Continuation of action from http://jeevankuruvilla.blogspot.com/2011/08/weekend-diary-2.html
Well, there were quite a lot of things happening in LR. The best part was that MD (with placenta praevia) slipped out of the LR without anybody noticing. She wanted to discuss something with her family. And suddenly she realised that she was bleeding. That was why they called me. There was a puddle of about 500 ml of fresh blood on the floor. We had to act fast. Blood or no blood available for transfusion - I had to do a Cesar to save both MD and her baby. As I was trying to hasten things, two more patients landed up in LR.
The first was MT. In her middle 30s, she was into her 6th pregnancy. Since 4 pm, she was having painless vaginal bleeding and she was almost term. I pushed her to the ultrasound room and there was a area of seperation of the placenta - Abruptio placenta. I was wondering how could this have happened. She also needed to be taken for surgery.
The second was VS. Also in her middle 30s, she was into her 7th preganancy. One look at her was enough to tell anybody that she either had twins or had too much of fluid in her uterus. She went in to the ultrasound room after MT and lo, she had twins. She was also trying to deliver elsewhere and had come when nothing was happening. Poor lady - her family did not even think that there was any worth in doing at least one ante-natal check up. Her family claimed that she has been seen by the local Sahiya. All this after she had multiple risk factors - elderly multigravida, previous history of twins pregnancy and severe swelling of her body. It seems VS was having contractions all through the day - but suddenly it stopped. On per vaginal examination, I found out that she was fully dilated and I prayerfully did a guarded rupture of her membranes. Then I went to the theatre to operate on MD and later MT.
I reached the theatre to find out that we did not have any blood to operate on MD. It was a miracle that the baby was alive. The placenta praevia had started to seperate. When I opened the uterus it was the placenta which came out first. The baby came out later. He was lucky to have made it. The rest of the surgery was uneventful. MT was the next one. On opening the abdomen, she had multiple petechial spots on the uterus - couvelaire uterus. They had not given a correct history. Neverthless, I opened the uterus. The baby was ok. The placenta was hardly attached to the uterus and there were blood clots behind. After we finished, the theatre nurses confronted the relatives about any additional history - they confessed that she had a really good massage of her abdomen in the morning. Massaging the gravid abdomen is a very common practice in our area. It is thought to improve blood circulation of the uterus and help in uneventful labour.
As I was midway between the surgery on MD, one of the ward nurses informed me that one of the patients who had come in with severe malaria had respiratory depression. We'll call him DS. DS was from the nearby village of Bari. DS was sick with fever since the last 5 days. He came in sometime in the afternoon. Almost in a comatose state. On investigation, almost 50% of his RBCs were infested with Plasmodium Falciparum. He looked quite healthy but his hemoglobin was just 7 and his platelets was just 24,000. I knew that he did not have much of a chance in our setting. Ranchi was too far away and he also looked to have developed a intracerebral bleed. I had explained everything to the bystanders. The decision was taken on doing whatever we could.
After admission, he continued to deteriorate. This could have been prevented. The relatives showed me the rapid test kit for malaria which was negative. However, they told me that he was diagnosed to have falciparum malaria by the local quack. I asked what medicine was given by the quack. They showed the medicine. I could not believe my eyes. The quack had given Ciprofloxacin tablets instead of Chloroquine. Poor guy - got the spelling on the blister packet all wrong and now MD did not stand a chance of survival.
Suman, our anesthetist nurse rushed to the ward to take a look at MD. She promptly intubated him and started him on CPCR. But with very poor blood parameters there was nothing much we could expect. We declared MD dead at midnight.
As I got out of theatre, I was called again to the LR. The first baby of VS was delivered without much difficulty. The second one appeared to have got stuck and the nurse was struggling. So, I went in and had to help do a breech extraction of the second fellow. Both the babies were doing fine by God's grace.
As I thought that this is end of the adventures for the day - we had one little girl in the emergency. She was having convulsions. The history was almost similiar to that of DS. The only difference being that her malaria smear was negative. It looked more like a viral hemorrhagic fever. I somehow convinced the relatives to take her to Ranchi - which they ultimately did in the morning.
I was lucky to get a little amount of sleep from 3 am to 5 am - interspersed with calls about medication orders. Early morning, we had a man with a krait bite almost 24 hours back, but with very definite signs of envenomation - he had ptosis and difficulty in swallowing. His respiratory efforts were fine. It was only very recently I had read this article about how silent and inconspicuous these krait bites can be. You can read about it in http://www.facebook.com/media/set/?set=a.208033779216299.52888.100000290346946#!/photo.php?fbid=208033929216284&set=a.208033779216299.52888.100000290346946&type=1&theater. This man had hardly any visible sign of the krait bite.
There were 2 more uneventful normal deliveries... Quite a handful for the start of a weekend. Do remember Dr Shishir as he is on call today...