Surgery at NJH

During my short vacation, it was quite a blessing to have Dr. Nandamani and Dr. Ango to be with us. 

And I believe that it was a big relief for quite a few of our patients, especially to 2 young men who came with acute abdomen. 

The first one was VK, a 16 year old who came in with acute abdominal pain and distension. Of course, it was intestinal obstruction. 

On opening the abdomen, this is what we found . . .  

In addition, there was an area of constriction caused by tuberculosis which caused the obstruction. 

Then, there was one more young man who is still recuperating from the surgery for a duodenal perforation. 

After quite a long time, we had quite a large renal stone (staghorn calculus) removed. 

It does not need much research to conclude that a surgeon is a very much essential component in the scheme of things in a mission hospital. I wish we had a surgeon who was always around. Our surgical load is immense. Dr. Nandamani did about 70 surgeries in a space of around 2 weeks. 

Dr. Nandamani coming on a bimonthly basis is a major relief for us. We praise and thank the Lord for his bigheartedness. 

Could I request prayers for a regular surgeon to be at NJH? 

VK just before discharge . . . 

Almost missed . . .

Couple of days back, we got a patient who came in late into the night with vague complaints of abdominal pain and weakness of the limbs. 

He was already seen at multiple places where diagnoses of all sorts were made. 

The history was that JPJ, a 40 year old man woke up at around 3 am in the morning with severe abdominal pain. He was immediately taken to the hospital where the doctors could not come to a conclusive diagnosis.

The relatives took him to a total of 3 places . . . over a period of about 18 hours. 

The snaps of the prescriptions are given below . . . 

Please note the diagnosis - Pulmonary edema with acidosis with cerebral malaria. 

The patient had investigations like widal and chest x-ray

By God's grace, somehow Titus who was on duty suspected that JPJ had a krait bite. There was ptosis. 

In addition to the complaints of abdominal pain and weakness, the team noticed that his respiration was becoming labored. 

After discussions with the rest of the team, we sort of convinced the family that it looked like a snake bite. 

Within no time, he was gasping. We had him hooked onto the ventilator. 

With ASV on flow, he made a slow recovery. After 2 days, we thought that he was ready for extubation. On extubating, we discovered that his larynx was all swollen up. It was only a miracle that we could get him re-intubated. 

The relatives were quite agitated. They just could not accept the fact that he was doing good and suddenly had deteriorated. It was then that we realized that the family was quite well off and had the required good connections in Ranchi. 

After quite a lot of discussions, we told them of the futility of trying to shift him to Ranchi without a mobile ventilator. After quite a bit of conference with the relatives with the help of couple of doctors in Ranchi, the family decided that they stay back. 

He was on the ventilator for 2 more days. 

Today, Dr. Roshine told me that he is doing good and would be going home soon. 

A strong reminder to all of us on how a krait bite can turn out to be. With no bite marks, it is quite a tough task for the clinician to come to a diagnosis. And more difficult to explain to the relatives. If JPJ had come to us early in the morning, we could have also made all sorts of diagnoses. 

It was a lesson for all of us . . . regarding krait bite presentation . . . and how misleading can the history be. 

In addition, a strong affirmation for our service and a glowing example of how NJH continues to be the only lifeline for people like JPJ in this part of the country. 

Acute Abdomen - Intriguing

At around 7 am today, there was a 11 year old girl who was brought into emergency at NJH.

She has been having severe abdominal pain since the last 3 days. She was writhing in pain. Very typical of how patients with ureteric colic do.

NK had been having similar complaints since the last 5 years. It occurs once every 4-5 months. Elsewhere, she had been diagnosed to have chronic pancreatitis. During one of such episodes someone had also done an appendicectomy on her. She also had a CT Scan of the abdomen taken elsewhere which appears normal. 

We have her given her non-steroidal analgesics and anti-spasmodics which seemed not to have any impact on her.

The investigations are as follows –

Hemoglobin: 7.6 gm%

Total Counts: 14,900/cu mm

Differential Counts: P83%, E3% L17% Metamyelocytes 2%

ESR: 90 mm/1^st hour

Platelets: 178,000/cu mm

Peripheral Smear:

RBCs: Moderate anemia, Hypochromia +++; Anisocytosis +++; Microcytosis: +++; Poikilocytosis ++; Few ovalocytes; Tear drop cells seen

WBCs: Total count – mild leucocytosis; neutrophilia, toxic granulations+

Platelet: Adequate

Serum Creatinine: 0.76 mg%

SGPT: 33.5 IU/ml

Urine Albumin: 1+

Urine Microscopy: Epithelial cells: 4-5; Pus cells: 1+; RBCs: 1+; Bacteria seen.

Ultrasound Abdomen: Pancreas with heterogenous echoes and peripancreatic collection. All other organs were within normal limits. There was no evidence of any gall bladder or renal calculi.

As per our instructions, the parents arranged for one pint of blood.

I look forward to further suggestions. We’ve already suggested that they move ahead to a paediatric specialist hospital in Ranchi. However, considering into fact that they have already been evaluated at multiple speciality hospitals primarily in Patna and Banaras, they are not much interested. They have invested quite a heavy amount of money in her treatment, going to the extent of selling their property and land.

It seemed to me that they do not have any more funds to go further.

I write this in Acute Care. She’s sleeping very peacefully. Over the day, we’ve found out that she responds very well to opioid analgesics rather than to Non-steroidal analgesics.

And of course, we would value prayers. 

Acute Abdomen . . . Unusual cause

The acute abdomen is has always been a favorite question with examiners in under-graduate and post-graduate examinations.

 

Just wanted to share one of our patients, RD, pregnant for about 8 months who came in with severe abdominal pain. She had already been in couple of places where a diagnosis of preterm labour and was made and she was started on all sorts of medications to stop uterine contractions.

We had already been burdened with quite a number of patients which has stayed put since the Golden Jubilee. RD came in sometime between SD's and PD's arrival in hospital.

I just could not make heads or tails of the diagnosis as the patient appeared to be writhing in pain, but had a very soft abdomen and the uterus was far from any sort of contractions. So, I asked Nandu to take a relook at RD. Nandu was also quite baffled. But he had picked up some chest findings and he asked me to look at the possibility of a pneumonia.

Yes, it was pneumonia. There was an area of bronchial breathing with fine crepitations in the left basal region. And the X-Ray chest confirmed it. In addition, she had a total count of 28500 with predominantly neutrophilia with toxic changes.  

RD responded quite well to antibiotics. As quite commonly seen in antenatals in this part of the world, she was also anemic and after we did a blood transfusion, RD's road to recovery was quite fast.

We thank God that RD reminded us to go through our text-books once in a while so that our grey cells remain active and refreshed.