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.

#https://en.wikipedia.org/wiki/Blalock-Taussig_shunt
*https://en.wikipedia.org/wiki/Winged_infusion_set
https://www.youtube.com/watch?v=dh2TB1M0mY0

Brevundimonas Diminuta

Brevundimonas Diminuta is a Gram negative bacilli.Rarely thought to cause any disease.Hardly a dozen reports of it causing clinical infections so far. If they grow in a specimen, they call it a contaminant. But if you are so unlucky to undergo 4 heart surgeries at 5 years age, treated with 7 different parenteral antibiotics over 2 months and send home twice telling that nothing can be done, could it be the one killing you?  


Let me call her Sarah and let me tell you right in the beginning that this story doesn't have an end.

I got a call from a nearby hospital two months back, telling that one of our old operated patients is there admitted in their ICU and asking if we want to take her over to our side. Being a resident in a highly specialized unit, I was supposed to be the first one to respond. I collected her previous records and discussed with my chief. It seemed that he knew much more than what was in the documents. Just as I mentioned the name he started telling me the whole story, a complex congenital heart disease with only one ventricle, how they did a 2 stage procedure and had to abandon the second stage mid way through surgery as her heart failed to pick up, and they ended up doing a palliative surgery. I saw desperation in his eyes. He asked me to go with one consultant and to explain the parents that nothing more can be done.

We went there. A little dark girl was there, with a tube in her chest. She was probably in cardiac failure with sepsis. We explained that we had nothing more to offer and came back.

Three weeks later the parents were in my OPD. She was planning to be discharged to a palliative care center. I took the file again to my boss and to my surprise he asked me to put her in. We went on doing a full re evaluation,She had developed a pseudoaneurysm, a thinned out sac like projection from ventricle, at her previous surgery site, which was taking all the blood her heart pumps.The strange combination of problems is  unreported in medical literature.

Unconventional problems require unconventional responses. Two more surgeries were done in the next week, repairing of pseudoaneurysm and closing a leaking valve. It was as if my boss and his team was waging a war against fate, bringing out everything in his armamentarium.

She will do good some days,sit up and even tell bigger kids in nearby beds how to do chest physiotherapy to get well soon, drink kanji with pickle and paint with crayons in a colouring book gifted by her attending nurse. At times she develops breathlessness on lying down, racing our pulses high and forcing some emergency responses.

It was in one of those days, our microbiologists reported that her samples had grown Brevundimonas diminuta. They thought its a contaminant. Frankly speaking, everyone of us was hearing that name for the first time. We checked the literature. There was hardly a dozen reports of this bug causing a clinically significant infection.

But if you are unlucky enough to get such a long history in such a short time what are the odds that a are infection is insignificant? Any way she was started on antibiotics.

But the question is why do some people get such a rare fate?

I always wonder what does she think, about herself, her parents, about world as such. Does she know that there is something called death. Does she believe in fate. I dont dare to ask. I want to beleive that she knows nothing other than that she has breathlessness and we are trying to get rid of it.
But kids are hardly predictable.

Everytime I pass her, I realize how lucky I am. I have spent 3 decades on earth, I have my own troubles, but everything is minuscule compared to her fate, and that of her parents.

As I told you right in the beginning there is no end for this story.She is still sleeping in our ICU, hugging the pink teddy our anesthetist gifted her with her slender arms having an IV cannula and oximetry probe.  

Cardioplegia... opening hearts...

[ Open heart surgery is any surgery in which you open the chest identify and put tubes to both Sene cava and Aorta , divert the blood away from heart and lung, pass it thorough a Heart Lung machine to maintain oxygenation and blood flow, open up heart chamber and do the surgery. Cardioplegia is a technique by which you use drugs (mainly Potassium Chloride) to stop heart beating while you work. ] 

  When I chose medicine as a profession, I never knew what was lying ahead of me in my future. At every point of time when I look around I used (and most of my friends too often do) compare myself with my non medico friends. I see them heading companies, running firms, doing research. I see the facebook pics of them  posing in Switzerland, South Africa, US, or whichever part of globe u name it. Its often frustrating to sit in a dirty dressing room cutting through an ugly diabetic foot or listening to truly irritating and insulting abuses from seniors and even the local politicians or by standers. Sometimes you feel you made a terrible mistake by choosing to be a Doc. End less years of studies and you never even realize that you are growing old.

  But there are a few times you feel privileged to do what you can and feel proud to be in your profession.

And then,  you feel your heart stands still for a moment.

  I first felt that pleasure when I took the labor for first time. The feel of catching a new born infant and being the first one to handle him/her in this world is hard to describe and share.

  One condition I always loved to diagnose and treat was pulmonary edema. The struggle to take a breath is perhaps the worst thing a man can get. A couple of injections, and may be a little postural adjustment can make life a lot better for a patient in cardiac failure and give a sense of achievement back in your mind.

  Since I chose surgery as my stream, I may not see those patients any more. But I still see a lot of old men with big prostates coming with urinary retention. Some of them not passed urine for days and their bladder will be filling whole abdomen. Put in a Foley catheter and u watch the expression over face , u really feel rewarded. 

  To see a heart going still and then after surgery , it starting to beat again is one such experience which make you feel privileged. Leave aside all the worries ,technical and aesthetic aspects, i believe its one of the greatest achievement of medical technology. The sheer idea of stopping a beating heart with drugs, something which will never stop otherwise from your conception till your death and the courage to attempt that for the first time would have been a great adventure in Medical history. Just being back from Cardiovascular and Thoracic surgery, i once again feel blessed for I would never have other wise touched a real beating heart most of the people around will never know the feeling I had. 

  To all medical aspirants around all I want to say is that this profession is not easy to manage, but despite all odds, many times you will realize that your heart goes still for a moment or two.

     

Escharotomy.. When you realise that you are not naked as long as you are in your skin!

[Eschar is a thick leathery tissue which replace the skin in deep burns patients. Removing eschar is a time consuming pain staking process. Its practically cutting the leathery thing off from rest of tissue. Some times done under general anaesthesia, sometimes sedation and sometimes in our uncivilised setting, "vocal anaesthesia"]
 Burns patients are one particularly frustrating group of patents. For many reason their survival is poor. Anything more than 20% has extremely high mortality, either by fluid loss in early days or late onset infections. Fire to me is fieriest thing on earth. I dont know how people can even imagine about setting onelself on fire. And still an unbeleivable number of people resort to self immolation to "prove their point". Almost every time when a female with burns come, the history will be invariably an "exploded kerosene stove" and for males, a tipped off lamp or attempting to burn wastes. Frequency of stove explosion is so high that you may start thinking if they are making stoves with explosives.
Almost always the patients and bystanders reach a good rapport with the Burns ICU staff in a few days and true history unviels. Sometimes the reality will be more stranger than those soap operas in TV channels. The one who made me write this blog is in our ward now, a 39 year old mother of 3 kids. Did her escharotomy yesterday. She has 55% deep burns extending and now her specimen showed presence of extremely resistant bacteria sensitive only to Imipenam, a drug costing 2000 Rs per day! The history was as usual exploded stove. She had no female bystander and was brought by a guy somewhere in mid 20s. As days passed, the real history surfaced. She left her home husband and kids 2 years ago to live with this guy who is working as a video editor.Neither of families care. Kids are in orphanage. She havent met them for the last 2 years. And as she developed some difference of opinion with him, she was just trying to scare him by trying to burn herself. She never thought the fire would catch up!
 For males its a different story. Its usually the alcohol that does work. Though most of them prefer to pour it on their spouses, some try it on themselves too. To make the matters worse they start having withdrawal symptoms on day 2! One intersting guy came with history of tipped of lamp. 2 weeks in to admission, the eschar came off. This guy used to drink spirits and abuse his wife and kids every day. One fine day his 10yr old son lost his temper and threw the kerosene lamp on his dad. The story was covered up and the guy went home despite his 40% burns. I always think about that boy. I wonder how much he might have suffered and what he will grow to become. I have sutured stab wound on a 16 yr old who works for "quotation" gang and perhaps they need more guys. Ofcourse everyone knows that world we live in is a dangerous place. Still we try to beleive that the soaps and serials are fiction. But as they say Sometimes reality is stranger than Fiction.

As the eschar falls off, the reality is revealed. Then you realise that you are not naked when you are in your skin.

Tracing an appendix.... till a mayflower tree

[For those who doesnt know... Appendicectomy is one of the basic surgeries. In it, we hook out appendix and trace it to its base before dividing and taking it out] She came in as just another patient, 14 yr girl with lower abdominal pain, clinically a routine appendicitis. As our lab doesnt do HIV screening at night, we asked for the by stander to get it done from outside. A frail old lady came in. Obviously we asked for someone more responsible only to realise that there is no else to come. She was an orphan, second of 4 girls, her father was missing for years and her mother died in Bombay 2 years ago. Old lady was her grandmother. We somehow arranged things for surgery and got it done next day. A beneficiary card in RSBY scheme or a BPL certificate is almost an Aladdins lamp in Medical Colleges these days. She had none. Atleast some certificate from local Panchayath can help. We were trying to find out which area she belongs to. Then I noticed her address. It was just her name, and the name of a bus stop near our hospital. So we asked were exactly and she described precisely.... "ünder the may flower tree there" As i drove through that road today I searched for the may flower tree. There was a shack, or more aptly a tent, covered by tin sheets exactly beneath the may flower tree. I have passed through the same place many a times. Never did I notice such a thing there. Nor would I have imagined a family of 5 staying inside that. Just the thought of an old lady and 4 young girls in such an insecure dwelling is horrifying. Especially when its just half an hour away from where Soumya was torn apart and brutally killed a year ago. On second thought, I know there are many homeless people around. I know its a dangerous world. Still when you cross roads with someone like her , it pauses you for a moment. But i have no option but to proceed with ward rounds! Do I? Tail Piece: When we took her to OT she was asking for my female ward intern. She wouldnt let us induce anaesthesia or do surgery without her. At first I was annoyed, then I felt envious, then I silently prayed for my HS "Oh God, let this profession dont destroy the humaneness in her!"

Scenes from workplace....

Found this suicide note from the pocket of an oldman brought to ER by police. His both legs were bought in seperate bags, apparantly nicely sawed down by wheels of a speeding train. Jumped in front of train clearly with intention to take his own life. I wonder why he failed. Perhaps he didnt like the idea of a mangled head. Or may be he changed his mind too late to get out,but too early from the end he once wished.
And I wonder how he feels now. I presume his life was miserable. Still it wouldnt be any better without both his legs.
Or perhaps it may change for good. Like the patient who rejoined with his family after 15 long years after getting his right leg amputated for severe infection. He had spend 3months in the no by stander bed with an open stump,enjoyed care and hospitality of every charity worker and by stander of nearby patients. I dont know for sure. Let the time prove it.
I know I can find answer to most of question
s just by siting beside him and talking to him. But I cant. Somewhere down the timeline,I guess, I have become a Doctor!

About blunt dissection....

Back to blogging after a long time. Blunt dissection is the art of surgery. Its simply splitting through the tissue planes, the non existent potential spaces, spilling no blood, discovering the hidden. Its a technique hard to learn, harder to master. When you miss the level and plane you loose. You hit a lot of vessels spill a lot of blood. This is an attempt to dissect many lives I see in my work. Exploring, without bleeding...