life of a smiling, full of life Swati who left this world too prematurely. Nor did it cover other breeding sites mushrooming around the hospital. It was an initiative taken to prevent any backlash from Swati’s death. Hence, the very purpose was defeated.

Nilesh, on the other hand was a classical example of a medical mystery. A case where all investigations were normal and the clinicians eventually have to rely on the age-old and time tested diagnostic techniques to draw up a final conclusion. He was a possible fall out of the high stress levels involved during the course of residency. Some can cope with it, others can’t. But the unnecessary stress created in the working environment is entirely avoidable. Nilesh is en route to a complete recovery.

Doctors treat patients, but who treats the doctors? The rising incidence of sickness amongst doctors should ring alarm bells amongst the people in power. But does anyone care? How can one explain the lack of a basic standard of living for doctors-in-training? How can one explain the poor quality of food available in the canteens for the doctors? How can one explain the fact that the very government which yearns to formulate policies for affordable healthcare for the poor, has no policies in place to safeguard the health of the same people who look after the sick! God save the doctors! And if there aren’t too many left, God save the patients!

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