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… (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 Assault’s (almost!)

Being a doctor in India, or specifically in the institute I was working in, not only required skill, but also strength. Skill to manage the heavy burden of patients unleashed upon you, whilst you’re still the unsuspecting, naive, freshly graduated intern. And strength, to manage the rowdy, almost obstreperous relatives of the poor patients, who couldn’t afford to go anywhere else.  One of the former Deans of the institute famously stated, “When you signed up for your residency program, you have signed up for everything that comes along with it, including being beaten up by angry mobs.”

There have been a number of near misses during my residency years, not only with me, but also my colleagues. However, a couple of these incidents stood out as a memorable ones.

The First Incident:

Rakhi (name changed to protect identity), was a 45 year old sweeper, who came to the hospital with severe abdominal pain and a continuous fever for a couple of days. Suspecting dengue, the medicine resident on call followed the routine pathway and sent her to the medicine ward for an admission. Her drunk husband, Manoj accompanied her that evening.

Two days after she had been admitted, we received a written call for a surgical reference, stating that her abdominal radiographs indicated gas under the diaphragm. Gas under the diaphragm is a commonly used term amongst surgical specialties to indicate a perforated bowel. However, considering her history it seemed implausible.

Clinical examinations and further tests confirmed their suspicion. She needed immediate surgery. Transfer protocols were initiated and the patient was shifted to the Operating Room (OR). It turned out that she was suffering from Typhoid, which caused her small bowel (ileum) to perforate and let loose the feculent matter into her abdominal cavity. It took us three hours and countless lavages to clear out her abdomen and suture the perforated bowel.

Manoj stayed around for most of these proceedings, volunteering to help in any possible manner. However, his countenance changed when he saw us shifting her to the intensive care unit on ventilatory support. Having seen his mother going through surgery and later being treated in the intensive care unit in the same hospital, a few years ago, his hopes of seeing Rakhi recover diminished.

He confronted us after we shifted her to the ICU, letting loose a tirade of profanities, “You ba*****s, what have you done to my wife? She would’ve recovered well without the need of the machine had she not been operated upon. All you doctors are scumbags.”

We were taken aback with this rant and tried to calm him down, explaining that this was just a temporary phase and that she would be off the ventilator in a day or two. He was assured of a reasonably good recovery.

He would have none of it. His ranting and expletives continued, until finally he broke down, sobbing uncontrollably.

Seconds later, he darted towards the exit. He was going to abandon his wife, leaving her at the mercy of the staff in the hospital.

Every resident is responsible for his patients, whether they have relatives or not. And if her husband would run away, the responsibility of her care would be thrust upon us. It wasn’t a particularly pleasing situation to be in. We were already running on a tight schedule. On a good day, we would get close to four hours of sleep, and we’d had a dearth of such good days. We weren’t willing to shoulder the additional burden of a critically ill patient without relatives.

In a split second, my colleague and I decided to give chase. At that point in time, we thought it’d be worth it. In hindsight, maybe not.

With stethoscopes hung around our shoulders and a white coat to differentiate us from the laymen around, we gave chase, running down the crowded corridors of the hospital and across the bridge, connecting the main structure to its sister concern, across the gates and onto the streets. We somehow managed to keep a visual track of Manoj’s route. Seeing two doctors giving chase, the security guards at the gate of the hospital also volunteered. The chasing party soon expanded from a mere two people (my colleague and I) to a formidable size. Amongst the new members were security guards from the hospital, relatives of patients, who were admitted under our care and were loitering around on the streets and some random bystanders who joined in for the fun of it. Neither of them knowing the reason of their indulgence.

For a relatively older man, Manoj seemed extremely fit. It took us a while to catch up with him. Seeing the chase party following him, Manoj tried to speed up. But we were close enough and I grabbed hold of his shirt by then. He freed himself from my grasp and decided to take matters into his own hands.

Turning around with a menacing look, he quickly shifted to his left. A colossal stone was lying on the street and Manoj lifted it over his head with the seasoned expertise, as if he’d hurl it over us and crush us with it.

In hindsight, I wish I’d never chased Manoj down. I wish I’d stayed on, in that wretched intensive care unit and let him escape. But then, hindsight always gives you a very obvious biased view of your quandaries.

A comical scene ensued. The chaser had now reversed roles and was chasing our company with a giant stone lifted over his head. The ten brave men who gave chase so valiantly, dispersed into the mob of surrounding people to escape Manoj’s wrath. That was the last we saw of Manoj, who dropped the stone, as we scattered around and fled with unimaginable pace.

Rekha was now our responsibility and we took care of her reasonably well. She recovered well, barring few minor complications and was discharged into a social welfare setup soon after. Manoj had disappeared and was nowhere to be found.

The Second Incident:

Just a few weeks after the ‘Great Chase’ and being the butt of every joke cracked in the hospital, came another incident. One which was more serious and had dire consequences.

The mornings in the emergency ward were usually very hectic. Partly, because most of the unit doctors would be managing the out patient services and partly because the patients, who came in late for the out patient services, would end up in the emergency ward, seeking a quick fix to their problems. These requests were rampant on almost all days. A strict diktat had been issued to service every patient that turned up for treatment in the emergency wards, causing formation of unmanageable crowds and a lack of dedicated time to the actual emergencies.

The only protection that a doctor had from being assaulted in such circumstances was a security guard (or two, if the doctor on duty was lucky). What would a lone security guard do against a crowd of a hundred people queued up outside the emergency wards?

A company of four men and a woman came to the emergency ward, on one such morning, while I was on duty. Being from the area and speaking the local language, they were surprised to find an on duty doctor who fumbled with the local language. The nurses volunteered that I belonged to a different community. The discord started there.

I had no control whatsoever on the local language, but spoke reasonably well in the national language. After examining the patient and prescribing some injectable medications, I went back to the desk to fill out the requisition forms for the investigations. I simply suspected a urinary tract infection along with a renal stone and advised an ultrasound and a urinalysis (a test to check for bacteria in the urine sample). I doled out all the instruction in the national language, only to be told to repeat them in the regional language (they understood both languages reasonably well).

Not knowing the language was irksome enough for the group. When I told them to get the urinalysis done from a private laboratory (the laboratory in the hospital was for some reason not performing the test at that time), it got them really wound up.

Communalism stems form age old practices and a legacy that has passed down through generations. Being a part of that city and state, I had never experienced a communal attack (verbal or otherwise) thus far. It changed that day.

Some expletives and raised voices asking me to go back to my parent state, were followed by the group throwing the glass bottle (that I had handed over to collect the urine sample), at me. Reflexly, I ducked and the security guard (the single man) shielded me from any further assault. The group was forced to leave the emergency ward, but that wasn’t the last of it.

The local community and the politicians got wind of the incident and lodged several complaints against me, alleging negligent treatment. How could a doctor working at this prestigious government hospital not know how to speak in the local language? How could an ‘outsider’ get admitted to such a reputed medical school, meant only for the locals? How could he order an investigation from a private laboratory outside the premises of the institution?

Questions poured out from almost every direction. Thankfully, I was shielded from most of these questions by the senior surgeons working in the same unit. Every question was answered tactfully and every answer written down and re-scrutinised.

We are all Indians. We are all expected to know the national language, Hindi. The constitution recognizes 18 regional languages, but the actual number far exceeds that. How can one possibly learn every regional language to cater to every community in different parts of the country!

Our constitution also proposes to provide every citizen with basic rights. Isn’t right to education without a bias towards caste, community and religion a part of these fundamental rights.

As for the investigations being ordered from a private laboratory. I wasn’t a part of the administration or the pathology department. If a particular investigation wasn’t being performed and was vital to patient diagnoses, should I have avoided it? Would that be negligent practice?

Eventually, when the answers were presented to the authorities, their case lapsed and normal service resumed.

The final diagnosis of the patient was: Urinary tract infection with a solitary ureteral stone, size 4 mm. I stood vindicated.

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…………..

 

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…..