YES, MASTER!

Have you seen those Kung Fu movies, where an enthusiastic student searches for the ultimate master of a Kung Fu style, so that he can fight the bad guys who’ve wronged him? Learning surgery is exactly like that. The master is often very different from what the student expects. He might be a hard-ass, who makes the student hate him, only till the end, when the student actually realizes how much he has learnt and changed. True masters are rare in surgery. True teachers are rarer.

The face of the surgical unit that I am part of is changing drastically. From the first of January, I will be the only one left in my unit, who was there originally when we started in May. The exit and entry of new teachers made me wonder about how surgery is taught and learnt in our hospitals.

In the beginning it takes a while to just get used to the body that’s deeper than skin. Just holding instruments and internalizing them takes months. Soon, the hand starts to work subconsciously. You look at the problem, and that’s all you look at, for the instruments are just extensions of your fingers.  And that’s when you start to understand the difference between those who teach you.

Some surgeons are fast in their manner. They go through the procedures in surgery like darts. Other’s are slow and meticulous, taking their time with every step of the process. Don’t get the wrong idea here. Both kinds are excellent surgeons. I believe speed is a matter of practice yes, but after a point it’s more a matter of character.

There are standard textbooks of course, but no other branch in medical science provides as much independence and ambiguity as surgery. Once you perform a procedure, it is yours. It is your imprint on that person for the rest of that person’s life. Did you use two sutures or one? Did you give a subcutaneous stitch, a mattress suture or just a simple knot? Did you cauterize the tissue or did you dissect it with the scissors, or even with your fingers? Did you skeletonize the structures? Did you clamp them together? The variations that are possible with every single part of every single procedure seem endless. And the more the masters that teach you, the more the variation, the more the styles.  But just like that, subconsciously and before you can put your finger on it, you have a character of your own.

One of my master’s once asked me when I thought I’d become a surgeon. Would a degree, a Masters in Surgery, make me a surgeon? Or adequate practice in a certain procedure? No matter how many procedures a student learns, there are more that he hasn’t, and there are more ways of doing one than he can learn. I believe, that you call yourself a surgeon when you are comfortable with providing the solution. When you don’t stand limply in front of a suffering patient, when something surgical from your side can save him. Even, if all you can do, is make constant calls for help.

You become a master, when you can do this, calmly, swiftly and precisely.

So here’s to the masters that have taught me, and those that I look forward to. May I prove a worthy disciple, and come out a master in my own right someday.

" SIR, THERE'S A LIVER IN YOUR CHEST ! "

The X-ray in front of my eyes said little about the person to whom it belonged. The lung on the right side looked almost completely collapsed. And still, the patient in front of me, a 48 year old office worker was standing normally, walking, talking, and doing everything a man at his age was expected to do. His only complaint was that that he didn’t take exertion too well. Climbing more than two flights of stairs would cause him to breathe heavily. It didn’t affect his daily work too much, but it had concerned him that his capacity to do the things that were once easy for him to do had started to get so exhausting over the last four years. My boss in the mean time was looking at a C.T. scan of this patient’s chest and abdomen. Handing me the films, he said to the man, “Sir, your liver is in your chest”.

A couple of days later R. N. Singh (name changed to protect identity), was lying on a bed in our ward, while I prepared his file for the elective operation he was about to have the next day. “I was perfectly well four years ago,” he told me, “until I had an accident. I was on my scooter and crashed into a car in front of me which had braked quite suddenly. I had dislocated my left shoulder which I got fixed and other than a mild ache in my lower right chest that lasted about a month, I thought I was fine. But over the course of a few months, I found it harder to catch my breath after straining myself. I just thought I was getting old, but it got worse in the last couple of months, so I thought I’d get myself checked just to get some peace of mind. And now I’m here.”  Mr. Singh had a post-traumatic diaphragmatic hernia.

The chest (called thorax) is separated from our stomach (called abdomen) by a large flat muscle called the diaphragm. The movement of the diaphragm helps us expand our lungs and draw air into our body. Various important structures, like major blood vessels and the food pipe go through this muscle crossing from the thorax to the abdomen or vice versa. In Mr. Singh’s case, the accident that he had, had caused a break in the muscle fibers at the right side of his diaphragm at the back where it attached itself to the posterior part of the rib cage.  His liver, had helped form a block at this opening, plugging it. But due to the continuous expansion and deflation of his lungs, the liver kept getting sucked into his chest albeit very slowly. Gradually, the right lung started to get compressed by the large liver abutting it at the bottom. Since the process went on over four years, his body had undergone some compensatory changes and so had he, in terms of his lifestyle. By the time he came to us, his liver had compressed more than half of his right lung, and was much higher than where it was supposed to be.

The plan for the operation was to take a look at the hole in the diaphragm before opening the abdomen. So we did a diagnostic laparoscopy. We filled the abdomen with air, to help distend it. Then we placed a long scope with a camera into the abdomen through a 1 cm incision just above his belly button. We were surprised to find very little liver actually in the abdomen. The larger part of it had now gone into the chest. Once we confirmed the location of the defect in the diaphragm, we planned our incision accordingly.

Once we entered the abdomen the process seemed simple enough. We thought we’d pull the liver back into the abdomen and close the defect with an artificial mesh. Although the defect was deep, the senior operating surgeon placed a hand around the liver, and was pleased to find that three of his fingers could slide around it, through the defect to its superior part. And then he pulled at it, to bring it down. But it didn’t. He tried to insinuate his fingers at various points around the liver, but no matter how much he yanked it, it wouldn’t budge. The part inside the chest seemed too wide to be able to be pulled back out. But then, how the hell did so much of it get in there?

We had to find out what was causing the problem. We needed eyes inside the chest. The only way  to do this seemed to be to  put a scope through the chest to see the superior part of the liver. But we weren’t prepared for a thoraco-scopy. So we took a different approach. We took the long camera that we had used for the abdomen in the beginning, and we tried insinuating it through the defect in the diaphragm below. It worked. We could see that the liver had actually gotten attached to the lower part of the lung at various places. These adhesions had made it continuous with the lower part of the covering of the lung. The two organs had gotten abnormally stuck together. 

This was tricky. Not only was it dangerous to try to remove the adhesions, we had only a one centimeter  gap to work with. We tried using long thin laparoscopic scissors, graspers and ultrasound based dissectors. And they worked on the outer ends, but we couldn’t even see the deep surface let alone reach it through the space that we worked with. It was time to make a tough decision. Open the chest or enlarge the hole.

Both options were risky.  The post operative complications of either approach could be dangerous. Finally after much debate with consultants lining up on either side, our senior most surgeon decided on increasing the size of the opening in the diaphragm. He let out a prayer, took a scalpel in his hand and made an incision in the diaphragm so that the defect that had caused all the trouble had gotten bigger. 

The laparoscopic instruments now fit through the new opening, and as we began to dissect the adhesions between the liver and the lung covering (pleura), we started to get more and more exposure, so that it became easier to pull down the liver. Soon, the liver was back in its rightful place. The large defect in front of us, now completely exposed had been about twice the size of a man’s fist. We closed it, and placed a mesh right under it, to help prevent it from opening up again under pressure.  We then placed a chest tube into the right chest of the patient to get rid of residual air and debris and then we waited.

We had the patient sedated and on mechanical ventilation for forty eight hours, allowing the radically repaired body to settle down. Then we took out the mechanical tube in his lungs and let him breathe. He was ok. 

Three days later, I found my boss unexpectedly at Mr. Singh’s bedside. This was odd, because he usually informed us when he came for his ward rounds. He had a bright smile on his face. Handing me the fresh X-ray of Mr. Singh’s chest, he told him how lucky he was. The surgical result had been much better than we had expected. In front of my eyes, was the X-ray film showing a completely expanded right lung, which in every way looked absolutely normal. Mr. Singh breathed a sigh of relief. It was a deep, fulfilling breath.

BOMB BLAST BABA

In the early hours of one emergency duty morning, a ‘BabaJi’ rolled into our midst. ‘Babaji’ is a blanket term for the long haired, thickly bearded old street dwellers who land up in our hospital mostly with rotting legs and a host of other medical problems. This one was no different. He had a badly necrosed left foot with maggots in it. We cleaned it, cut off the necrosed parts, removed the worms and dressed it up nice and good. It isn’t the best part of our work, specially that early in the morning, but it is very much a part of our work. We thought we’d keep the Baba overnight, give him a somewhat decent bed to sleep in for once, and then he would be on his way in the morning, to wherever he came from. My God, we were wrong!

The next morning, he refused to go. He just lay there semi naked, on the bed. And because he was so disheveled, no one else wanted to sit or lie on the same bed as him. So even when there were two, even three patients on each bed in the emergency, he lay alone and comfy on his own. We gave it up trying to convince him after a few minutes. Besides, there was no one to take him anywhere anyway. He had just walked into the hospital with that leg. The day after an emergency is quite hectic. We got busy handling our OPD and the critical patients that had been operated the previous night. Besides, he wasn’t hurting anyone just by lying there.

That evening we got a call from the nurse at the emergency. The ‘Babaji’ was still there and they were getting angry. They needed the bed for new patients that were coming in. We requested them to keep him the night. We dressed his leg again. It was obviously better. All he had to do was come in once a day for the dressing, but he just wouldn’t leave. We aren’t in the business of throwing people out of our hospital. We’d talk to the consultants about it the next morning we thought.

The next day, our consultants got pretty busy in the operation theatre doing a complicated laparoscopic operation. And then we got the news. There had been a bomb blast at the High Court in Delhi. There were orders to cancel all pending elective surgeries. Soon, the OT would be flooded with Bomb Blast victims.

We all got pretty involved with handling the Bomb blast casualties soon. The consultants started operating, the senior residents inserted chest tubes, classified and prepped patients. Us junior residents started stitching, cleaning, removing shards and debris and managing burns. By that afternoon, the situation had been controlled and things had settled down. That’s when there was an alert from the hospital police post. A line of white and black government vehicles with flashing red lights were arriving. There was a lot of press around, and soon the emergency was surrounded by cops and kurta klad politicos.

We were cleared from the emergency, and I decided to get a snack since I hadn’t eaten the whole day. I met one of my interns in the canteen. He was excited. He told me to come to the T.V room. Rahul Gandhi-yup THE Rahul Gandhi- at the time the president of the Youth wing of the Congress (and heir apparent to the political legacy of the Gandhi Family), was in the Surgical Emergency ward, meeting the bomb blast victims and assessing the situation. He looked at all the patients there, and then stood right beside one of them. This was an old shaggy ‘Babaji’, who had been covered by a blue gown by our nurses to hide his semi-nudity. It was our Babaji. Bur hold on just a minute. He wasn’t a Bomb Blast victim. And here was Rahul Gandhi promising him adequate compensation for his pains, pointing to his bandaged leg, and calling it an attack on our integrity. Babaji had made national television, although for the wrong reasons!

The next morning when the nurse told him to go back home, he said very rudely “Why? I haven’t even had Breakfast yet”. We got a call immediately. That evening, we had a discussion with one of the smartest sisters in the emergency- although some people might have called it a scolding and not a discussion. “This is not a hotel doctor. I wont have the nurses here being treated like waitresses. I won’t have our critical patients lie on the floor because that man stinks so much that you can’t stand near him.” She understood that we were all but helpless about it. She just asked us to go and be on our way. “I’ll handle it”, she said.

We got a call at 8 AM the next morning. “Just come and dress his leg nice and good”, said the sister to my colleague. When I met my colleague for lunch that day, he seemed visibly impressed. He had gone to the emergency expecting another scolding. Instead, he found a nice and clean ‘Babaji’, with some fresh clothes. He dressed his leg and made it look peachy. An hour later, some people arrived from an NGO which helped old street dwellers. She had convinced them that all he needed was daily dressing from a local dispensary and he’d be well. The national attention he had gotten had probably helped their decision to take him. Half an hour later, he was in a van to an institution with three meals a day and probably better than the street where he came from.

Where we failed, the sister came through. It happens much more often than we doctors would like to accept. This time, the effort was undeniable. I wonder sometimes what became of Bomb blast Baba, and everytime another Babaji walks into our emergency, I still can’t believe the series of events that happened with that Babaji that week.

INTO THE VALLEY OF DEATH

Seeing a person bleed is a tough thing for most people. I know girls who faint at the site of a needle entering a vein. Now imagine making a large cut on the skin, then going deeper and deeper to the deepest reaches of the human body. Controlling blood loss is one of the pillars of modern surgery.  And after a while, it seemed easy enough to me as well. Until one night,when we got a call from our colleagues in Nephrology.

The department of Nephrology (Kidney doctors), helps a lot of people with end stage kidney disease. These are people whose kidneys are so badly damaged that they can’t continue living without dialysis. This doesn’t have much to do with general surgery though, so getting a call from them at our emergency at 11 pm was a bit odd for us. My senior resident attended the call and 15 minutes later, he called me in the emergency room to tell me that I had to get the Emergency Operation Theatre informed and prepped for a case of trauma to the abdomen.

The patient that rolled in on a trolley was a young boy, who must’ve been 17 years old. He seemed to be in shock, and when I saw his Hemoglobin (the red pigment in the blood that carries oxygen), I flipped. It was 2.7. The normal should’ve been over 10. As soon as they laid him on the table and exposed his abdomen (called the stomach in lay terms), I saw a strong reddish –purple discoloration of the right side and the back. The senior resident quickly filled me in while we waited a few minutes for the Consultant to arrive.

This boy was a patient of End Stage Renal Disease. His body had turned on his own kidneys and damaged them to the point of no repair. He used to come to our hospital for dialysis twice in a week. And that night he had an accident. While walking home, he had been hit by a car. The driver, who was drunk, had swiveled on a curb. The car had skidded and the boy had been hit hard on the right side of his abdomen from the back. Instead of coming straight to the emergency, the father took him straight to the Nephrology Department, the only doctors he was most familiar with.

The Consultant arrived and we opened him.  As soon as we opened into the abdominal cavity, we were greeted by a large blood clot. We got it out of the way, fast. On further exploration, we couldn’t find a single large blood vessel that had been injured. The blood was coming from a large laceration of his right kidney. We had to take it out. There was no way of fixing it. Whatever minimal function it was providing would go. But the patient was on lifelong dialysis anyway. So we took it out. We controlled the blood loss. We closed him. We transfused him with lots of blood and platelets. We saved his life. Almost.

The next morning he seemed better. We had placed a drain in the place where the kidney was and there was no blood coming from it. That was good news. His Hemoglobin though, had only risen to 4.8. Given that we had transfused him adequately, it seemed too low. Still, we were hopeful. We had an Ultrasound scan of the abdomen done just to check anyway. This time, I called the senior resident, and we went back to the Emergency Operation Theatre. On the Ultrasound scan, we found a large clot in the same area where his kidney used to be. Although, we had placed the drain, a large blood clot had occluded it. He had to be operated again.

This time, we took out the blood clot again. It was significant. Almost 130 cc. we tried to search for the bleeding. But we couldn’t find the source. There was no bleeding vessel or organ. It seemed to be emerging from the walls. Just diffusely pouring down in little drops everywhere to form a puddle in the area where his kidney used to be. We cauterized the bleeding points (made small burns that coagulate and block the points of bleeding). Most of the bleeders stopped. Except from this little crevice at the upper part of the cavity we had opened. The bleeders here were so tiny, that the blood just seemed to emerge out of nowhere. No problem. We tried to cauterize it. But it didn’t work.  The bleeding re-emerged. We took an Artery forceps and tried to tightly clamp a good part of the underlying tissue. Five minutes later, when we removed it, the blood emerged with the forceps. We took a good bite of the tissue in a hemostatic suture. We tied it, and tied it, and it failed. In fact, the act of putting the needle through the tissue just made it worse. We extended the skin incision so we could see the area better. Maybe there was some large blood vessel we had missed. But there wasn’t. The blood just refused to stop coming. The puddle would just emerge out of nowhere in that deep tiny, crevice. We were scared that if we explored further, we’d just make things worse.

We had used all our tricks in our bag. There was only one thing left to do. We packed that crevice nice and tight, with Surgicel, an absorbable sponge that would pressurize it temporarily and over that with snugly fit towel mops. Eight of them to fill the entire opening. Then we tied the area with bandage. And we waited. We waited for 48 hours.

Meanwhile, we investigated the patient for the cause of such inconspicuous, unstoppable bleeding. His coagulation profile seemed deranged. But not by too much. And then, our nephrologist friends pitched in with a D-Dimer report that showed more than moderate elevation. This meant that this boy had Disseminated Intra vascular Coagulation. His weakened state due to his pre-existing kidney condition, and his blood loss had made his blood clotting system go haywire. His body had probably consumed all his clotting factors in making the large clot that he came with. If he just had a bleeding vessel, the clot would have stopped it. But his kidney had been lacerated due to the accident in such a way that it bled slowly and continuously from multiple small parenchymal arteries in the kidney. The irony was that this had kept him alive till he got to the hospital. The blood hadn’t emptied form him fast enough to kill him quick. But this had also led to his present dangerous condition.

We tried correcting whatever abnormalities we could. But by evening, even through the eight towel mops we had placed in him, we could see blood soakage from the corner of his wound.  Thankfully, his Hemoglobin wasn’t dropping. So we decided to keep waiting for the standard 48 hours to get over. It was a tough 48 hours. The pressurizing mops had irritated and obstructed his gut. It wouldn’t move and so he kept vomiting every hour. The pain was very bad. He was drowsy from lack of sleep, because the pain and the fullness and the nausea kept him awake inspite of medication. 48 hours, I said to myself. Just hold on. I was scared that in his drowsiness, he would aspirate his vomitus. That would be fatal. We tried placing a stomach tube to prevent that situation, but he wouldn’t tolerate it.

Somehow, the 48 hours went by and we took him back to the OT. We started removing the mops, slowly, very slowly, one at a time. It reminded me strangely of a poem I had read in my early schooling- The charge of the Light Brigade. “Into the Valley of Death, rode the Light Brigade”, it said. Reaching that little crevice in the upper part of his wound, where walls of muscle created a valley where a little stream of blood would flow to become a pool and then a flood was one of the most tense moments I’ve seen in my six months of operative surgery. The deeper towels were soaked thickly with blood, but they were otherwise dry. That was a good sign. We took that last towel out so slowly, it seemed like an eternity. And there it was, the ‘Valley of Death’. Clean, dry, without blood. We went a step further and washed the whole wound. There was no blood. We placed a drain, and closed him.

After ten days under our care, the boy improved. Not only did he not have any more bleeding, his health got better with repeated dialysis. It was a miracle he survived. He comes for his dialysis regularly like he used to. Someday soon, we might re-enter that valley, on peaceful terms, and transplant a new kidney there. 

Missing House MD Part II

In my earlier post I wrote about a middle aged lady who was just not passing any urine. And the problem didn’t seem to be in her kidneys. Her body was swelling with the water she was taking. All of it was just going into her tissues, and the swelling was rising. Soon she had at least 2-3 liters of water just in her stomach (abdominal ascitis). The nephrologists advised us to investigate her heart. So we went about getting her a cardiac consultation. The coronary care unit in our hospital did an echo cardio graphic study of her heart. It came out positive for mild mitral regurgitation and rheumatic heart disease. She had had episodes of this kind of swelling in the past two decades, but it was never so severe and it went away on its own in a day or two. At least we had a diagnosis. Or so I thought. The cardiologist said that the extent of mitral regurgitation and rheumatic heart disease was just not enough to explain the severity of her swelling or the severe lack of urine output. Yes, there was a problem with her heart, but it wasn’t the thing causing her the trouble she was having.

We were back to square one. It wasn’t her heart, it wasn’t her kidneys, what about the liver? You see, her albumin was low. Albumin is the protein in the blood that helps keep the water in the blood vessels, within the blood vessels. We had been correcting her low albumin with albumin infusions. It didn’t rise too much, but even with the amount at which it was, her edema shouldn’t have been that severe. Her liver enzymes, which are a marker of liver function, were raised, but marginally. She had mild jaundice. She had no viral infections that would affect the liver. We had to get a CT scan. Maybe that would give us some answers.

Meanwhile, her two sons, who were about 25 years old, were getting frustrated by the day. They had been told that it was intestinal obstruction, and then they had been told it was a problem with her kidneys, and then they had been told that it was a problem with her heart, and then they had been told that the problem with her heart was not responsible for her symptoms. Tempers were starting to rise.The patient was highly unco-operative from the start. We had to encourage her every time we gave her any medication. Soon, the swelling in her limbs was so much that she needed a central venous catheter to deliver the drugs right into her central blood stream. Not a single vein could be found in her limbs, at least not one that lasted more than a few hours.  A central venous catheterization has inherent dangers. There have been incidences of death, although rare. Still, the permission and co-operation of the patient are absolutely necessary. Co-operation was the one thing we were just not getting. She wouldn’t consent for it; she wouldn’t even keep her head still for the procedure. This was dangerous. If the anesthetist tried to place the line, and she moved, it could puncture into some pretty dangerous places. Without the central line, we couldn’t give her any drugs. 

The next day, I had a huge fight with them. Finding a peripheral vein in her for giving the morning drugs would’ve been impossible for me. They kept asking me to do it. I told them I would, but I could only find the time after a few hours. I had too many patients whose work was pending. They accused me of negligence. They started saying loudly that I was purposely ignoring my duty. I’m not sure if I raised my voice at them, but I think I did, because the nursing staff came to my aid when they heard me. The central line was ready for placement I told them. I had borrowed it with a special request from a different department, so that they wouldn’t have to spend their own money. They just couldn’t get her to co-operate. If she wouldn’t listen to them, if they couldn’t even convince her to keep her head still for a minute, how could they blame me, I told them. I felt bad, terrible really. It’s hard to get things done quickly in government hospitals. There’s a waiting time for everything. I had been running for days to get her scans done quickly, her echocardiography, her references, her CT scan, getting her free central lines, getting her two failed anesthetist consultations, which came and just went  because she just wouldn’t let them do anything. It’s a terrible feeling when you work so hard, and get blamed in the end. But their mother was dying. And if that had been my mother, I probably would’ve been worse than them. This thought was my only solace.

The CT scan report came that day. There was nothing in it. Only water water everywhere in her abdomen. Her kidneys were structurally normal, so was her heart. So was her liver. In fact, so was her bowel. Her intestines had no sign of a block, no perforation. It seemed perfectly fine. Why she had presented with obstructive features initially, I don’t know. One thing was clear. She didn’t need surgery or surgical management. My bosses wrote to the medicine department to affect a transfer. There was not much that we could do in our capacity. But then, they refused to go.

I tried to explain to them that they needed a medical diagnosis, not surgical management. But they wouldn’t budge. It was getting to be an impossible situation. That night at about 2 am, I got a call from her ward. It was our emergency day, so I rushed from the emergency to see what was wrong. The patient had started to have severe anxiety and breathing difficulty. We put her on oxygen and respiratory dilator inhalation. Then I rushed to get the anesthetists. She needed an ICU bed. But all the beds were full. The anesthetist on duty came with me to see her. There were two things we could do, she said. The first was to continue on high flow oxygen and monitor her every half hour, or put a tube into her throat and put her on a portable ventilator. But this was a woman who wasn’t even letting us give her medication through a central line. If we put a tube in her throat, she would just rip it out. I sat with the patient and her family. Every half an hour for the next 2 hours, I took arterial blood gas samples and didn’t leave till I knew she was going to be better. After an hour or so, her sons apologized to me for the allegations that morning. It was nice to hear, but by then it didn’t matter somehow. 

The next morning, she consented for a central line. She got her medication. Soon they agreed to be transferred to the medicine department. That evening I asked my co-pg’s in that medicine unit what they thought the problem was. They said, they didn’t know, but it might be some tumor that was causing her symptoms. It’s true, some tumors do have para-neoplastic syndromes that could resemble her symptoms, but it would’ve shown up on the CT scan. There was nothing there. I got back to work. Five days later, I called up her son to find out how she was. Her son wasn’t in the hospital, neither was she. She had died, 2 days after her transfer from a cardio-respiratory arrest. Her son had been told that her blood vessels were just not able to hold the water within them. This was because of the blood transfusions that we had given her at the start. Some immune reaction had probably happened that caused a septic shock like state. I kept down the phone. This was not an explanation. It made no sense.  That patient made me realize how important sense is in medicine. 

I’ve seen patients deal with cancer. I’ve seen them deal with the loss of a leg, even extensive scars and disfigurement after burns. But dealing with not knowing, that’s the worst. Continuously searching for answers, not knowing what's wrong, what can be done. There’s no way a person can move on from that. I guess that’s the point behind House MD. That’s the point behind a man obsessed with answers. Because answers are often more important than solutions. In this case, the family wanted answers. They needed House I guess, and I was missing him dearly.

Missing House M.D- Part I

Making a diagnosis in surgery is usually easy. Most of the time we worry about what happens after the diagnosis- how will we approach the problem? What kind of surgery will we do? should we even operate? what if something goes wrong during the operation or afterwards? Oh yes, I thought diagnosis was easy. Until I met this one patient that presented to us at night in our emergency.

 She was a 50 year old woman who came to us with classical symptoms of intestinal obstruction. This is an obstruction of the gut or food pipe. If something obstructs it and food cant pass through, the stomach (abdomen) starts expanding due to the block. The patient obviously doesn't pass any stool or gas, and usually there's bouts of vomiting. She had all these features, so we started to give her initial management and didn't worry about her too much. As we expected, by morning she had passed gas, there had been no more vomiting and her abdomen had flattened. The only problem she had was that she hadn't passed much urine (there was a pipe placed in her bladder so we could monitor how much her fluid input and output was).

 Her Hemoglobin was 4.5 when she came to us. Hemoglobin is the red pigment in blood that helps take oxygen to our cells. The normal for her would've been above ten. We had given her two units of blood overnight. My Senior Resident thought that this was the reason for her dehydration. She had been asked not to take any food or water from her mouth to prevent loading her blocked food pipes, and since blood is thick and takes a few hours to be transfused, she just hadn't gotten enough fluids. Obviously her urine output was low. So we upped her fluid intake for the day. But by that evening, her urine output was even less that earlier.

 By the next morning, she had developed some swelling of her ankles and feet. This indicated to us that the fluid we were giving her was probably not removed by her kidneys. That's why it wasn't coming in her urine. The fluid had to go somewhere so it came out of her blood vessels and into the tissues of her ankles and feet. We sent her to the kidney specialists for an opinion. They asked us to start her on Lasix.

 Lasix is a medicine that forces fluid to draw itself into the kidneys and would help decrease the swelling in her ankles. Meanwhile, her general condition would improve and her kidneys would start functioning well again. So we gave her Lasix- it didn't work. We increased the dose and gave her more Lasix- it didn't work. To improve her general condition, we transfused her again to improve her Hemoglobin. We gave her protein through her veins to help draw in the water back into her blood vessels. We gave her only water and juices by mouth, fearing that the gut would get blocked again if we gave her solid food. It didn't work.

 By the next day we could see swelling of her stomach, her hands and her thighs. She was still not passing much urine. Something had to be wrong with her Kidneys. The kidney specialists (Nephrologists) differed with us on that. You see, in her Kidney function tests, he Urea was grossly elevated, but her creatinine was normal. What this meant was that the problem was arising before the blood got to her Kidneys (Pre-Renal). The Kidney was doing its job, it was something else that was wrong. A kidney wouldn't remove something that couldn't get to it to be removed. They asked us to investigate her Heart. Meanwhile, fluid kept accumulating in her tissues. Her hands had swollen to her elbows, her stomach was filled with fluid, and the swelling of her legs had gone upto and above her knees. If we gave her less fluid, she'd feel extremely thirsty, if we gave her more, it would just fill up her tissues. It seemed to me as if she was drowning, from the inside......to be continued.

ACTORS

Contrary to what people might believe, surgical wards are relatively quiet and clean. Occasionally you’ll hear someone screaming in the silence, but only momentarily. Its clean because no matter how dirty the wound, the thick white bandaging makes it look as nice as wrapped candy. You’ll be surprised if you see how dirty the wounds are when people come to us in the emergency and how neat they look (or are made to look) after a day or two in our ward. That’s why many of our patients love being in the ward, especially the ones who are destitute, or don’t get any attention at home. Not to forget the attraction of three square meals a day-free. And so, when the time comes to pack up and go home all fixed up, they become actors.

The first time I met a serious actor, it was the Mother of a 25 year old girl with cancer of the Rectum (almost the last part of the Gut).  We had diagnosed that the Cancer had spread so much that surgery at that stage wouldn’t have been feasible. She needed radiotherapy, which isn’t available at our hospital, so the patient had to be referred to a center which had this facility. For some reason the Mother of this patient believed we were making an excuse to get rid of the patient (a common perception among many patients in government hospitals). She liked the standard of care we had given her daughter. She liked the cleanliness we maintained and the helpful attitude of our nursing staff. She kept asking for us to treat her ourselves. But it wasn’t possible. This girl needed radiotherapy. So she started to butter me up. She kept referring to me as her son. She kept telling me how much I resembled her son. She said she had gotten us fruits, she asked for my shirt size and when I refused to co-operate, she kept pulling on my cheek and grabbing my chin to draw my attention, like they do to little children! That’s when I lost it. “Firstly”, I told her, “I’m not your son. Second, unless you can spend a few million and buy the radiotherapy machine for this hospital, you are wasting your daughter’s precious time by staying here. So go get her some help and stop stalling”. You should’ve seen the frown on her face when she left.

Probably the best actor I’ve met so far was a 30 year old man who had suffered an assault at his home. He had been beaten by a bunch of guys with fists and slaps and had landed in our hospital with the police. He had no severe external injuries. But he complained that his head and chest were paining. Although we were quite confident in our clinical diagnosis, this was a Medico-Legal case. That meant that it could go to court and we might be asked to testify. So we left no stone unturned. We got a CT scan of the head and an X-ray of the chest and as we expected, he had no internal injuries either and was good to go. But he wouldn’t. He just lay in bed with his head down and pretended not to be able to sit up. His voice was normal and he seemed fine, but when I made him sit up he just fell back on the bed. It was too obviously, fake. We gave him some time. But he wouldn’t move. So my senior told me a little trick he used during his PG days. I went and told him that we needed to place a Ryle’s tube into his stomach. This is a plastic tube that goes through the nose, then through the throat and into the stomach. It’s perfectly safe and very useful in patients with intestinal obstruction, but it’s very discomforting for the patient during insertion. He was so stubborn in his efforts though, that he agreed. He actually bore the discomfort of the tube and had it inserted. Seeing all this, his relatives asked to speak with me in private. They told me that the reason why he wasn’t ready to leave was because if he went home, the guys who beat him up might just do it again. He was scared. But staying in the hospital was no solution. He wasn’t ready to tell the police the truth either. He had to go home sometime.

We decided to get him a psychiatric consultation, but just before we did, one our most senior residents joined us during the duty change. When we explained what was happening to him, he went and saw the patient immediately. He asked the patient about his complaints. He looked and sounded very sincere and serious about the patient’s condition. Then he had his attendants pick him up and make him stand. It’ll be interesting to know that a man cannot voluntarily fall from a standing position with the intention to hurt himself. The body reflexly protects itself. He acted as if he was wobbling of course, and my boss was acting as if he was encouraging a disoriented man to walk. In the end, the man walked a good distance and back and told us that his aches had mysteriously disappeared, that his head wasn’t turning and that it was all because of the Ryle’s tube (that had practically done nothing) that we had placed in him. We took out the tube and he left voluntarily. I silently gave him (and my boss) a standing ovation for the entire performance.

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