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..

 

 

Shocking Saturday!

clostridium

It was spreading, his leg had become black above his knee too. A decision was in order. It wasn’t going to be an easy one. Operate right away and the Operation room (OR) would be unusable for 6 hours (for cleaning and fumigation-an essential process after operating on patients with transmissible infections such as HIV, Hepatitis B, Gas gangrene), risking a delay in treatment of all the wait-listed patients. Delay it and the patient would lose his life, let alone his limb. Being the junior most person in the unit, I just stood there, while the seniors discussed the options, slipping in a profanity here and there (not uncommon with surgeons) with voices loud enough to awaken all the patients on the floor from their deep slumber. It was after all midnight.

A decision was made. The patient was to be operated urgently. Saving a life took precedence over anything else.

The patient had Gas Gangrene. A wound over both his legs a few days back, coupled with inadequate care, both by the patient himself and the primary physician, led to this condition. The wound was infected with deadly organisms, which released toxins, causing rapidly spreading death of the muscles and the skin. The infection would continue to spread, unless his limbs were amputated.

A few hours back, Mr. Dattatray had come to the emergency ward, walking, on an otherwise uneventful Saturday evening, with complaints of mild discomfort in both his legs. He complained of a wound over both his legs, a consequence of overzealous farming 4 days ago. Within hours, his leg was turning black, with a sickly sweet door, an unmistakably characteristic feature of Gas Gangrene.

My job was to prepare the patient for surgery, to make sure he had a urinary catheter inserted before entering the OR, he was hydrated well and that the hair was shaved off (important part of every surgery). The patient was to receive anti-gas gangrene serum, which was essentially a cocktail of antibodies obtained from horse’s blood after injecting them with the causative toxins. The cost was immense (40,000 ) and beyond the means of his family. The serum would at least give him a fighting chance. Without the serum he’d die.

As with all public hospitals, KEM hospital too had provisions for concessions for poor patients, provided they’d give proof of the same, in the form of a ration card. The procedure was tedious. The first step was to fill out a form in the book provided to each unit with a signature of the junior most and senior most person on call. This was the easiest part. It then required the relatives of the patients to run across the breadth of the hospital to obtain signatures of 4 other administrative officials, who more often than not, couldn’t be found. Eventually, it took at least four hours for the relatives to come back with the required medicines.

We didn’t have the luxury of time. As doctors, we wouldn’t get involved in administrative hassles, letting them take their own course. But this was different. A matter of life and death. No sooner did the relatives return with the concession book empty handed (they’d been asked to try again the coming morning), did I dart towards the Casualty Medical Officer and in a arrogant, semi-aggressive manner asked her to sanction the concession for the Serum.

In my short time thus far at this hospital, I had come to realize that when patience and tolerance weren’t helpful, a sound clinical argument and aggression most definitely were. Raising my voice to prove my point wasn’t necessarily the best way of going about things, but it produced the desired results.

“Madam, why don’t you understand!! This patient will not live to see tomorrow morning if you don’t sanction this Serum right away,” I said, raising my voice, realizing that all heads turned in our direction. Adding that touch of drama helped. The Medical Officer, who clearly didn’t expect a junior resident to argue in such a manner was stunned. “I…. I’ll see what I can do,” she said. She dialed a couple of numbers, spoke to what seemed to be people higher up in the administrative hierarchy and finally relented. The importance of administering the serum before the surgery could be comprehended only by the operating surgeons.

Finally, the patient was ready, 4 hours after first arriving in the emergency ward and 2 hours after developing the gangrenous changes. The extent of surgery was to be decided in the OR. I shifted the patient into the OR, which lay adjacent to the emergency ward and was sent back to deal with the remaining patients.

That was the last I saw of Dattatray till 8 am the coming morning. “Last night’s Gas Gangrene patient has been shifted to SICU in an isolated room. Go and see him first,” Shrikant, my registrar told me hurriedly, while I was preparing to go to the ward to round the patients.

After exchanging customary greetings with the nursing staff and ward boys, on entering the ICU, I went towards the isolation room. I entered to see him, as expected, on ventilatory support and in deep sleep. I started with my rounds, examining him for any signs of dehydration, checking his vital parameters and ventilator settings. I sent his blood investigations and finally removed the bed sheet to check on his dressing. I was shocked.

The dressings were soaked with blood. The smell was unbearable for anyone without any experience in this hospital, but that wasn’t the reason for my shock.

Both his legs had been amputated. Yes, it was as expected, but a little more. Both his legs had been disarticulated from his hip joint, a procedure we commonly refer to as hind quarter amputation. All that was left of him was his upper body, i.e his head, neck, chest, abdomen and upper limbs. He had no lower limbs, not even a small trace. I was speechless.

My immediate senior, Sonal and I toiled everyday to dress him, our fixed time being 2 am, a time convenient not only for us, but also the patient as the sedation given to him would put him out for the night.

3 days post-op, the patient developed fever and his lower abdomen turned blackish-blue. The gangrene was spreading. He would need another surgery to remove the skin and soft tissues over the abdominal wall. And operate we did, leaving his abdomen exposed to the atmosphere, a catastrophe our unit chief, Dr. Gandhi had planned for in advance. An absorbable mesh was placed over his abdominal contents to prevent his intestines from coming into direct contact with the atmosphere with a light weight dressing placed on top of the mesh.

This was the epitome of suffering and all the available means to alleviate his suffering were attempted. None seemed to work. His ventilation tube (oral tube) was changed to a tracheotomy tube (by making a hole in the neck- a more permanent alternative) as time passed by. His dressings became more tedious, often taking us over an hour to complete. However, all this while, his close kin stood by him, providing the invaluable tender loving care, no doctor could provide.

Mr. Dattatray had a daughter, Prerna (Sanskrit for inspiration), a pretty 10 year old, who was adamant on meeting her father. During a routine counseling session with the family, his wife requested me to arrange for permission for her daughter to visit. As per hospital regulations, children younger than 14 years weren’t allowed to enter the wards, ICU’s and OR’s. However, no regulation was stringent enough for us residents to get around.

The little girl was whisked into the small isolation room, away from the prying eyes of the nurses and ward boys on a lazy Sunday afternoon. She’d almost let her emotions get the better of her, but somehow kept them under control. Dattatray, who up until now was generally unresponsive and inattentive, noticed her presence. He made an effort to sit up and patted her head. A writing pad lay nearby and Dattatray signaled for a pencil/pen. The first written words were the marathi equivalent of ‘I Love you’. Prerna picked up the writing pad, kissed it, held Dattatray’s hand and sat there for close to two hours. We held fort for the entire duration.

The weeks passed by and Dattatray was actually improving. His daughter had ‘inspired’ a miraculous recovery. He was being weaned off the ventilator and his wound, irrespective of its size had shown some signs of healing. Our efforts were paying off. He started conversing with his relatives and the doctors using a writing pad and a pencil, often expressing an intense desire to go home to his family. Notwithstanding this, his chances of survival were slim.

3 weeks after his surgeries, Dattatray was off the ventilator and was able to converse through written words and gestures(his voice impeded because of the tracheotomy tube). However, the condition was a morbid one and the improvement only transient.

Four weeks post-op, he suffered a sudden massive heart attack. Dattatray had slipped into a coma and was placed on ventilatory support again. To bring him back seemed almost impossible. A week and two more cardiac arrest’s later, Dattatray finally passed away.

It was the saddest day of my residency. Here was a 30 year old farmer, with a simple wound, which if managed better may not have led to such disastrous consequences. It wasn’t his fault. The primary medical care given in this country is at times farcical. Quacks abound in the rural areas, using their inadequate knowledge and age old practices to do more harm than good. This makes the job of tertiary care institutions a lot more difficult.

A simple wound lavage with application of an ordinary not-so-expensive antiseptic solution would have prevented this complication. A complication, that resulted in the death of an otherwise healthy 30 year old. If only the primary physician had the requisite competence…..