About Renal Failure . . .

Yesterday, as I saw a patient, the relative asked me if I remember a young man who came to us about a month back. It was not difficult to remember the young man. We shall call him DK.

DK was just 17 years old. He had quit his studies couple of years back and was making a living doing odd jobs around our town. 6 months back, someone told him about big opportunities in Mumbai. He went off to Mumbai only to fall sick within few months.

He just had unexplained vomiting. Nobody could find out what was wrong with him.

DK came back to Kachhwa and came to us. The doctor who saw him did not have to delve much into his complaints. Renal failure was written on his face.

His blood pressure was 210/140 mm Hg and serum creatinine came as 24 mg%. We sent him off to a tertiary hospital near by.

He came back after 1 week in quite a bad shape. He already had 3 dialyses. On reaching the public tertiary care centre, the doctors told him that there was no free bed to admit him for emergency dialysis. They offered a referral to a private hospital.

The family coughed up 60,000 INR from various sources and slowly they realised that it was a losing battle without adequate funds.

They took discharge and him to us. One of the relatives told me that they are already in debt of about 30,000 INR. They could not afford to go into any more debt. We also could not offer anything.

Yesterday, I came to know that DK died the next day.

I’m glad to see a news report about the burden of Renal Failure in the country.

DK is the 3^rd patient I encountered over the last 4 months of our stint in Kachhwa who died. We’ve about a dozen patients who are in the verge of going into End Stage Renal Disease. 2 causes predominate here – poor control of diabetes and hypertension, abuse of NSAIDs.

There are 3 options, no four for our countrymen once someone has End Stage Renal Disease. In the absence of public healthcare facilities to tackle ESRD, the best option for many of our countrymen is to go home and die. The next option is to do peritoneal dialysis which would cost up to 20,000 to 25,000 INR per month theoretically – in practice, I’m yet to see someone on PD who does not incur an expense of less than 30,000 per month.

The second best thing would be to have hemodialysis provided you have good centres near your place of residence. The article says 1200 to 2000 INR per session. You need about 10 such sessions every month. Then, there is the additional cost of medicines. That also comes up to around 25,000 to 30,000 INR per month.

The best treatment is to undergo a renal transplant. I understand that transplant laws are quite stringent that it is quite difficult to get a transplant done. And then there are costs involved. Many patients thing that renal transplant is like a magic bullet. After a renal transplant which costs between 100,000 INR in government centres to as high as 800,000 in private centres, there is the prohibitive cost of immunosuppressive medicines to be taken for life. The average expenses post transplant run to about 15000 to 20000 per month.

The best bet seems to be preventing renal disease. Avoiding and promptly treating urinary infections and early diagnosis and optimal treatment of hypertension and diabetes should be given priority in all primary care centres of the country.

Otherwise the burden of renal disease is just going to overwhelm us.

Maybe, we should have send her home . . .

Couple of days back, we had a very sick pregnant lady being wheeled in.

As DD was wheeled in, we were quite sure that we were dealing with a very sick patient. She had been in labour for more than 4 days. It was very obvious that she had been through a tough time. She was in a terrible shape; all bloated up; the birth canal was so edematous. The baby was obviously dead. The head was so high up and appeared to be stuck. The abdomen had a very abnormal contour which is quite commonly seen with those who sustained a rupture uterus.

There was a high chance that the bowel and the bladder were all ischaemic because of the abdominal massage she had over the last 4 days. There was only a 4-5 centimeter diameter of the birth canal. Even if we tried a craniotomy, there was high chance of severe birth canal injuries. There was also a chance of a rupture uterus.

She was also in severe sepsis.

There was only one thing that we could think about . . . to operate and remove the dead baby. The family were very very poor. They had not even a single rupee to take. They had been to couple of other places. The travel from their home to the various centres and lastly to NJH had taken up all the money they had.

Considering the chance of a rupture uterus and bowel injury, we decided to operate. On hindsight, the decision was a ill thought one. The uterus was not ruptured. But, the lower segment was like mincemeat. Putrefaction had set on the baby. On opening the uterus, there was a gush of pus and foul smelling gases.

The bladder was distended and edematous. So was the bowel. There was no necrosis or ischemia . . . but it was obviously unhealthy to look at.

I somehow closed the uterus and came out of surgery.

She did well for the first 24 hours. Then, her condition just deteriorated. She was running high grade fever round the clock. We had to hook her to the ventilator. There was foul smelling material coming out of the uterus. Her urine output was fine, but it was getting bloody and brownish. Her creatinine is about 6.

Today evening, she is all puffed up.

The costs of the treatment has been on the house. However, we will not be able to give her high end antibiotics like Piperacillin-Tazobactum. We helped the family arrange one pint of blood. We’re quite sure that we would not get any payment for this patient. The family had a RSBY card. We’ve blocked her under the scheme.

Please remember DD in your prayers . . .  

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.

Near death experience of a young man with diarrhoea

DD, a 20 year old young man hailed from the nearby village. DD earns a living by selling off wood which he brings from the forest.

DD was suddenly taken sick yesterday afternoon, when he developed severe vomiting and loose stools. DD’s parents got hold of the local 'jhola chap' (travelling quack) who gave him a prescription of intravenous fluids, Injection Amikacin, Injection Dexamethasone along with some more medicines. I had managed to get hold of his prescription which is put here.

DD was brought to NJH at around midnight yesterday. He was very very sick. He had a thread pulse and we could not record his blood pressure. The symptoms were very much typical of cholera. Since it was midnight, we had to wait till day time for a ‘hanging drop test of stool’ for cholera bacteria.

 

Later I found out that DD had not put out any urine since yesterday morning. We put him on a catheter and there was hardly any urine.

DD responded quite well to intravenous fluids and Tablet Doxycycline. By morning, he had started to put out urine in small amounts. Although the frequency of passing stool had decreased, we managed to get a sample for the ‘Hanging Drop’ and it tested positive for cholera.

He had come to NJH on time. If he had waited some more time, we could have lost him. The management of the quack continues to be the same as that of what used to happen 20 years back. I wonder if we could train some of these quacks to provide life saving treatment.