One gram hemoglobin and survived - The Miracle

SD came today afternoon to my office. I thought we had discharged her. She told me that she wanted to go only after she was absolutely sure that she would survive. So, the delay in discharge. She had been with us for almost 4 weeks.

She was quite thankful. Her family had gone through the valley of the shadow of death. She had seen my anxious face as she was wheeled in. She might have even got a glimpse of my gestures while I explained to her husband that there was very little chance of her making through.

For all of us in the hospital, it was a miracle. With hemoglobin of 1 gm%, I’m not sure on how many could have survived.

It has been a long haul for the family. They had to face quite a number of hurdles. She received a total of 7 pints of blood during her time in the hospital including the one given by Mr. Dinesh, our maintenance supervisor. In addition, getting poor quality blood from the blood bank in town did not help.

We waited for the hemoglobin to rise before we could attempt anything regarding her placenta accrete. Ultimately, we decided to go ahead with a hysterectomy with a hemoglobin of 3.2 gm%. When we saw the uterus, we were sure that it was a miracle that SD has pulled on so far. It was stinking so bad and the placenta was so well adherent to the uterine wall.

The gangrenous uterus along with the adherent placenta

SD has two little boys. She looks forward for a new life with her family and she knows she is extremely blessed to have survived against all odds.

There is a sad part of the story too. The treatment has taken a toll on SD's families' finances. The total hospital bill had come to a whopping 26,000 Indian Rupees. In addition, they must have paid quite a lot of money to get the 7 pints of blood. SD's husband was not going for work. And there were mouths to feed in the house.

When SD's husband came to pay the bill, he told me that he was ready to pay Rs. 5000. I asked him how he managed that much money. He had sold quite a lot of his land. It was heartbreaking to hear that. Another family pulled into selling off valuable assets just for want of poor public healthcare.

The Mob

Violent responses to adverse events in healthcare is a very common feature nowadays. It has been there for quite some time. Most of the EHA hospitals face the brunt of it on and off. The latest incident was in Chattarpur where few of the senior doctors and officers of the hospital was beaten up after the death of a lady who had come for delivery.

And I had to face a fuming mob today afternoon. The reason was a boy whom we had seen in our Out Patient Department couple of days back. He had been prescribed Tablet Perinorm for nausea and vomitting. Today afternoon, he had developed abnormal posturing which we call extrapyrimidal syndrome secondary to perinorm.

The boy was from the local village and of one of the prominent upper caste families. Couple of people were shouting that the hospital was trying to poison him and another two were babbling about poor quality of medicines kept there. I recognised two quacks from the nearby villages. I was expecting at least couple of slaps or beatings. I had not yet come into the room where the boy was.

By God's grace, nothing happened. As I walked in, there was a sudden silence. Dr Johnson, the doctor on duty had already told me that it looked like extrapyramidals secondary to perinorm. So, it was a bit more easier for me to talk. And, of course, it was extrapyramidal syndrome most probably secondary to perinorm. I asked the nurse to give Inj Phenergan. The boy recovered very soon.

The incident was over in a flash. But, I am well aware that things could have turned for the worse. The mob dispersed quite quickly.

Meanwhile, I wonder whether there could be some law whereby doctors and other healthcare providers are protected from such violent responses from patient's families. One option would be to make violence against healthcare providers a non-bailable offense and increase the punishment for such offenses. That could deter people from doing such acts against healthcare personnel and institutions.

Miracle Baby

Around 7:00 pm yesterday, I was called into the emergency to attend to a patient with a viper bite. As I finished writing up the orders for the patient, the screech of tyres outside indicated that I had one more patient to attend to. I walked upto the gate and asked the driver what sort of patient he has just brought in. Delivery patient - was the reply.

I told the chowkidar (security guard) at the gate to shift the patient to labour room. Just as I turned to walk back towards labour room, one old lady ran behind me yelling, 'doctor, doctor - have a look at my daughter before you ask her to be taken to labour room. The baby's hand is coming out and my daughter has been in severe pain since morning.' 'The hand coming out' statement woke me into my senses. I asked the patient to be rolled straight to ultrasound.

AB was a G4P3L3 who had an uneventful antenatal period and presented to the adjacent district hospital at around 10 in the morning for normal delivery. At around 5 pm, the nurses who was monitoring her informed the family that there was a problem and she needed to be rushed to a higher centre. The hand was coming out first rather than the head. They told the family that the baby was alive.

I watched with trepidation as I scanned her abdomen. The heart rate of the baby was about 40 per minute and it was very sluggish. I told the bystanders that there was no point in doing a cesarian section as the baby was highly bound to be moribund. They were quite resigned to whatever we could do to save the mother.

I took the patient to the labour room straightaway and did a per vaginal examination. It was a compound presentation with the right arm coming in front of the head. The head was also quite descended. I weighed my options. I asked the nurse to look for the fetal heart rate which she could not find.

Using all the force I had, I pushed the head back into the uterus and slipped the hand back into the uterus behind the head. I was quite surprised at how easy the hand slipped behind the head. However, having seen a poor fetal heart in the ultrasound, I knew that there was hardly anything we could do for the baby.

Meanwhile I got a call from the Acute Care Unit. Leaving the delivery to be conducted by the nurses, I rushed to the ACU. As soon as I reached the ACU, I recieved a call back from Labour Room saying that the AB delivered and the baby was gasping. I rushed back to LR. The baby was quite sick - I got into the routine of resuscitation of the baby - but with quite a resigned attitude.

To my surprise, the baby responded quite well. There was poor respiratory effort with quite a lot of secretions. So, I had to intubate and do direct suctioning of the trachea. I ventilated the child for about 10 minutes when I noticed that the child was trying to cry. I removed the endotracheal tube and to my surprise the child started crying.

The cyanosed right forelimb of the baby which was the initial presenting part.

I could not believe it. Even the female relative, who was inside the labour room could not believe what had happened.

Now, what is interesting is events which happened after this. The next thing, the lady relative wanted to know was the sex of the child. The child was a girl. She was quite crest-fallen. AB started to weep.

I looked like a villian to the family for having rescued this baby. However, after some amount of talking, they were fairly convinced that the baby whatever be the gender is a gift from God and it is upto them to bring her up well.  

Today morning, I was quite glad to find AB tenderly caressing the baby as I called on the family to see things were going. It was a close call for the baby. Even for AB, if she had kept on contracting, she may have ended up with a rupture uterus.

But, the saddest part of the story is that AB was referred from a district hospital and there was not even one doctor to attend to her and take a decision about her management. We thank God that we could avert a perinatal adverse event.

Beaten Black and Blue into Shock

Yesterday night, we had a very difficult patient.

AS was on his way back from work to his village, when he was waylaid by a gang of thugs and beaten up. The excuse for the gang beating him was that he refused to give a lift to one of them in his bike after they had flagged him down.

I know many of you may be wondering why I’ve put in this post. The basic problem is that AS came in a shock with no pulse or blood pressure measurable. But he was conscious and could narrate what had happened.

We searched high and low for a possible cause for the shock. The only thing we could find was a hematoma of about 200 ml in his left hemithorax. Other than that, there were only bruises all over the back extending from almost to the neck to the buttocks.

He had recovered with intravenous fluids but he continues to go into shock. We are still at a loss to find out the cause of the shock.

We have already offered to refer him to Ranchi for which the relatives have not been very forthcoming.

Today morning, we have re-examined him and come to the conclusion that he has multiple hematomas in the subcutaneous and intermuscular planes of the back of his body. In addition, there is also evidence of pre-renal failure most probably because of the myoglobin which must have been released from the muscles which have been crushed up during lynching.

I happened to pass through the ACU today afternoon. It was good to know that the relatives ultimately decided to take AS to Ranchi. But, there was something else happening there. There was a man giving a good massage to AS and he was giving it more on his head. AS' family had got hold of a traditional healer and was trying him out in our Acute Care Unit.

I did not bother much as AS was going anyway. It is so surprising that people in this place still put quite a lot of trust on people who hardly know anything about medicine. It was a paradox as AS was still in a shock and we had started him on a dopamine drip. I wonder if the relatives are really taking him to a higher centre.

The Birthday Party

Shalom had turned 4 on the 29^th September. Unfortunately, there were pressing things from the hospital which prevented us from having his birthday party on the same day.

So, we arranged for a party today. We had been discussing for a long time about what we would give for the party. The usual fare in the campus birthdays is either samosas, egg chops, or potato bajjees along with one of the umpteen sweets. More of less, it was predictable and it was quite common to see food being wasted.

There was couple of children who had been sending feelers that they would like to have idlis. So, ultimately we decided on having idlis. For Angel and me, it was going to be a herculean task. My sweet wife was quite up to the task and after quite a lot of planning, did a quite superb execution. By 4 in the evening today, we had 180 idlis – made with a small 2 litre grinder and an idli cooker which made 16 idlis at a time.

The party went on quite well. Shalom wanted his favorite Gems cake – we had managed a heart shaped cake tray – so it was quite a good sight to the eyes. Along with the idlis, Angel also managed to make about 7 cakes.

We had about 30 children for the party.  It was quite heartening to see the idlis disappearing so fast. Our next project would be trying out making appam and chicken stew for the children’s Christmas party this year.