The Defiant Destitute- I

    pancreas-and-kidneys

Photo Credit: ADAM

No Surgical resident wants to admit a destitute in their unit. Admitting a destitute in the unit implies that he will be taken care of by the residents of the unit, not only medically, but even otherwise. Its the job of the resident to arrange for clothes, food and accommodation after discharge

I hadn’t admitted too many destitute’s in the units I’d worked in. But Ganesh was an exception!

Wheeled into the emergency ward with an accident on the roads nearby, Ganesh on primary inspection seemed to be, primarily an orthopedic case. His right limb was almost split into two parts by the impact of the accident. Fortunately he wasn’t bleeding as much.

A quick secondary survey revealed some bruises on his abdomen, a tell-tale sign of a blunt injury to the abdomen. Under the influence of alcohol, his partially conscious state made it impossible to extract any details of the accident. Ganesh would have to be cleared from the surgical end before he landed in the orthopedic OR. A CT scan was arranged for Ganesh, while his limb was immobilized and the routine blood work was done.

All the resources are stretched to the maximum when any trauma patient is admitted to the emergency ward. A destitute trauma patient would impose the maximal strain. There were no relatives, friends or policemen, just the doctors, nurses and ward boys.

A quick review of the CT images revealed nothing of great significance in the brain or the abdomen. Ganesh was cleared for a transfer to the orthopedic ward.

As an exercise to test their skills, the senior registrars in the unit reviewed the CT images. Taking a closer look and getting an unbiased opinion always helped. The review of the images revealed a fracture at the tail of the pancreas, an organ sitting in the abdomen just behind the stomach and responsible for regulating the sugar levels in the body and digesting proteins in the gut. A duct (just like a plumbing pipeline) runs through the organ, dispensing the digestive juices into the gut. Fractures of the pancreas disrupt the duct and cause the juices to leak into the surrounding space. These juices are highly active and can digest the proteins in the normal tissue as well, hence causing inflammation and destruction of the surrounding structures, including the stomach and the colon. The spleen is closely related to the tail of the pancreas and in a fraction of patients, the tail is embedded in the spleen.

These findings led to a knee jerk reaction and Ganesh was transferred back to the surgical side.

Ganesh’s problem was picked up relatively early and operating him to remove the fractured part and oversew the duct would probably save him from the consequences of a damaged pancreas. Ganesh was planned for a ‘Spleen preserving Distal Pancreatectomy’, a prolonged and complicated procedure in the emergency setting and was shifted to the operating room.

On opening his abdomen, we realized that we had gone in relatively early. There was minimal inflammation with a very minor leak. However, on inspecting the pancreas it was badly fractured, with the duct completely transected, as predicted on the CT images. The procedure was underway in the operating room, while another procedure was going on in the adjoining room. I was assisting the Assistant Professor, who was performing the surgery. While dissecting the pancreas for a resection, the team on the other table ran into some difficulties. The Assistant Professor had to scrub in for that surgery and permitted me to carry on with the procedure.

Ganesh was a part of the unfortunate fraction, who had the pancreatic tail embedded in the spleen, which made it mandatory for us to remove the spleen. The inability to preserve the spleen actually made the surgery a little easier and faster. After completing the procedure and placing a drainage tube close to the pancreas, the orthopedic team fixed his fractured leg with an external fixator.

Ganesh was shifted to the surgical ICU after the procedure on ventilatory support. Two days after the procedure, he had made a remarkable recovery and was removed from the ventilatory support. Three days after that, Ganesh was shifted to the ward.

This remarkable recovery surprised us, as did the arrival of his mother and two wives, the day after he was operated. Ganesh wasn’t a destitute after all. No doubt that his family reeled in poverty, but he did have a family, albeit a very dysfunctional one.

His mother came in drunk every morning and would pick up a fight with everyone. His two wives publicly quarreled to assert their rights over him. Ganesh, who had been an alcoholic, progressed to a state of alcohol withdrawal. Disoriented and confused, he added to the drama created by his family in the hospital. Ganesh, his mother and his two wives made a living out of selling flowers form a roadside stall. The money generated form sales was used to fund their addiction to cheap country-made liquor and tobacco. How he had managed to shelter two wives in the same house was beyond me. But it didn’t matter. We just wanted him to get better and move out of the wards.

On one such Sunday, immediately after my morning rounds, I was paged by the nurses in the ward. Ganesh’s mother in one of her drunken stupors, had fed his son some food lying by his bedside. Ganesh, who was still in a state of alcohol withdrawal was unable to swallow the food and aspirated the food particles in the respiratory tract.

There was an immediate response to the food particles stuck in the respiratory tract. Ganesh became breathless and blue and vomited large quantities of gastric secretions. Our worst nightmare had just been realized….

 

To  be continued…………..

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