Weekends with Dr Jagadish, episode 2: A snake bite to remember

I met Mr P at a function organized by a society of my community, to honor me in my home district. They claimed, I was one of the few from my community, who returned to work in India after working in Melbourne. Also my uncle was standing for elections in the society that year, so he actively went about organizing the function to subtly convey to the voting members, that he supports young achievers in the community. 

A certain Mr P was invited to be the MC (master of ceremony) in that function, he later told me he was felicitated by the same group earlier. Mr P has great command over English and his mastery has to be heard to be believed. He is an expert in languages. His PhD thesis was about a dialect in Naga language. Government of India approaches him for work related to North eastern languages. To top it all; he was a student of Prof U R AnanthaMoorthy. Yes, the same alleged rationalist who had claimed that he urinated on (his) village deity at night when no one was looking.  I was in my early thirties at that time and he was in late forties. When we spoke to each other we came to know that we stay in the same neighbourhood in the city. So we decided to keep in touch.

Our meetings were feared by Mrs P, let me call her Babhi. We used to be loud and argumentative. I never believed a word he said and used to make fun of Nehru, Gandhi and Socialism. He a true follower of AnanthaMoorthy used to give me back in kind. We still fondly remember the day Babhi came with a chapatti roller in hand and threatened us to stop fighting in such loud voice. She said: she was scared that the kids will think we were actually fighting (although I believe she was scared herself). We turned out to be great friends and still are, to my credit Mr P today has turned capitalist and agrees that “woke” phase of life should not last beyond adolescence.

This weekend article, is about his younger daughter S and her husband. S was a 16 yr old when I first met her. She was a bright student and went on to become an engineer in computer science. Like all CS engineers of early 2000, she moved to Amrika and started working in the Silicon Valley. It was here she met her John Doe. Mr P the liberal that he was did not oppose to their marriage. I used to occasionally rake up about S to tease him; by repeating his old dialogues about communism being a product of capitalist oppression blah blah...

Newly wed S and her husband Mr John Doe visited India and stayed in Mr P’s home. Me and my wife invited them home and had lunch together, discussing about life in US, harping about non availability of domestic help in the US, which is taken for granted here. Mr P and a friend of his had arranged for their visit to Madikeri and surrounding areas so they were off to Madikeri next day.

By 3 PM next day, my wife called me (I pick only her calls on my cell inside hospital) and told me to talk to Mr P, that he was calling me continuously and I had not replied his calls. I knew something was wrong, so I called Mr P immediately. He was almost crying and it took me awhile to understand that John had been bit by a snake and was not responding after first aid in Madikeri Govt Hospital. I knew Dr Ravi, an old student now a colleague who was working in Madikeri Govt hospital and called him immediately, he appraised me of the situation and told me snakebite was on right elbow and John was responding to painful stimulus. Dr Ravi had done all the necessary first aid. I requested Dr Ravi to accompany John and S to the hospital where I was working at that time.

It was 11 PM when they reached our casualty. I was waiting there after hand-holding Dr Ravi in managing the patient through the transit. John was awake but intubated and Dr Ravi was giving him artificial breaths using an ambu bag. He was able to manage a weak thumbs up sign when he saw me otherwise his muscle power was very poor. He was shifted immediately to the ICU, snakebite protocol started and put on artificial respiration through a machine called ventilator. He appeared to have stabilised for the night. I explained to Mr P and S that their presence will not help John and made them leave to their home.

Next day it appeared as if John had gone into a coma. His heart rate seemed to be fixed in a window of 50 to 60. He was not responding. His GCS was 3/15 with absolutely no response for even deep painful stimuli. His pupils were not reacting to light and not a muscle moved in his body. I was deeply worried, had no idea how to face S or Mr P but I had to do it. When I met them in the counseling room; S was crying hard and Mr P had tears in his eyes. I explained everything to them dispassionately (years of ICU practice has converted my heart into stone: says my wife) and gave them no guarantee about John’s recovery. Hope and prayer was the last resort, so I told them to pray. 

John’s condition did not improve the next day; my staff and junior doctors had already started susurrating behind me, I could perceive them make eye signs to each other. Sir “patient’s pupils are not reacting to light”; they informed me three times in the day as if I had not heard it the first time. I had my doubts too; I rummaged through all available data on snakebites and found one similar report by a doctor called Rallis. I emailed him and asked for his phone number. Dr Rallis a nice man, he called me back. I explained to him John’s condition. He asked me to stay put and continue the supports as long as John’s heart holds and if necessary support aggressively and last but not least: don’t worry about non reacting pupils.

After 3 agonizing days I got a call from ICU at around 2 AM. I thought John may have kicked the bucket; but to my merry, I was informed that John’s pupils had started reacting to light. I got ready and drove to hospital to check and was wonder-struck to see him, showing signs of life. It was pure ecstasy nay jouissance. Very few understand how a doctor feels when his almost dead patient comes back to life. I thanked Mahadeva Mallikarjuna Swamy for it.

Next day I allowed my next in-charge to explain the good news to S and Mr P while I observed his performance carefully. It had become my habit by then, to allow juniors give the good news while I personally discuss bad news with the patient relatives.

In the next 2 days John improved very fast and was off artificial respiration. S and John send me a card now every year for my birthday.

Doctors like myself carry the burden of a graveyard in our minds of all the patients we lost. Amidst the graveyard, we do remember these beautiful memories like a lost person in desert who comes across an oasis.

Dr Jagadish J Hiremut is a superspecialist medical doctor based out of Bangalore, a medical author, blogger, medical technology expert and is a proponent of Value Based Ethical Medical practice. He is Director for clinical services and Advanced Medical Technology in the home grown multinational medical equipment company Skanray Technologies Pvt Ltd. He is also CEO of ACE Embedded Intensive Care Units Pvt Ltd a company which runs outsourced Intensive Care Units for hospitals. You can follow him on twitter @Kaalateetham or mail to drjagadish10@gmail.com

Weekends with Dr Jagadish: A beautiful child called Poovi

Dear friends, I will be writing to you every weekend on issues which are nice or important or maybe something which caught my eye or taught me a lesson.

In this episode, I shall write from one of my first experiences as a doctor in an ICU taking care of a child.

Eighteen summers ago as a freshly minted Doctor out of a university hospital, I joined a hospital to work in ICU. The concept of paediatric ICU was not so well developed in India then, whilst NICUs were ubiquitous. The children were invariably kept with adults in the ICU if they needed extra support beyond the ability of ward staff/facilities.

A child was brought to the ICU where I had just joined as ICU in-charge. The baby was little more than a year old and was suffering from severe breathlessness; the attending Paediatrician had diagnosed it as community acquired pneumonia and treating the baby as such. On admission we had put a small tube into the stomach of the baby and did a wash. The lavage screening later confirmed an organism called streptococcus pneumococci as the cause of pneumonia.

We used to allow an attendant to be with the baby in ICU if the baby/child was less than 4 year old, as we could not afford our nurses to babysit. Invariably with all babies we were accustomed to see the mother/grandmother of the child babysit in ICU. In this unusual case, it was not the mother but sister of child who took to the job of babysitting.

It was here I saw this beautiful little girl; she barely looked like a 10 year old. My first reaction on seeing the child was; why is this child inside ICU?  I was concerned about her contracting resistant nosocomial infection. I called for the nurse in charge, requested her to send the child outside and bring mother or someone else the baby is familiar to accompany him. At that moment, the girl spoke to me directly (the voice was sweet as any small kid’s voice would be) and said “Doctor uncle: please allow me to be with my brother, there is no one other than me here, amma is back in village, she has work to do”. I ignored her sweet voice, with the faux authority of a man in-charge and asked the nursing in-charge present there, to check for her dad or anyone else to be brought in, instead of her.

The nursing in-charge was a smart lady, she had already done it and told me that the girl was right and she was the only one available to baby sit the kid. I asked the nurse attending the child “can you manage the baby without her?” To this too, the nursing in-charge replied that the baby cries incessantly, if Poovi goes out. That was the first time I heard the child’s name. At that point, I went to attend to other patients, the ICU was full, I was new and had to impress the staff and the boss who paid my salary.

In the next eight days, I was greeted by the radiant smile of little Poovi whenever I entered ICU and I got used to it. She grew on me, my rounds in the ICU started with her smile and ended with a small chat to her. She became the raison d’etre for me spending extra time in ICU. In her own innocent way she told me about her alcoholic father, her hard working mother and how she (little Poovi) used to take care of her brother.

On ninth day myself and the paediatrician decided that the baby was better and can be shifted to ward, so little Poovi and her brother were sent to paediatric ward. The paediatric ward was in the far corner of the hospital which I seldom visited it as I did not like to be amongst crying babies; except that on this instance little smiling Poovi lured us (me and 2 other nursing staff) to visit her. I spent twenty rupees and got her a dairy milk chocolate, boy was she happy!  I remember telling the nursing staff on many occasions, that I had never seen such a beautiful child and mera nazar na lag jaye usko.

In the next four days the baby was discharged, an uncle of Poovi along with her mother took the children back to their village in Coorg, called as the Scotland of Karnataka. A month or so elapsed and our memory of the baby and Poovi were almost evanescing.

One morning at 5 AM, I was woken up by the nonstop ringing of my phone (landlines were the life savers of that time). I was asked to come and see a child immediately. Staying in the quarters given by the hospital, it was just a 3 minute walk to the casualty. I was shocked to see Poovi brought unconscious to casualty and her inconsolable mother. She was admitted to the same ICU where she used to welcome me with her beautiful smile. In the next 3 days her condition worsened and we lost the most courageous, caring and beautiful child to the dreaded pneumococcal meningitis.

I can never forget her smile or her love to her brother or her ability to adapt to the needs of her family; she has always made me wonder “are all girls born mothers”. It always brings me tears to even think that I was somehow responsible for the death of this beautiful child and I curse myself for allowing her to be with her brother in the ICU. Lesson learnt at a great irredeemable cost.

PS: This series "Weekend with Dr Jagadish" will be published in @indsamachar and as usual all my articles will appear on my personal blog.

Dr Jagadish J Hiremut is a superspecialist medical doctor based out of Bangalore, a medical author, blogger, medical technology expert and is a proponent of Value Based Ethical Medical practice. He is Director for clinical services and Advanced Medical Technology in the home grown multinational medical equipment company Skanray Technologies Pvt Ltd. He is also CEO of ACE Embedded Intensive Care Units Pvt Ltd a company which runs outsourced Intensive Care Units for hospitals. You can follow him on twitter @Kaalateetham or mail to drjagadish10@gmail.com