Wednesday, January 12, 2011

The miracle we have been waiting for

One of the greatest challenges of working in a small hospital is the outdated understanding most places have of the role of aggressive resuscitation of sick patients. Our hospital is no different. And the reason is obvious. For many years, it has been noticed by all the staff that once a patient started gasping, he or she invariably died! Subconsciously, the words 'patient gasping' come to signify impending death. And that subconsciously guides the aggressiveness of resuscitation that was offered (which, for the most part, is minimal).

This was the same in my hospital in Jharkhand. In those days (listen to me sounding like an old sage!!), there was no intercom. And so, if the nurses in the ward wanted to contact any of the doctors, the age-old 'copy' system applied. (Copy, as in a small notebook.) It was a well-oiled system. The first step was of course, that the patient started gasping. The second step was that the nurse on duty had to notice that the patient was gasping. This was not always as easy as it sounds, as at night, there was an acute shortage of nurses and one nurse would be managing 2 or 3 wards! So if the nurse happened to be in another ward, it depended on the relative of the patient to alert her to the situation. This was not always possible as the relative was usually under the bed of the patient, soundly asleep! But the moment the relative (usually female) identified the patient was taking his or her last few breaths, the whole hospital would then be alerted to the situation. For a loud wailing would ring through the corridors as the relative rushed to inform the other relatives who were waiting outside of the impending doom.

It was usually at this stage that the effective information mechanism (earlier termed the 'copy' system) rolled into action. The 2 or 3 nursed on duty would gather in the ward of the sick patient and chalk out the strategy. The junior-most would be dispatched to find the on-call chowkidar. This was not always an easy task, as this personality would have found himself a cosy place to spend the night in dreamless slumber (often the result of liquid intoxicants!). The other sister(s) would then proceed to write the dreaded words in the 'copy' - 'patient gasping'. When the grumpy chowkidar had finally been feretted out he was then handed the copy and sent to find the doctor. As some of the chowkidars (which, by the way, means guard) were well past their prime and most had far too much association with the bottle than was good for them, the best effort they could muster up even in a situation of such extreme emergency was hardly more than a walk. So they would peacefully meander through the campus to the doctor's residence with the precious 'copy' in their hand! In most cases, even if the doctor charged at full pelt back to the ward (and there were some who even used bicycles!), the patient had long gone to meet his or her Maker. In fact, some of the doctors would not even bother rushing to the ward as they felt it was pointless. Better to go slowly and declare the patient rather than have to wait in the ward till the actual point of death!

Thanks to some young and aggressive consultants, over the two years I was in Jharkhand had many discussions and arguments with the people involved about the need for aggressive resuscitation. Slowly, the wards began to have resuscitation trolleys and nurses began to anticipate problems rather than send namesake 'patient gasping' summons. And technology lent a helping hand - the intercom arrived which drastically reduced the response time of the doctors. And I remember very clearly at least 4 patients who arrested, were intubated and actually lived to tell the tale. Well worth the many hundreds of times we rushed to the ward to intubate a patient who finally succumbed to his or her illness.

Here in Shillong, things were nowhere as bad as they were in Jharkhand. But the aggressive attitude that is called for in acute resuscitation was still not a normal response to a sick patient among the hospital staff. Though things improved over time and the age-old ventilator began to be used, we were still waiting for the first miracle to happen - a patient who had arrested being revived after intubation. It was obvious that unless this happened, the subconscious feeling of the inevitability of death once the patient started gasping would always remain.

Well, after nearly 2 years, it has finally happened. A 72 year old man came to us 10 days ago with a 5-day old gastric perforation. We operated him and his abdominal problem was settling. But his chest just got worse and worse. A smoker with more than 80 pack years (Packs smoked per day x years as a smoker) behind him, even aggressive chest physiotherapy including suctioning the thick black secretions from the trachea every few hours (all you smokers out there, beware!) did not prevent him from gradually developing respiratory failure and arresting. Fortunately Amy was in the ward when it happened and resuscitated him. And today, after 4 days on the endotracheal tube, he was extubated. Of course, we don't know if he will make it to his home yet - he still remains extremely weak. But there is much joy in our hearts for after all this time, we can finally show that it is worthwhile to aggressively resuscitate patients, at least for the sake of the 1 person who will make it. And we thank God for his miracle in the life of this sweet old man.

P.S. - Sorry for this long post - wasn't planning on it..... it just kept going!!

3 comments:

  1. hey.thats really nice that you could put it down in words...somethin that i go through almost every other day in my hospital.. wish we had a functional ventilator too....

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  2. Hi Arpit, once again a great article-The way your depicted the gurkha is very realistic. It is true and very sad about the way things run in many parts of the world. Medical advances in the US are amazing but the imbalance of opulence and wastage in the western medical world compared to the needs of so many places is distressing and also frustrating. I can understand your joy in getting the vent, b/c this was much needed where I did my bond too. We used to bag ventilate pts for 2 hours en route in an 'ambulance' to Madras. And the lack of appropriate neonatal resuscitation still haunts me. Someone I know recently had a baby with congenital cardiac anomalies and the doctor in a well know hospital in Madras told the distraught parents, 'It is cheaper to have a new baby than waste all your money on this sick one" -what can you say about that?! Do you criticise the inconsiderate and :$#^& terrible doctor or do you sadly agree with his practicality.
    And then there is the whole world of special need children....
    Anyway, God knows the need and He will supply according to His riches.
    So good luck with the new vent.

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  3. Kudos to Amy and you, Arpit for proving a point by your perseverance and for extending the period of grace for the 72 year old by your timely intervention. You have described the "patient gasping" situation so vividly that it brings out the gravity of the situation so starkly. This is indeed a gift. God has given you of being able to highlight a desperate issue without making it heavy and morbid. Thank you for sharing this miracle.

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