An Incurable Disease?

pancreas-and-kidneys

Surender wasn’t the typical patient suffering from cancer. A healthy north Indian male with a voracious appetite and a waist circumference substantiating it, he depicted no signs and symptoms of the ‘crab’ growing inside his pancreas. His only complaint was an unbearable desire to itch.

Physical examination revealed a deep yellowing of his eyes. This coupled with the unbearable itch convinced us to admit him to the wards, to investigate the cause further. Not only were his eyes yellow, but his skin also wore a golden tinge, the color of pusillanimity and inadvertent cowardice. The culprit being that tumor, inconspicuously growing in the seat of the endocrine system (a system which produces and distributes hormones to the body), the pancreas, an organ hidden away in the upper abdominal cavity behind the stomach and intestines, beneath the liver and in close proximity to the spleen. So complex is the location of this organ, that any surgical therapy requires removal of not only the tumor mass, but even parts of the intestines, the stomach and the tract carrying juices from the liver to the intestines (billiary tract).

So abysmal is the survival rate amongst patients with such a tumor, that some ‘humane’ surgeons even go to the extent of leaving patients to their fate. The aggressive nature of the tumor coupled with an equally bellicose surgery reduces the chances of survival.

Falling amongst the healthier cohort of cancer patients, Surender demonstrated a strong resolve to take on the challenge. His work-up for surgery was effortless, and within a week Surender lay on the operating table in the OR.

“Doctor, come what may, please do not prolong my misery if things don’t go well. But leave no stone unturned to make things go well,” Surender told us just before he went ‘under’ (a colloquially used term amongst anesthetists to describe a patient who has been anesthetized)

The surgery commenced as the clock in the OR struck ten. Bit by bit, the insignificant organs were reflected carefully so as to reach the organ of interest. So deep and conspicuous is the pancreas, that exposing the organ alone takes up a significant amount of time during surgery.

The duodenum (part of the intestines running from the stomach to the small bowel) was mobilized around the pancreas and cut out right from the stomach to the upper part of the small intestines, the bile duct entering the pancreas from the liver was dissected and cut open and finally the pancreas was transected, removing the culprit.This was the easy part. Cutting things out took little skill and precision, the real challenge lay ahead. The small bowel was meticulously juxtaposed against the stomach, the cut end of the bile duct and the cut end of the pancreas.

Using all the skill garnered over the uncompromising years training as a surgeon, the lead surgeon skillfully sewed the small bowel to the cut ends to maintain continuity in the digestive system.

Notwithstanding the skill required and the mammoth proportion of this surgery, the survival rates after surgery were also abysmal. But, human beings are hopeful creatures. They repose faith in even the remotest of chances working out for them.

Surender woke up to the sound of his wife reciting the Gita as she ensconced herself onto a  small chair that lay beside his ICU bed. The recovery was quick and painless.

Surender bid adieu to us ten days after surgery.

2 weeks after an uneventful and unforeseen recovery, Surender reported to us again, complaining of a foul smelling discharge from the operative wound. Concerned and anxious, we whisked him off to the radiology suite and performed a plethora of imaging tests. None were conclusive. Baffled at this idiosyncratic development, he was admitted to the wards once again to monitor his progress.

Copious amounts of discharge warranted us to innovate a different method of dressing to prevent his clothes from soiling. The wound was surrounded by an adhesive paste sprinkled with granules of activated charcoal, with a bag placed over the adhesive to collect the fluid. The bag drained the fluid and the charcoal adsorbed the gases responsible for the foul smell.

Four weeks passed by and the amount of discharge hadn’t decreased. It was by then established that a tract had formed from the pancreas to the skin and the pancreatic juices found an alternate escape route. However, our team wasn’t convinced.

On a whim, a week later, the senior resident decided to open up the wound to explore the problem further.

“The smell,” he said, “isn’t that of pancreatic juices.”

Relying solely on his keen sense of smell, we took the patient into the operating room again. The wound, which had mostly healed by now at all places barring the discharging portion, was injected with a local anesthetic and incised.

A horrific smell engulfed the operating room, strong enough to weaken even the strong hearted. There lay the culprit. The fat in the subcutaneous space had liquified and formed a roundish structure, no larger than the size of a fist. Pus emanated from the structure and was well contained by the thick walls formed around it. This surprised us. The initial CAT scans didn’t reveal the abscess, and it continued to grow in size.

For every major surgery, surgeons always expect major complications, sometimes ignoring the smallest ones. Look no deeper, if you haven’t looked superficially.

There was an immediate improvement. Surender was sanitized of all the bacteria breeding in his wound and was soon discharged to go home. The real challenge was his subsequent survival. Such patients usually survived for no longer than a year post surgery.

Chemotherapy was given to Surender, as a part of his treatment course, taking care of not only the tumor site, but also the small fragments that tried to enter the bloodstream and seed themselves elsewhere.

6 months later, Surender was actually gaining weight and showed no signs of spread of the tumor to other parts of the body. He was eating well, exercised daily and even went for long trips to the Himalayas.

“I feel better now than I have ever felt,” Surender said.

We still warned him that a sudden deterioration would not be wholly unexpected. Surender brushed us off, saying, “If I live with the fear of dying everyday, I will not live life the way I should. Don’t worry doc, I still have plenty of time.”

His optimism was encouraging, but we all knew that the end would come. Sooner rather than later. What were the odds of him beating the odds!

Surender went incognito after that day. It was assumed that the worst had befallen him. That the disease won the battle. Cancer had once again reigned supreme and brought a premature end to a jolly good life.

Our myth was shattered three years later when Surender re-emerged. He had taken a trip to his hometown and went on to reside there uneventfully for the three years that we hadn’t seen him. It didn’t seem like a tumor had once swallowed a part of his pancreas. That he had undergone a surgery so mutilating and challenging, that people often succumbed to complications arising from surgery before cancer stepped in.

A momentous occasion to celebrate survival of a patient with a tumor in the pancreas, a tumor so indolent and debilitating that sufferers actually welcomed death when it came to their doorstep.

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When the going gets tough… (III)

The night before Jeenal was to follow up with the unit head, she presented to the casualty with weakness and pain in her belly. She had been running a fever throughout the day and felt uneasy and giddy. Her mother called the unit head, who advised her to come over to the hospital as soon as possible.

Before she could reach the emergency surgical ward, Jeenal had collapsed. She was unconscious, her fever now transmogrified into an eerie coldness, a sure shot sign of a drop in blood pressure. Her pulse rate had slowed down and acquired a feeble quality. Sweat had started dripping off her brows and forehead, a cold sweat, one that made every attending doctor nervous.

Jeenal took laborious breaths, and with every passing moment, it became obvious that she required artificial ventilation.

Even though the on-call unit wasn’t the same as the one that had treated Jeenal, they still knew how special this patient was.

Jeenals blood pressure was unrecordable, her heart rate had slowed down dangerously, and she had become incapable of breathing independently. The ABCD approach (A-airway, B-breathing, C-circulation, D-differential diagnosis or disability assessment) mandated an endotracheal tube to be placed in-situ (a tube that entered the airway through the mouth and provided air directly to the respiratory tract), followed by artificial ventilation with an AMBU (ambulatory mobile breathing unit), and eventually the placement of an access line into the neck veins, in order to infuse fluids and drugs to maintain the circulatory system.

 

After initial stabilization, Jeenal was shifted to the SICU (surgical intensive care unit) and placed on ventilatory support.

She was in a state of septic shock, a condition wherein the infecting organisms released proteins into the circulation to activate various immune defense mechanisms, which when over activated, can cause more harm than good.

It was strongly suspected that the anastomosis performed during surgery had given way. The sutures that held the tissues together had fallen apart and caused all the organisms within the gut to spill out into the abdominal cavity. The only option left for Jeenal was another surgery.

The sutures had indeed given way, as could be seen during surgery and her entire abdominal cavity was filled with the toxic substance, bile, an agent so corrosive that it could cause even the skin to break down when applied over it.

A through washout of the abdominal cavity was performed along with a restructuring of the failed anastomoses. Even though the procedure had been performed fairly quickly, Jeenal continued to remain unresponsive and passive.

 

I saw Jeenal in the SICU the following morning. Her hair had been oiled and tied back, her eyes were padded with moist gauze to prevent excoriations on the exposed parts, a tube stuck out of her mouth and connected to a large machine which beeped constantly, the ventilator.

The smile that adorned her face, when she was leaving to go home, lingered on in my memory. But, all I could see now, were a pair of dried lips with crusts on them. Her face was expressionless, and her hands tied to the railings along the side to prevent her from pulling out the tubes, but it seemed unnecessary. This was the one time that I hoped for one of her tantrums or an angry outbursts, but none was forthcoming.

Her mother came and hugged me. She was inconsolable. She cursed their poor luck and herself, for giving in to Jeenals demand to go home earlier than the doctors would’ve liked.

I spent the day moving in and out of the SICU, running personal errands for Jeenals family and hanging around to support them.

Jeenal life support system was the only thing that kept her going. There were four infusion pumps, six stands to hold the intravenous fluids and drugs and a colossal ventilator that surrounded her. Above her lay the pulse oximeter and electrocardiographic monitor sending out multiple channels which lay haphazardly over her chest.

At 9:40 pm that evening, two days after Jeenal had turned twenty, her heart, which was being flogged like a tired horse, gave up. The monitors showed us a flat line and she had stopped breathing. Dr. P and I were both present there at the time, and tried everything we could to revive her. But it was all in vain.

Jeenal had passed away.

Her mother and brother were heartbroken and Dr. P was gallant enough to offer them support.

A terrible gloom fell over the unit and the surgical wards after Jeenal passed away. Such was her presence, such was her power to liven up a conversation, such was her grit, to go through it all before she even turned twenty.

 

Could we blame her luck, her stubborn nature, the surgeons expertise (which was never in doubt), or just fate!

A surgeons knife is a powerful tool. Not only can it heal and cure, but it can also complicate and kill. The cure rates are always higher than the rate of complications. But, that single complication can prove to be fatal.

 

Some patients just disappear after treatment and are forgotten, some valiantly escape death and immortalize themselves in the hospital folklore, but a minority group of patients continue to linger on in your memory even years after they move on.

They aren’t the strongest, bravest and haven’t necessarily escaped death. These patients may have given you a terrible time whilst under your care, but they’re the ones who stand up and truly take it in their stride, when the going gets tough!

 

(The End)

When the going gets tough… (II)

A month later:

The head of unit made a quiet exit as soon as the out-patients queue receded. The residents were entertaining some medical representatives from the pharmaceutical industry, a task that they had to endure, no matter how much they disliked it.

Patients and their relatives were being herded out of the out-patient department like cattle in a farm. Thats how patients were treated in government hospitals, unfortunately. They were literally the ‘cattle class’, a term colloquially used for travelers in the economy class of airlines. Whereas the airline travelers had the means to pay for an airline ticket, the class of people in the government hospitals were truly penurious.

Whilst the commotion occurred outside, we sat within our chambers, entertaining information about drugs from these representatives. In the midst of it entered a frail girl, looking middle aged, with a hunched back and a solemn look. She walked in alone with a hand over her belly and a natural fish-face, owing to the loss of her buccal fat (fat over the cheeks). Her hair was shaggy and her eyes sunken in. She took a seat in the chamber and waited. Puzzled, Dr. P and I immediately left our seats to tend to her.

Just a few minutes later, her mother and brother entered our chamber. It was Jeenal. A month had passed by, and Jeenal hadn’t followed up. We presumed she was feeding well and wouldn’t need the follow ups. However, that was clearly not the case.

Unrecognizable from her past form, Jeenal had stopped feeding from the jejunostomy tube. On prodding her, we realized that the tube had been blocked since a week and she hadn’t bothered to come in. Jeenal had been starving for an entire week and ignored it.

Without giving it a second thought, we immediately admitted her to the ward. Unblocking the tube was an easy task, but making up for the malnourishment due stoppage of feeds was the biggest challenge. Overload her with nutrients and she wouldn’t tolerate it, underload her, and we risked causing further malnutrition.

To control her nutrient intake, we started Jeenal on parenteral nutritional supplementation (injection of nutrients through the veins, directly into the vascular system). The feeds through the jejunostomy tube were started simultaneously.

Our worry lines increased, and all of us in the unit put in extra hours to ensure Jeenal’s nutritional status would improve.

Two weeks later, Jeenal had gained sufficient weight to allay all our fears. Her jejunostomy tube was functioning well and the parenteral nutrition had ceased. It was time to discharge Jeenal again. However, this discharge came with a promise to follow up weekly.

Jeenal followed up diligently over the course of the next four months. A month before Jeenal was to undergo a definitive procedure, I moved to another unit in the same ward.

 

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I saw Jeenal in the ward, on the day before she was to undergo a definitive surgery. Her esophageal (food pipe) scars had healed, leaving behind a scarring of the outlet pathway of the stomach. She would be subjected to a commonly performed procedure, gastro-jejunostomy, wherein a part of her small intestine would be connected to her stomach, to bypass the narrowing at the outlet of the stomach due to scar formation.

Jeenal seemed happy and calm. There was a palpable excitement in her voice, when I mentioned that she would finally be able to eat through her mouth.

Jeenal’s mother had gone to the Gurudwara (temple) to pray for her well being. Her brother was alongside her, holding a polythene bag housing all the surgical materials (that wasn’t available at the hospital), required for the forthcoming procedure. Dr. P, who by now had been relieved of all his duties, to prepare for the forthcoming exams, strolled in at the same time.

“Jeenal!” he exclaimed. “Everything’s going to be alright. Boss is an excellent surgeon and he’s planned everything in detail.”

Jeenal smiled. Her brother clutched her hand, whilst holding on to the same polythene bag.

Dr. P politely enquired about the contents of the polythene bag, glanced at the prescription for the surgery and winced.

“How could anyone prescribe all this material worth thousands of rupees to this family? Haven’t they spent enough on her treatment already,” Dr. P mumbled to me in an tone that was inaudible to Jeenal and her brother.

 

Dr. P promptly called the chief resident to make arrangements for the surgical material. Jeenals brother was instructed to return all the material and retrieve the money that had been spent.

Jeenal was moved to tears. She’d repeatedly mentioned to us of the financial burden facing her family, due to her illness. Dr. P had the maturity to understand the sacrifice of her family and waive off the charge of surgical materials.

“I hope the both of you will be in the operating room while I’m being operated upon. I trust you two the most!” Jeenal pleaded.

Unfortunately, neither of us could be in the operating room while she was being operated. However, we did step into the ward to wish her luck, just prior to her being taken into the OT for surgery.

Jeenal had become a part of Dr. P’s and my residency. The three of them were our family in that hospital, a place where every doctor is treated in a ruthless and relentless manner. Jeenal and her family understood our travails and helped us out at every step along the way, while she was in the hospital. Be it carrying our instruments around while we rounded patients, or packing some food for us, when we were on emergency duty, with a seemingly never ending ingress of patients.

 

Jeenal was operated upon, laparoscopically (minimally invasive), as she was concerned about the scars that it would leave behind on her abdomen.

A fugacious stay in the Surgical Intensive Care Unit (SICU), was followed by a transfer to the general ward.

The clishmaclaver of the ward patients, a point of annoyance in the past, suddenly felt like music to her ears.

Two days after surgery, all the invasive tubes had been removed and Jeenal was walking around the ward and even sipped on water. The eudemonic pleasure of taking something (read:anything) orally was unparalleled.

Jeenal insisted on a discharge before her birthday, which happened to fall on the sixth post-operative day. However, on the fifth day post-surgery, Jeenal developed a fever, albeit a mild one. One that disappeared after its first appearance, flattering to deceive.

Inspite of the fever she had developed, Jeenal insisted on going home the next day, to celebrate her birthday. The crest of her tantrums forced everyone in the unit to bow down to her demands, and Jeenal was discharged on the sixth day post-surgery, without a hint of fever, albeit reluctantly. She was strictly instructed to follow up 2 days after discharge, in the ward, with the unit head.

The morning of her discharge, Jeenal had dressed up and ordered cake. She cut the cake in the presence of the nurses, her mother, Dr. P and myself. Her brother had planned an elaborate birthday party for her at home.

Jeenal’s gambol knew no bounds. This was her happiest moment since that fatal day seven months ago, when she’d ingested the corrosive poison.

She waved at us as she left the ward. But, something told me that this wasn’t the last time we’d see her as a patient!

 

(to be continued…)

When the going gets tough… (I)

The out-patient department was busy as ever. The senior resident (Dr. P) was seeing patients by the dozen, his hands were constantly moving and so was his mouth. His pen left the warmth of his hand only at such times as would be absolutely essential. This was a daily occurrence for the doctors at the bustling government hospital, which managed far more patients on a daily basis, than it was  equipped to handle.

Wiggling his way past the scores of patients, a ward boy from the medicine ward managed to find his way into the chamber of the senior resident. I happened to be sitting alongside, observing, helping and occasionally writing down a few prescriptions. Seated firmly in his grip, so that it couldn’t fall while navigating the mad rush, was a book, no bigger than the size of his palm, but as thick as the vintage spectacle frame that adorned his face. This book was unkempt, looked ugly and showed off signs of wear and tear.

Inscribed, on one of the worn out, discolored pages of the book was a statement.

To,

The Surgical Registrar on call,

Kindly call over to assess patient Jeenal, a 23 year old female with a history of accidental corrosive acid ingestion. The patient has undergone endoscopy and the gastroenterologists have advised a surgical reference.

It isn’t everyday that one got to manage a case of corrosive acid poisoning.  There was a spark in Dr. P’s eyes. Without even giving it another thought, he wrote back,

Kindly transfer the patient to Ward 8 by 6 pm today. A bed will be made available accordingly.

The archaic world of exchanging written notes, to call doctors over for a reference, still prevails in government hospitals. The Internet of things finds it almost impossible to percolate into these settings.

 

I met Jeenal for the first time on my evening rounds. A pretty girl with a charming smile, it didn’t seem like she belonged there. She sat silently, cross-legged on the bed, alone. A naso-jejunal tube (a tube that was placed through her nose and passed through the stomach into the intestines) was stitched onto her nose, and, as if that wasn’t enough, an unaesthetic adhesive tape reinforced its position there.

It was evident that the tube bothered her. She fiddled around with it and tried to conceal it from everyones view, albeit unsuccessfully. She was noticeably uncomfortable around the patients in the ward and looked unsettled. As I went around the ward surveying the patients admitted under our care, Jeenal called out to me,

“Doctor, are you in charge here?”

“Yes”

“Good. Please come here and remove this menace from my nose. It hurts me and I look so damn ugly.” She spoke impeccable english, which was surprising for patients seeking healthcare in the government setup.

I walked over and took a look at her file.

A h/o (history of) corrosive acid poisoning (accidental). Endoscopy has been performed and revealed mucosal injury to the esophagus and parts of the stomach. Naso-jejunal tube has been placed during endoscopy to provide nutrition.

Strictly, NPO (nil per orally, i.e nothing to be taken orally)

There was no way I could remove that tube from her nose, even though I empathized with her, having undergone a naso-gastric intubation myself at some point in my life.

“Sorry Jeenal, I will not be able to remove this tube. Its very important that it stays in, so that you can take some food through it. The acid that you ingested has scarred your food pipe and stomach.”

That was all I could offer her at that time, being the junior most resident in the unit.

She was visibly miffed and turned her face away, ignoring my presence and failing to acknowledge the ensuing questions. As if on cue, her caretakers walked in just then.

A mother and a brother, were her only family in the city. They were as jocular, as Jeenal was gloomy. They offered to answer my questions, even offered me a seat (which was very unusual) and at the end of the history taking and examination, struck a conversation with me completely unrelated to work.

The accidental ingestion of the acid was dubious and uncertain. No one had seen her drinking the acid. Her version was that it looked like a soft drink. There was no reason to disbelieve her.

Other than a very recent development. As we spoke, her brother volunteered that she had been involved in an affair gone bad, recently. It was possible that there was some intent behind her action.

 

Jeenal was all of 19. She threw tantrums, had mood swings and even craved for chocolate, just like any other 19 year old girl. Her friends had been given strict instructions not to visit her, as she wouldn’t want to be the butt of all jokes. Especially, after an insensitive friend labelled her as an anorexic version of Lord Ganesha (due to the naso-jejunal tube that extended outwards from her nose, à la the elephant trunk of Ganesha).

The aiguille of her tantrums occurred on the unit head’s rounds a few days later, when she pulled the tube out of her nose. Dr. P and I were flabbergasted, expecting a barrage of angry comments from the unit head.

Instead, he allowed her to play the role of a thespian to perfection. He had a plan in mind.

When he reached her, she was crying, her nose had a reddish hue in lieu of spilled blood and her mother was trying to restrain her. Dr. P and I immediately rushed over to take care of the bleeding and calm her down.

“Leave her alone,” the unit head said.

“Jeenal, we shan’t put that thing in your nose again. But, we need to feed you to keep you healthy. How about we perform a small surgery to put the tube directly into your intestines (a feeding jejunostomy).

You can easily conceal the tube then. In time we shall discharge you and call you back once you’re ready for the final surgery.”

A faint smile engulfed her face. The liberty of living life on her own terms outside the hospital was enticing. Details were explained and a plan was drawn out to operate on her a couple of days later.

The decision to operate eased the pressure on us. While she still remained demanding and continued throwing her tantrums, she showed us what she was like in reality.

Dr. P and I spent a chunk of our time on rounds with Jeenal and her mother. Her brother showed up too, but sparingly, as he was working, to bear the expenses of treatment.

Jeenal and her mother felt comforted in our presence, and we in turn learnt something new about Jeenal everyday. She was a singer, a dancer, and an excellent student, who had to give up her pursuit of higher education after her fathers death, to care for her mother and younger brother.

The transformation, after the tube had been removed from her nose, was astounding. We saw a self confident girl, who was ready to fight everything that came her way.

The time before her surgery, established our relationship not only as a doctor-patient, but as friends.

Jeenal was eventually operated upon, a tube was placed in her intestines and test feeds were started the same evening. She insisted on my presence in the operating room, even though I was instructed by the unit head to be elsewhere.

As always, she got her way. And in the process, also happened to be the patient on whom I performed my first feeding jejunostomy surgery.

 

But, this wasn’t the last surgery Jeenal had to endure. The poison had eaten up a part of her stomach, which needed surgery too. But, that had to wait for the healing process to take its natural course.

6 more agonizing months awaited Jeenal, wherein, she wouldn’t take a single morsel of food through her mouth..

 

 

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…………..

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!

A Stitch in time saves Nine- II

DU perf suturing12 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…………..