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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Running for blood

If you see a first year post graduate student of surgery running in the hospital, it’s probably due to one of three reasons. The first, is if there’s a patient dying, probably due to a sudden cardiac arrest – this is not very common in the surgery ward. The second, is if the PG is late, and there’s a senior waiting for him- this is very very common. The third, is if he’s running for blood.

If you think you know how much blood it takes to keep the hospital running, your wrong. It takes more. That way, the blood bank is like the heart of the hospital, constantly circulating blood from donors and giving it to the needy. Its like a Robin Hood of sorts- take from the rich and give to the poor. Give to the poor…that’s the complicating part. Because the poor are so many. Not only are there those who have no one to donate for them, there are those who’s blood group is so rare that its hard to find blood for them. That’s what happened to a patient of mine recently.

This patient was an 18 year old girl with tuberculosis of the abdomen. Her gut was so horribly stuck together that no food could pass through. She had started to develop signs of infection that ran into the blood vessels and was circulating to the rest of her body (septicemia). We had tried to operate her once, but we avoided aggression, lest the bowel tore in its place and we made things worse. She improved after the first operation for a few days, but soon, it became clear that she would need another surgery.

On the morning of the second surgery her Hemoglobin level ( a measure of the red pigment in blood that carries oxygen to our organs), was 8.5 gm/dl. The normal for her would have been 11 or 12, but 8.5 was a safe enough level for her to have emergency surgery. We sent a repeat hemoglobin level just before she went into the Operation theatre which was at 11 pm at night. An hour into the operation the report revealed a level of 6.8. And, she had probably lost one unit (about 1 more point), during surgery already. The anesthetist freaked. But there was a solution of course. The patient had a lot of donors, and we had been prepared for such an eventuality. We called our blood bank and sent for blood, only to discover that the blood needed for her type-O negative- a very rare blood group, was unavailable. They had just sent it for two women who had had too much blood loss during childbirth. We had least expected this. The anesthetist literally had a stroke. Get me blood Nishant, she screamed. I don’t care how you do it, just get me blood.

Thankfully the guy at the blood bank had a solution. The Red Cross blood bank had the kind of blood group she needed. But they needed a stamp and signature from someone at the hospital. So I ran. I ran to the Emergency officer who didn’t have the stamp. I ran to the Boss of the Emergency officer, who didn’t have the stamp. Finally I woke up a senior consultant and drove my bike to his place and had him stamp and sign the blood requisition form half asleep in the middle of the night and then back to the blood bank. They were ready and waiting. They sent their guy and got 2 units of blood. I came back with a sigh of relief. The blood would arrive soon. I changed into my scrubs waiting to be proclaimed a hero. But our patient had bled more than I had expected. She had lost at least another two units more. More blood Nishant, we need more blood!!

I called the Red Cross blood bank personally. They had no more O negative blood. The two units they gave us were their last. The blood bank in our hospital called everyone they knew. All the major government hospitals. But they were at a distance. I looked at the blood soaked towels in the operating room. Something had to be done. I looked at her family waiting outside. Something had to…wait.. Her family wasn’t poor. It wasn’t rich, but it wasn’t poor. I could tell from the clothes they wore. Maybe they could buy the blood. But this had never been done before. None of my seniors had told me about this route. I didn’t even know if people could sell blood legally. There was only one way to find out.

At three in the morning I called the only people I trusted for information about pizza places and movie shows in and around Delhi. Just Dial. You know those phone based companies that give you information about places you want to know about in your city. This was the one we used in Delhi. I called and the response was prompt. I explained to him the situation, the urgency and the need for fast information. As soon as the guy realized that this wasn’t the usual call for late night eating joints he started speaking quickly and vociferously as if a timer had been set and he was about to win a million dollars. I liked him. There was indeed a blood bank close to our hospital that sold blood. The Lions Blood bank.  I called them. They had the blood. They charged 1900 Rs per unit. It was worth it. I got the address and sent the relatives who probably drove like madmen, because they reached there much faster than I’d expected them to. Back in the OT, the anesthetist was looking for me. She needed to vent, and I was the chimney. There aren’t too many places to hide in the OT complex.

The Relatives were taking too long at the blood bank, so I called them. The technicians there were making them wait, because they had a 40 minute processing time for matching the patient’s blood to the blood they were giving us. This was longer than usual, so I asked them what the holdup was for. “We have a world class matching process sir”, said the voice on the phone, “ We test for antibodies that few centers do in Delhi, giving you quality matched blood”. He sounded like a salesman. “ Listen my friend”, I said to him, “ This girl is being operated right now. She’s losing blood fast. And she needs blood. Those extra antibodies you test for to prevent reactions in 0.0001% of patients won’t really prevent anything if she dies.  Just do the usual cross match and give us the damn blood”. I heard a few ‘ but, but, buts’, on the phone, but there was nothing more to be said. He probably followed the whole procedure anyway. I wouldn’t know, because I was called back into the OT. The operation was over. She was going to be shifted to the Intensive Care Unit. The Anesthetist was still tense, but at least there wasn’t going to be any more bleeding. By the time we shifted her, to our grand elation, there were two units of O negative blood waiting for her. It was our very own hospital blood bank. They had managed to find O negative blood at the Army Hospital blood bank nearest to our hospital. It had been unconventional for them, but hey, it had been a weird night. And by the time we gave her those two units, the blood that her family had gone to purchase had arrived.

After fighting a significantly long battle in the ICU, the patient, I’m glad to say, did well and is to be discharged soon. I had promised the anesthetist and her PG assistant a Samosa treat if this patient made it. Guess I’d better go buy some. I’ll be relaxed when I do. Not like when I’m running for blood. The patient’s attendants wanted to thank me for my efforts. Instead I redirected them to some real heroes. The people at the blood bank. They run for blood every day. They don’t even come to know if they manage to save the patient most of the time. They just run.