Diagnosing the unknown

One of the major challenges in a poor resource setting is to diagnose conditions when the history given is poor. Of course, there are occasions when one cannot come to a straightforward conclusion even with the latest equipment.

Last week, we had a patient where we could not come to any conclusion about the diagnosis.

RRD, a 12 year old girl was wheeled into emergency one day evening with a history of becoming confused after having returned from the fields. She was frothing from the mouth and nostrils and had a bradycardia. She was not able to narrate anything. Her uncle who had rushed her to hospital told us that she claimed that she was bitten by something.

The first thing we thought about was a scorpion bite. However, I was not sure about bradycardia being a part of a scorpion bite syndrome. I expressed my doubt if this was a scorpion bite. The relatives told that there was very less of a scorpion bite as it is very harsh winter and the region they come from does not have scorpions.

Then, one of the relatives told us about the possibility of her having accidently ingested some poison. Maybe, she has eaten some vegetable on which pesticide was applied very recently. A phone call to home and someone confirmed that she had eaten couple of tomatoes and peas as she walked across the fields. But, she did not have constricted pupils. Rather, it was dilated, but reacting to light.

Giving a benefit of doubt, we gave her atropine. The bradycardia got taken care of. But then, we realised that she was going into pulmonary edema. Soon, we had to intubate her and she was on manual ventilation. Nevertheless, the pulmonary edema was quite bad. We had to pump her little body with over 120 mg of Frusemide over couple of hours. And even after we had got the pulmonary edema in control, she needed 10 mg Frusemide per hour.

She was not fit for transport. However, she improved miraculously overnight and we could extubate her and by morning next day, she was sitting up and talking. But, she was not all well. She was breathing fast and there was tachycardia. We suspected myocarditis.

RRD also told us that she felt a searing pain on her right ring finger as she was searching something on the ground. She did not remember about what happened after that. She faintly remembered being taken to a witch doctor.

Her family was well off. We told the family of getting a consultation elsewhere. They happily took her further. We’re yet to hear from them.

I still think that she had a scorpion bite. The only hitch was that there was no local sign of a bite.

I wonder if we could have given the Prazocin tablets without confirming that it was a scorpion bite. I also think that the Atropine did more harm than good. But, then, we did not know what we were dealing with.

I shall let you know as soon as we hear more about it from the family . . . 

Thru' the valley of death

RD was a very non-suspecting high risk antenatal patient. The issue was with her hemoglobin. It never crossed 8 gm%.

However, considering her family’s financial situation, wehad decided to take her at NJH for delivering her baby by Cesarian section. This was her second baby and her first baby also was delivered by Cesarian section.

None of us had any inkling of the crisis we were going to face.

She had a blood transfusion before the surgery. Unfortunately, the doctor who operated did not do a repeat hemoglobin value before taking her in for surgery. Per-operatively, she developed a reaction to the blood transfusion. There was nothing much of a problem.

After the surgery, she was comfortable. However, there was a nagging issue. She was not maintaining her saturation. However, the saturations became normal when oxygen was given. A hemoglobin done on her turned up a value of 6.6 gm%.

Alarm bells started to ring on my head. We decided to wait overnight.

The decision turned out to be almost fatal. She started to have breathlessness in the night. Her saturations took a dip for the worse. She was going into pulmonary edema.

By morning, she was in the ventilator. But, she was also putting out pink frothy sputum. We had to give about 1 gm of Furosemide over the first 24 hours to control the pulmonary edema.

By God’s grace, she responded well to treatment.

And she got discharged last Sunday, exactly 7 days after her surgery.

However, RD’s incident has prompted me to put in strict control on hemoglobin values of our prospective patients. Anemia is quite prevalent in our part of the country. It is not very common for a pregnant lady to have a hemoglobin of above 10 gm%.

Meanwhile, the debate on anemia always cause me to wonder if we have some form of a blood dyscrasia in our part of the country, which is not yet diagnosed. 

2 very bad eclampsia patients . . .

Over the last 10 days we had 2 very sick eclampsia patients.

The common aspects of both patients . . .

-         They were very rich.

-         The relatives wanted to take the patient to a higher centre in Ranchi but could not as both of them had severe respiratory distress.

-         Both of them had GCS of 3 on arrival.

-         They had spent time at home for more than 5 hours after the first episode of seizures.

-         The decision to take to a doctor was made after 5 hours.

-         Both patients did not get magnesium sulphate from any  healthcare providers. In fact, I got the snap of what one patient got . . . You can see it below.

-         Both had pulmonary edema with pink frothy sputum coming out. In fact, the second one had coffee ground gastric contents.

-         Both had diastolic blood pressures of more than 140 mm Hg on arrival.

-         Both of them have survived the surgery.

-         They needed mechanical ventilation for less than 24 hours.  

The differences . . .

-         Both were from different castes and religious communities.

-         For the first case, the baby was dead. The second case has got a alive baby.

-         One of them is discharged, whereas the other one is yet to go home.

-         The first one, who is already discharged had to be intubated on arrival whereas the second one was intubated only for general anesthesia.

The significance of both these patients: The classical teaching of eclampsia with pulmonary edema is to stabilise them before we take up for surgery. Our experience shows that if we take them for surgery as soon as possible, they survive. However, you need to have basic ventilation.

And of course, we pray quite hard here.

Any takers for this from the speciality of Obstetrics. We have four patients who survived over the last 3 years with this sort of management. The above are the last 2 patients. The first two patients, you can read here . . .

1.    The first patient 

2. The second patient 

I’m sure that we don’t see this sort of patients in clinical set ups in most of the other obstetric set ups. However, I understand that we have such patients turning up in most of the other EHA units.

Eclampsia with Pulmonary Edema

The ink had hardly dried in my pen that wrote the Death Review forms of the last maternal death. Today morning, I had another shocker of a patient. 

GD, another young mother-to-be at term pregnancy came to us with hardly any breathing, and putting forth pink frothy phlegm with each gasp and having seizures. GD had gone into labour at her home in the adjacent district yesterday evening. The family thought that everything was going on normal. 

Around midnight, GD started to have seizures and became unconscious. They could not arrange a vehicle till dawn. In between, she had 3 more episodes of seizures. 

They reached the first healthcare provider sometime around 5 am, who referred her to the adjacent district hospital. They went to 2 more hospitals, both of whom referred them to NJH. 

Something which was quite disturbing was that in none of the hospitals did a doctor examine the patient. Considering into fact that she had seizures and she was unconscious, it was quite pathetic that nobody took her blood pressure, leave alone give her a dose of Magsulf. 

Well, as soon as she reached NJH, which was around 10 am, we had to intubate her and hook her on to the ventilator. I clearly remember all the eclampsia patients who had come to us with pulmonary edema. We could only save one of them. SDe was her code name. And this is the fourth patient. The other two died. 

Accidentally, a technician from Medisys, our provider of ventilators had come down to service of ventilators. He was quite taken aback by the load which we were putting on our ventilators. He started explaining to us that we needed more high end Intensive Care Unit ventilators to deal with such patients. Well, that would cost us about 600,000 INR. 

Our basic ventilator was not enough to deal with GD's problem. We bagged her manually. And she was maintaining saturation. However, the pulmonary edema was worsening. With a huge dose of Lasix and a GTN drip, things appeared to have settled. 

However, we had more problems. The baby appeared dead and there was sepsis. Most probably a dead baby in the uterus for long. The per vagina finding was hardly encouraging. 

We discussed with the relatives and took a decision to do a Cesarian and take the baby out. I know I would have enough consultants contesting this decision. 

Per-operatively, there was pus inside the uterus. The baby was macerated. The uterus was so unhealthy that couple of times, the thought of doing a hysterectomy crossed my mind. Then after we sutured up the uterus, the uterus was not contracting. B-Lynch suturing was done. The uterus was so flabby that we had to do it twice over. 

GD continues to be on GTN drip and on ventilator. Please pray that she would make a smooth recovery . . . 

The culprit identified . . . SK.

Yesterday, SK who had come with an unknown bite and went into quite a lot of complications ultimately went home.

She was looking quite cheerful.

The diagnosis on her discharge summary read -

UNKNOWN BITE RESULTING IN

- DRY GANGRENE OF THE RIGHT LEG FOLLOWING COMPARTMENT SYNDROME,

- ACUTE RENAL FAILURE,

- MYOCARDITIS RESULTING IN PULMONARY EDEMA AND

- SEPTICEMIA.

Her highest level of S.creatinine was 7.8 mg% and we had wished that we could try out peritoneal dialysis.

We are thankful that she pulled through. She was in the ventilator as well as manually bagged by her parents for almost 72 hours.

Now, we made an attempt to identify the culprit. When Seema came to my office before discharge, I decided to give it another try. She clearly told me that she was bit by a 'Khapar Bitcha'. I summoned some of the local staff and tried to figure out the creature. 'It looks like a large lizard and a coarse chameleon' - that was how someone put it.

I figured it is something like a monitor. So, I searched the web and came up with some pictures. Ultimately, when I showed her the wikipedia page about the Bengal monitor, she was absolutely sure. However, I had a problem. I could not find out anywhere that the Bengal monitor was that poisonous.

Sometimes I wonder if we had made her more sick by giving her Anti Snake Venom - we did it as her Clotting Time was more than 20 minutes. Or was it a result of septicemia which resulted following the gangrene which set in because of the compartment syndrome.

I look forward for comments regarding the same. Especially from the experts on such bites. Maybe we've found something new that could be reported.

The story about SK would not be complete unless I put in something which we did for her family. If you have read my previous blog about SK, you will understand that her father wanted to take her home to die. We pleaded with him not to and give us a chance to try to heal her. Ultimately, I had to tell the father that we would treat her for free.

Unfortunately, once the father saw that SK was getting better, he had gone and sold a part of his land and got some money. He was ready to pay about 10,000 rupees when the discharge was all made. The total bill had come to about 30,000 rupees. I kept my promise and did not take a rupee.

However, such things are quite burdensome for the institution. We look forward for contributors from well wishers towards SK's treatment.

Unknown bite - and more venomous

SK about whom we were quite concerned about for quite a long time finally improved well enough for us to start thinking about discharging her.

SK came about 10 days back with a history of an unknown bite. The relatives were quite confused about the identity of the creature which bit SK. We send for the clotting time which came elevated. There were local signs of envenomation. So, we came to a presumptive diagnosis of viper bite and started anti-snake venom.

SK improved very soon and her clotting time came to normal limits. There were 2 other patients with viper bites and the 3 families formed a sort of bond. The other 2 patients recovered without much problem. SK also had compartment syndrome and underwent fasciotomy. The 3 patients send us into a situation where Anti- Snake Venom was running short.

However, we noticed that SK’s renal status was deteriorating and was going into anuria. Meanwhile, the other 2 were improving. I called up SK’s father and told him about a possible need for referral. SK’s father told me that he has already sold 2 of his bullocks and 1 goat to fund SK’s treatment. And as he was not going for work – so he had to provide for the family’s day to day existence.

A funny side of the treatment process was the constant stream of visitors that SK had – mostly local leaders and pretender leaders. Couple of them came and met me and told that they would take care of all the costs and to do the best for the patient. After some important looking leaders came and met me – I called up SK’s father and asked him about it.

He would start sobbing – telling that none of them including his villagers has given even a single rupee for the treatment even to the extent of taking responsibility to care his other children. He told me that if we cannot manage her, he would rather take her home to die.

We convinced him to allow us to do whatever we could to try to save SK.

Meanwhile SK was worsening. We realized that she was going into pulmonary edema. We were juggling on what could be the cause of the pulmonary edema. Renal failure was thought of as the cause and we became quite stingy with the fluid management. However, there was no relief. In addition, we had to put her on mechanical ventilation.

She had also gone into sepsis. We changed antibiotics – but without much improvement. Later, Dr. Nandamani explored the chance of cardiogenic pulmonary edema. Ultimately, we decided to start SK on a GTN drip.

And we praised God when she responded to the GTN drip. After 3 days in the ventilator, SK was weaned out of the ventilator. She is quite tired. 3 days on the ventilator was quite a bit stressful on both our ventilators – the older one and the newer one – and for quite a lot of time, she was manually bagged by both the parents.

I’ve send for further investigations about her renal status. Clinically, she appears to be on the road to recovery.

Today morning, I got to talk to her. We were already a bit suspicious about the creature which bit SK. SK was quite sure that it was not a snake. She told that it looked like a large lizard. SK’s father told me that if it was the creature – usually people die after this creature bites. After the case of a spider bite which caused quite a lot of stress to a family, it is quite interesting that we do have other creatures which can be as dangerous as venomous snakes like cobras or vipers.