Tetanus . . .The Saga Continues . . .

I never had any inkling that I would end up managing quite a lot of tetanus patients. After MS, who was the first tetanus patient who got into this blog - we've had quite a few of them. In fact, at any given point of time, we had one patient in the ward with tetanus. And we praise God - all of them have gone home well.

LO is our latest tetanus patient who has been discharged well. We had a tough time with LO. LO was a bit of a adamant boy throwing up all sorts of tantrums - And then, you cannot blame him. One of the problems we face with tetanus patients is the difficulty in putting a nasogastric tube during the initial phase. LO was adamant that he would not allow anybody of us to put a nasogastric tube even after we felt that it could be put.

Maybe, he must be the only tetanus patient in the world who would have survived without a nasogastric tube. His mother was so loving - and somehow she improvised a way to feed him without allowing him to choke on the food. Everyday, we used to fear that he would choke himself to death.

Well, couple of days before we discharged LO, we had a replacement for LO. SK, a 8 year old girl has landed with a quite a bad tetanus. She is presently responding well to treatment. We pray that SK would also go home cheerful.

Worst of all poisonings . . .

Well, kindly take a look at the photograph below. Does it not look like a bucket of floorcleaning solution freshly prepared for cleaning.

Sorry, you are mistaken. That is contents washed out from the stomach of a 65 year old lady who had come to emergency yesterday. She was totally unconscious and had a poor cardiac activity - heart beating at around 10 per minute or was it a total cardiac arrest? I was not very sure. The pulse oximeter was not picking up any signal.

We started off the CPCR. Unfortunately, both our ventilators were already occupied. There was no other choice other than to bag her manually. By God's grace, we had enough hands to do that.

The history was that CD had taken some unknown poison sometime in the afternoon when her relatives found her unconscious. They had called a local doctor who administered some medicines after which she had become unconscious.

On arrival at NJH, CD smelt of organophosphorus poison. But, it was funny that she did not have the characteristics of organophosphorus poisoning. She had already been to a quack. The relatives got the quack over the phone - he had given her a shot of Betamethasone, Gentamycin and Multivitamin. However, her pupils were normal but she was frothing in her mouth.

After CPCR, I somehow got her heart going and she was put on an Atropine drip. Another line went in with Dopamine. Simultaneously, we were doing the stomach wash and then I suspected that she had mixed Phenol too into the cocktail. ECG showed features of hyperkalemia. In went a dextrose-insulin drip.

For our hospital, she looked out of place. With the mechanical ventilation and 3 intravenous lines running, it was a real sight. The relatives bagged her through the night.

By morning, she was trying to breathe on her on and move her limbs. We are in the process of gradually weaning her out of the dopamine drip. I suspect that the old lady had taken a cocktail of organophosphorus poison and phenol perhaps laced with a third poison like Aluminium Phosphide or maybe Endosulphan.

We thank the Lord for the recovery so far. However, she has a long way to go - the relatives have told me that she is regular anti-depressant medication. Please pray for her.

Violence . . .Living with it . . .

Our region has been in the grips of regular violence for quite a long time. Finding dead bodies on the road, news about gun firing and bombs going off are quite regular stuff.

As I had mentioned in one of my previous posts, we had been having quite a number of bandhs since the last 10 days. In fact, bandh has been called today and tomorrow too.

However, today morning, I woke up to the rude shock of a mine blast quite near our hospital which was aimed at a Member of Parliament from the adjacent district. From the latest reports, 12 people, almost all of them policemen have lost their lives.

As I sat reading the news in the newspaper, I got a call from Manika Police Station. They were bringing in someone with a bullet injury. The inspector did not have much idea about where the injury was.

The victim was in his early 20s. The bullet had entered his right flank more towards the back and exited on the left flank. Clinically, it looked like it may have gone through his vertebral column. However, his neurological examination appeared normal. But, he was in severe pain.

We did X-Rays and a ultrasound. It was almost certain that it did not enter the peritoneal cavity. Amazingly, there was no obvious involvement of the vertebrae. On very careful examination of the lateral spine X-Ray, we could make out an area suggestive of cavitation of the soft tissue with some involvement of the spinous processes of the vertebrae.

We gave the family the option of taking him to a higher centre which they obliged. The story was that the victim unwittingly got in between crossfire between two naxalite groups.

Many of our friends and relatives question our logic of serving in such a place where there is always danger lurking around. After the gruesome murder of Sr. Valsa John, it is quite obvious that anybody working for the welfare of the poor can fall victim to the violence that can be unleashed in communities like ours.

The patient with the bullet wound was an ominous reminder about the very dangerous society we are part of. We request your prayers. . .

X-Rays with findings - all on a single day

After the quite dramatic X-Ray that we had of NR quite fresh in our minds, I had the shock of my life when I reached the outpatient department today sometime midmorning.

The below are the X-Rays which were put on the line to dry -

1. A 60 year old man with partially treated tuberculosis who has come with severe cough. We await his sputum AFB.

2. A very sad story. 30 year old man with cough of 6 months duration. When I asked him on what treatment he was on - he showed me the medicines shown in the snap after his X-Ray snap.

The blister packet on the left is the Category 1 Intensive Phase under the Revised National Tuberculosis Control Programme of the Government. And Levofloxacin is one of the drugs used to treat MDRTB. It seems that a local practitioner has prescribed it. A good recipe for XDRTB.

The young man was quite breathless. He had a saturation of only 70%. The relatives has begged me for admission. His total counts is 25,000 with 90% polymorphs. He needs a miracle to make it.

3. 70 year old man - again partially treated tuberculosis. In addition to this he had bilateral basal crepitations on examination. Shishir did a cursory look at his heart and has concluded that cardiac activity is quite sluggish - hypokinetic.

More concerning was the lesion he had. He is awaiting sputum AFB and an ECG.

4. Well, the winner is the this one. 45 year old lady, weighing 27 kilograms with cough and loss of appettite since 6 months.

After seeing the X-Ray, I initially thought of a malignancy. Then Nandamani thought about doing an ultrasound and seeing if there was any collection. Shishir reported cystic lesions within the chest and then this is what he saw in the liver.

Hydatid cysts. . . We did not know much on what to do. I thought about referral. On discussing with the husband - he told me that 3000 rupees is the maximum he could afford. I prescribed her Albendazole tablets and Prednisolone in a tapering dose for a month.

I had two more interesting X-Rays but could not take the snaps because of the lack of time. However, sometimes when I see the tuberculosis patients, I continue to wonder whether we are really winning the war against tuberculosis.

Would appreciate if you could pause a minute and pray for such patients who do not have much of a hope as well as for the need for healthcare personnal in enough numbers who will be able to cater to such a population quite early during the course of a disease.

The Rush Continues . . .

(Kindly note that the picture in this blog is a bit gruesome for non-healthcare readers)

The last 3 days of November were relatively manageable at NJH. So, most of us were comforting ourselves that we would slowly be moving into a season of rest and celebration. And, from the second week of December till almost the first week of January, we would not be more than 2 doctors at a time in NJH. So, we would have preferred to remain a bit quiet - enough patients to just keep ourselves financially stable.

So were my thoughts as I walked out of office for the Unit Management Committee meeting yesterday, the 30th November.

However, as I came back, I knew that at least we would not be starting December the same way.

There were 2 patients in labour room. One of them had come in sometime early morning. A teacher in a school in the adjacent district. She had been leaking since the previous day. She was screaming for a Cesarian section. Ultimately to satisfy her, I had to do a examination which was not really warranted - and was almost sure that if she could hold on for another 4 hours, she could deliver.

Then, we had PD, who had been with us for the last week - leaking at 32 weeks. Ultrasound had shown that her baby was just around 1500 gms. We tried our best to refer her but to no positive response from the relatives. Sometime in the morning, we had done an ultrasound which revealed hardly any liquer. In addition, I wondered if she was running a mild fever. Total counts were elevated. We had to induce her, which is what we did sometime in the evening.

As I left the labour room to check on MY, there was one more patient being rolled in.

I reached ACU to find out that there has been a road traffic accident and couple of people who were quite serious has turned up. I met Dr Shishir who was on duty who updated me that one of them had a very bad degloving injury of the foot and he had called Dr. Nandamani to review. The second person appeared to have a blunt injury foot.

Then, there was one more case of poisoning which had turned up - this time, it was organophosphorus poisoning. AK was doing fine so was MY. I wrote for repeat liver enzymes for MY and returned home. As I passed through Labour Room, I enquired about the new patient. I was informed that SD has come in with most probably a dead baby and Dr Shishir was on his way to examine her.

Today early morning as I made to office, I was informed that SD turned out to have a rupture uterus. Her story was so painful. I hope to post it sometime later. She continues to remain sick after undergoing a hysterectomy in the night.

Then, there was PK, a young man - an alcoholic on regular pain medication for non-specific body pain who had come in with quite a bad duodenal perforation.

The theatre team was in hospital overnight. They had arrived at 8 PM the previous night and had returned at 5 AM in the morning. In addition to the two laparotomies, there was the young man with the degloved injury of the leg. Nandu informed me that the unfortunate soul would need a tendon transplant later.

However, I was glad to know that both the other labour patients had delivered normally. The teacher delivered a 2.25 kg girl sometime before midnight and the 32 weeker with leaking delivered a 1.5 kg boy.

Later, there were 4 more deliveries over the day including KD, a G5 with abruptio placenta.

The previous night would have been busier had a primigravida in frank pre-eclampsia with a horrifying blood pressure of 170/130 and a Urine Albumin of 3+ not decide to go home inspite of all our pleadings... It was so unnerving.

However, to compensate for her, today afternoon, we had another primigravida who has come with severe eclampsia at around 7 months pregnancy. By ultrasound, the baby weighs about 1400 gms. We had decided to give the baby a chance by with steroids acting for 24 hours.

SD who had the laparotomy continues to be sick. We request your prayers. Meanwhile, we thank the Lord that MY has survived. His liver enzymes are within normal limits. I plan to discharge him tomorrow.

And to top it all, all this rush on a day when the whole nation is on strike . . . If this continues, we would find it difficult to manage from next week with only 2 doctors . . .