The OPD was less in April and May because parents and kids, both were on vacations. I was about to leave my chamber when a woman and a man carrying a child rushed into my clinic. Their child was unconscious. There was a strange blueness on his skin and lips. He was even frothing from his mouth. What had happened? The mother who was panting for breath just kept on muttering, "Snake…Marble… Rat hole...”
"Snake? Marble?? Rat hole???” I was stunned.
I examined the hands and legs. There were marks in an inverted V (?) which were broken in between. It definitely was a snake bite mark.
The child was playing marbles with his friends in the building garden. His turn to hit the marbles came, he did so and the marble went into the rat hole. Without any fear or apprehension he placed his hand into the rat hole. Maybe it was a snake pit, who knows? And immediately something like an electric current hit his hand.
He just withdrew his hand. He noticed blood oozing from his right index finger. His friends saw something wriggling out of the rat hole. Before they could make out what it was it disappeared into the bushes. It was probably a snake, they presumed. Hearing the commotion the building's watchman rushed to the spot- "Ye toh saap kata hai, iske mummi ko jaldi bulao” (A snake has bitten him, call his mother soon). He was a little unconscious by then.
Luckily, his mother who is a regular officer goer was at home. The watchman carried him in his arms to their residence on the 2nd floor. He explained her as to what the situation was. The watchman with the child in his arms and his mother had come rushing to my clinic. The watchman had tied a handkerchief as a tourniquet to lessen the poisonous venom effect.
Little I knew of what I had seen about 10 years back in pediatric intensive care unit of Nair Hospital and in my AMOship practice. I gave a call at the nearby chemist and he gave a call at the nearby stockist and within an hour the anti-snake venom was made available in my hospital. But anti-snake venom can cause life threatening allergies. So a small test dose was given on his arm. It did not show any reaction so the entire dose of the snake venom was given.
An intravenous line catheter was established, blood was collected for testing, IV fluids, pain killers, and oxygen was started, the child was drowsy but responded to oral commands. He was moving his hands and legs. Probably, it was not a neuro-paralytic bite of a cobra.
Cobras are venomous and their bites are usually paralytic, vipers are the smaller ones whose bites are hemorrhagic, they cause disseminated intravascular coagulation and the patient dies due to internal blood loss. Blood reports showed that his bleeding parameters were disturbed.
Hence, blood products like fresh frozen plasma were given to the child. Vitamin K injections were given, electro cardiograms together with the prayers of the anxious parents. The father of the child had reached by then. Destiny is such a thing that you can do nothing but pray. And so did these parents, their prayers were answered, he responded right from the first IV line treatment. He really made me feel proud. 'Rat, hole and the marble'.
*
Must have seen cases and more cases, more complications, some related, unrelated. A fifteen days old child got fever up to 103oF daily. The mother being a pharmacist first tried home remedies, then local paracetemol, then the pediatrician medicines. Medicines didn't work so she came to my clinic. The child grew twenty five days old and he kept getting high fever daily. His blood reports were normal. Other than the high fever, the child was normal. High fever – paracetemol – normal temperature – high fever – paracetemol, the cycle continued.
All repeat blood tests, blood cultures were normal. Only the white blood count was marginally raised. It was decided to admit the baby and start on antibiotic injections thinking of late onset of sepsis. Three days passed by and still fever was continuing, the same way. Rather it was a challenge for me or for the parents, as they were not sleeping. I too had insomniac nights, what the hell was the cause for the high fever?
In the mean time, ultrasound of skull and abdomen were done which were normal. A lumbar tap for ruling cut meningitis was normal. Coincidentally on the fourth day, we noticed that the child was not moving the right leg, rather the right hip, but there was no swelling. On the same evening, the child developed a swelling on the right hip. An ultrasound of the hip revealed a pus collection there. Rare but an abscess anywhere in the body is definitely one of the causes of fever. It was decided to remove the pus. Two options were given to the parents.
Option I was an ultrasonic aspiration of the hip joint but there were chances of the abscess cavity filling up again. Option II was open surgical drainage. Since option I was less invasive parents decided to go in for option I. 8cc of thick yellow pus was aspirated under ultrasonic guidance. The pus showed staphylococcus infection. These germs usually go from skin into deeper tissues.
But as fate would have it, the abscess cavity filled up again after the procedure, the fever returned, so did the swelling. A repeat ultrasound confirmed the pus collection.
Option II – the more invasive surgery was planned. 25 days old baby was given general anesthesia. Written high risk consent for death on table was taken and given with a heavy heart. Under anesthesia, the child was totally calm, only breathing and heart beats were on lub-dub-lub-dub. A strong surgical incision and a big splash almost 30-50cc of pus jetted out soiling the operation theatre's bulb, the surgeon's cap-mark, something pus like did go in the nose of the child which could to be removed as snot.
The abscess cavity was left open, given a Betadine – hydrogen pack so that whatever daily pus comes out could be drained. We were done with the operation. The lub-dub was going on fine when he was recovering from anesthesia. Quickly, he was out of Anesthesia and into his mother's lap. I had a gut feeling he would cry his balls out but yup-yup-yup he was just gobbling at his mother's nipples, forgetting all his pains.
He had sustained the pain of the operation but shortly he started having breathlessness and pallor due to severe anemia. The child was given the blood transfusion. Child improved immediately after the blood transfusion. He was given injections so that his pus shouldn't form again. Imagine injections thrice a day for 4 weeks, more than the baby his mother used to cry.
In this process it was told to parents that there might be limb shortening or limping or a crooked gait. The father immediately changed his name to Phoenix. Today he is one year old, leave walking, he runs without a limp. He has risen from the grave.
*
Motherhood is one of the greatest joys known to humanity. This can be measured by the number of infertility clinics and specialists sprouting in the city. The best thing about babies is producing them, obviously naturally because in IVF, lakhs are spent as compared to free natural reproduction.
A mother was overjoyed after confirming that she was pregnant. But her joy was short lived. She had an acute episode of jaundice diagnosed as viral hepatitis. Her bilirubin level had shot up quite high so she was under tremendous mental tension- whether the child would be normal or abnormal or whether she would have to abort the child. Her jaundice episode lasted for about ten days after which she improved but the tension remained. What followed were serial ultrasounds, about seven were done which showed normal progress.
The eighth ultrasound showed evidence of a PDA (Patent Ductus Arteriosus) in her unborn child. PDA is a small connection between the Aorta and pulmonary Artery. She was referred to a pediatric echo cardiologist. The lady doctor examined this pregnant lady. She confirmed that it was a very large PDA. She advised that they should better opt for an abortion. Normally PDA is present in every child but such a large PDA would certainly require a surgical closure immediately after birth.
But what was the cause of such a large PDA? Was it the jaundice of the mother? Was it other infection? Would the baby be normal after the operation? Would the heart function normally thereafter? Would the child lead a normal life? And if PDA is normal physiologic connection, why at all abort? Only because it is large? Or are there other problems?
After a battery of questions the echocardiogram was repeated at two–three places. All the doctors confirmed the presence of a PDA. But the question remained whether to abort or not. Since it would be a small surgical closure the parents decided to continue the pregnancy. At the end of nine months a healthy, cute baby girl was born. The parents were overjoyed. Apparently the child looked healthy and it was advised to repeat the 2D echo after one week.
The 2D echo showed a much disastrous picture – Cyanotic heart disease (CHD) with total anomalous pulmonary veins with ventricular septal defect. The parents were very angry. They had been told it was only a Patent Ductus Arteriosus (PDA).
"Our lives are ruined. I will take them to court.”
They were just not willing to accept the truth.
"God is an imposter,” they shouted.
They did not even believe the 2D echo report. They repeated the 2D echo at 2 different places but they all confirmed that she had a complex heart disease.
"If we had known that it was such a complex heart disease we would have aborted.”
I tried to put it across to them that in the 2D echo before birth, the small pulmonary veins and septal defect could not be visualized and what could be seen was only the large PDA. Without the PDA, the pure and impure blood mixing wouldn't have taken place and if that would not happen the child would not survive inside the womb. This was like a medical dilemma, doldrums, Bermuda triangle which can not be predicted beforehand.
After this daily soap like high voltage drama followed, the climax was well known. They flew the baby to a well known hospital in south India where they saw that they were not alone. There were hundreds of children with heart defects from all around the globe. Humanity was at its best there. Nigerians, Germans, Indians, Pakistanis all under one roof. With only one concern which humanity should have, tender loving care for their children and a hope for better tomorrow.
The child by then had started turning blue with refusal of feeds, the harbinger of the unknown. An immediate open heart surgery was planned. The child was in the high profile operation theatre for sixteen hours. While the child was in the operation theatre all the parents of the children being operated were in the common waiting room.
In the meantime, they had received news that the Nigerian child had died on the operation table. Grief knows no language. Sorrow, crying, sobbing requires no bondage. It was like a dagger hovering on their heads, sixteen long hours of waiting in the waiting room when finally their turn came. The senior surgeon told, "All is well. The child's surgery went on fine.”
They had placed the veins in the right atrium, closed the septal defect, and ligated the patent ductus arteriosus. The child had tolerated the procedure well. The child was in the intensive care on the ventilator for 7 days after which she was shifted to the wards. Ventilator, oxygen, IV fluids, IV antibiotics- stepped down and stopped, gradually. It was more like a realistic Hindi movie with lots of emotions as if a child got lost in the great Kumbh mela was found again by the parents. It was a happy ending. The parents would never forget the sixteen hours of their stay in the waiting room.
(Taken from 'Someone Inside the White Apron' by Rajaram Weling)
