Sunday, December 27, 2015

The BT Shunt Conundrum

[Blalock Taussig Shunt # is a surgical procedure done in new born kids with cyanotic congenital heart disease, otherwise called the blue babies. The disease is caused by a variety of anomalies in heart development, all resulting in poor blood flow to lungs, thus leaving blood deficient of oxygen. BT shunt is a palliative procedure till the child grows up . It involves making a connection from your aorta(the vessel that supplies oxygenated blood to your whole body) to pulmonary artery(vessel that supplies impure or de oxygenated blood to your lung). Challenge in managing a BT shunt is balancing the flow through the shunt. If too much blood goes to lung, rest of the body is deprived of blood flow leading to complications. If too little blood flows to lung, the oxygen content remains low and whole surgery goes in vain. This relative flow is maintained by different medicines which can increase or decrease the flow through either system]

Making choices are the biggest challenges in life. In many real life situations, there is hardly anything black and white. There is no absolute right or wrong and at times, either choices can make you regret later. At some point of time, we all regret at the choices we made, as well as the ones we didnt make. At times money or rather lack of it helps you choose a default decision.

One day, a young Nepali lad, may be in his early twenties popped up in my OPD with his wife, probably in late teens and a 7 day old baby. Baby was Manisha, named after the most iconic Nepali beauty in India. She was indeed beautiful, except for her dusky blue colour.

She was sleeping in her mothers arms. She  had a yellow butterfly cannula * loosely hanging from her left wrist.
She was one of those kids with a congenital abnormality of heart called Tetrology of Fallot more commonly called a blue babies. Her oxygen saturation level was 70%, barely survivable, way below 98% of you and me. Any time it can further spiral down, some thing called a spell,  even claiming her life.

I knew exactly what she needs, a BT shunt.

But in starred subscripts I have to mention, "conditions apply". Firstly its only a bridge procedure, only till she over grows her shunt, warranting a further surgery, probably a couple more depending on how her heart develops. Her brain is already deprived of oxygen in most crucial period of growth which could have already hampered her cognitive development. She will bear a centipede scar on her chest and branded as a heart patient for a life time. Even a successful surgery means some 5-6 hours work of a dedicated team, advanced infrastructure, some 20+  medicines and intensive care for at least a week. Translate everything to financial terms, it becomes a fairly huge amount even for a middle class family, let alone for a partially employed migrant family.

Almost all treatment for kids are now covered by some scheme name RBSK started by silent Manmohanji. But that is applicable only for Indians, that too in Government hospitals.

I hope Manisha will come back, somehow with the money for her BT Shunt. But I am also quite unsure how that will alter their family dynamics. They might pledge all their possessions and divert all their resources for this particular event such that finally they all suffer and die of poverty. If they have any other kids, they will also suffer for her sake.

Its not just one Manisha, it happens in lot of scenarios, particularly those suffering malignancies. There are scores of people who end up spending their life savings for a couple of years of life of suffering. The act of balancing cost effectiveness of a treatment is a big worry.

Unfortunately, docs are not good economists. We are realistic dreamers. We prepare to embrace the worst while wishing for the best.We wish to try out even the last arrow in our arsenal before accepting failure.

Once upon a time my IIM graduate friend told me that cost of life is just the cost of replacement. He might be correct in a sense. But I dont know how and at what cost, someone can replace his dad or mom or kid.

I really wish we had a formula, a mechanism to measure the realistic value of life, not to buy or sell, but atleast to help us decide how much to spend, and may be when to give up.

Just like how much flow the BT shunt should have....

Tail piece: Try those links if it was too technical. Last one is an HBO original movie about first BT shunt.



  1. It's really a thought or issue in anyone's life which leave them most confused, yet a decision is needed at the earliest, but a decision which can't be made so easily!! A replacement cannot be made for sure!! Only a way to make it easy is, a realistic vision about life in this world, which not everyone can digest. It's nothing but life doesn't end here, it continues... replacement, though it's made only for a very short period in life, we get them back in the next phase of life, persistent and sincere prayer is key!!

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  4. Interesting. I'm about to become a doctor and this question will probably haunt me. I'll for sure hate those patients who say "Doctor, do what's best". Please keep blogging, malayalam or here

  5. Thank you Doctor ! Please Blog in English ! 🍎🍎🍎🍎