Diagnostic Dilemma . . .

We had a very interesting case yesterday night . . . 

I shall call her DDe. DDe, 26 years had delivered her first baby 7 days back by normal vaginal delivery at home following which she was fine for the next 3 days.

On the 4th day after delivery, the family noticed rashes all over her body including her face. There was no fever. 

They took her to a local hospital where she was being managed for the last 2 days. As she was not improving, the relatives brought her here. In addition to the above skin manifestation, her fingers had become stiff and was blackening. 

Below are the significant snaps . . . 

Actually, the nose was all gangrenous and was smelling bad . . . it had rather become like a bag of pus. In addition, the tips of the fingers also had become gangrenous. There were ecchymotic patches all over the trunk and body. 

There was discoloration of the toes too. However, it had improved in the morning. 

Blood investigations: 

Total counts: 44,000/cu mm 

Platelets: 115,000/cu mm, 

Differential Count: P85, L11,Myelocyte2, Metamyelocyte2

Serum creatinine: 1.79 mg%, ESR: 70 mm/1st hour. 

My first diagnosis was septicemia in a setting of a connective tissue disorder. 

We tried to refer the patient all through the night . . . And we succeeded to convince the relatives by morning. 

On admission, she had tachypnoea. And it had worsened overnight. However, she was maintaining her saturation, although there was coarse crepitations all over the chest. We could not get a Chest X-Ray. 

However, we got a different diagnosis after the peripheral smear examination - which showed a hypochromic microcytic picture, poikilocytosis with ?? sickle cells. There was marked leucocytosis with neutrophilia, shift to left and toxic changes. 

The patient is now on her way to the Medical College, BHU, Varanasi. After the peripheral smear, I wonder if it is a sickle cell crisis following septicemia. Since the peripheral smear result arrived after the patient left, we could not get any more history. 

Please do give your opinion on this patient. 

Maternal health care . . . Quo vadis . . .

 Last Wednesday, I was quite content that I would be able to sail through the day without being very busy. Wednesdays are usually quite light at NJH - the major reason being that it is market day in Satbarwa. Most of the local crowd would not be free enough to come to the hospital and there would be fewer vehicles available to bring in the patients as most of them would be eying the market crowds . . .

I was wrong. . .  And to top it, I had 4 maternal near misses of which already one is a maternal death, one is on the verge of a possible maternal death, one is out of danger and there is no blood available for the fourth one . . .

I would not go into details - but just a glimpse into each patient. We shall call them A, B, C and D - just to protect identities.

Patient A: A previous Cesarian, had been having pain since yesterday night. As she came in, we had a very alert Titus who ensured that the baby was delivered within forty minutes of the patient entering the hospital. It was impending rupture and the baby was quite sick.

Patient B: A very interesting case. Came with a history of seizures in a hospital at the nearby town. Urine albumin was 3+ and there was gross hematuria. We gave the option to go on to Ranchi. The baby was alive. We took her for Cesarian. The surgery was uneventful - but the mother became sick soon after. Went into respiratory failure and suffered a cardiac arrest and died. The baby although sick was doing well.

Patient C: If Aamir Khan knows about this, he could make SMJ Part 2 against the doctor community. But, then he'll have to pull few of the policy makers also. Patient C, a mother of 2 had been having labour pains since Monday afternoon. She was trying for a home delivery. Nothing happened till Tuesday morning, following which she was taken to the local Primary Health Centre. They were told that nothing much could be done and she was taken to a private practitioner who kept her till the evening. By around 4 pm yesterday, the relatives were told to take her to the district hospital. She was given one unit of blood . . .kept overnight. One more unit of blood was transfused today morning. By afternoon, she was told that she had some major problem.

She reached us by around 4 pm. The abdomen looked as it had ruptured.She was toxic. 

There was nothing much we could do. The fact that she was mother to 2 girls made us take a decision to try to save her. Two of our staff donated blood. 

Per-operatively, we knew that it was going to be tough. The blood was very dilute and the whole abdomen was stinking. On opening the uterus, there was a gush of toxic gases - it was like a little volcano bursting. One of the nurses went searching for eucalyptus oil which we keep for such occasions. 

She was stable after surgery. However, we decided to keep her on the ventilator. 

Although she made it till the next day, she suffered severe hypotension followed by cardiac arrest sometime during the afternoon. She was dead . . . most probably multiorgan failure secondary to severe sepsis.

Patient D: She came in as we finished operating on Patient D. A previous Cesarian section done at Garhwa couple of years back, the patient had been trying for a home delivery since early morning. It was almost quite late in the evening. She was visibly pale. And we needed blood. Clinically it looked rupture uterus. 

Blood  came sometime past midnight. Again Nandamani had to be called in. It was a very bad rupture uterus. She has done fairly well so far. 

So, on a unusually busy Wednesday we had 2 Dead Babies, 2 Dead Mothers - one of whose babies was alive although sick. The other 2 mothers could have also died. The 2 babies born alive were also born with low Apgar Scores. . . 

Well, to nail the facts once more - 

Patient A: Mother alive, Baby sick - Impending Rupture

Patient B: Mother dead, Baby sick - Eclampsia

Patient C: Mother dead, Baby dead - Impending Rupture

Patient D: Mother alive, Baby dead - Rupture Uterus

All the 4 patients came within an interval of 10 hours. All mismanaged elsewhere . . .

I wonder how long will this 'tamasha' will go on before sanity dawns on the policy makers and the government . . .

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.