THIS CAN HAPPEN: VOLUME VI
Dr. Gangadhar Sahoo
It is early 1980s. I was in the OPD of the Sub-divisional Headquarters Hospital, Deogarh. I got a call from the labor room that a patient in very low condition was admitted. She needed urgent attention. I almost ran to the labor room. Before wasting time in taking history and completing the admission formalities I examined the patient. The patient was very sick almost in shock, severely pale, tachycardiac and hypertensive. Abdomen was distended, severely tender with free fluid inside. Immediately took anti shock resuscitation measures. Catheterization was done. Hardly 50 ml of highly concentrated and blood stained urine was drained. Abdominal tapping revealed frank blood inside peritoneal cavity. She was the mother of two children and had undergone sterilization operation in a camp one year back just after delivery of her second baby. She had missed her period for 15 days followed by severe pain abdomen, fainting attacks and slight bleeding per vaginum. After thorough clinical examination and peritoneal tapping I confirmed my diagnosis to be RUPTURED ECTOPIC PREGNANCY with massive intraperitoneal hemorrhage and shock. She needed immediate surgery and blood replacement. I wanted to refer her to a higher center with facility of anaesthesia, surgery and blood transfusion. But she was not in a position to be shifted to the nearest center which was about 100km away. Transportation at that time was almost impossible. The husband of the patient was too poor to handle the case. He surrendered completely before me, “Doctor! You are my God. Whatever you feel good, please do. It's her luck and your healing touch. If she is destined to survive nobody can take her away. If not I will not blame anybody rather accept my fortune. "
At that period of time there was no facility of anaesthesia, blood transfusion and constant supply of oxygen cylinder. Oxygen was procured from nearby centers more than 100 km away .Many a time hospital was running without oxygen for months together. I planned to open the abdomen immediately to minimize blood loss and save the patient. Open ether was the only anaesthesia method available at that time and one of our assistant surgeons was trained in that procedure. Under open ether anesthesia, oxygen inhalation, intravenous fluid and mass prayer I started the operation. The abdomen was distended with dilated intestines floating. Moreover because of open ether anesthesia she was pushing. With two tissues holding Allis forceps peritoneum was carefully and gently lifted and a small nick was given to allow the blood to be drained. That blood was collected in a separate kidney tray filtered with multilayered gauze and auto transfused. This was the oldest method of auto transfusion by which we had saved many lives. Today if you talk of this to anybody, you will be laughed at by the younger generation.
Abdominal cavity was filled with blood. After cleaning the peritoneal cavity it was found that the left tubal pregnancy had ruptured. All the staffs were watching my operation and waiting to prove me wrong in my diagnosis. When it came out to be tubal rupture all in unison congratulated me and expressed their surprise how it happened after tubectomy operation and how could I diagnose. I explained everything how a micro recanalisation of the operated tube can occur. Then I told them the secret of my diagnosis. “When a patient presents with amenorrhea, severe pain abdomen, fainting attack / attacks and vaginal bleeding think of ruptured ectopic pregnancy unless otherwise proved. On examination if features of shock associated with severe pallor, distended abdomen and free fluid in abdominal cavity is found, it is most probably intraabdominal bleeding. If per vaginal examination reveals rocking sign (on movement of cervix there is excruciating pain in abdomen) clinically ruptured ectopic pregnancy is diagnosed. At that time no investigation facility like Ultrasonography was available not even a pregnancy test kit.
Abdominal tapping was the only confirmatory method. If frank unclothed blood comes out then diagnosis is confirmed. That was how the diagnosis was confirmed.
Any surgery on the tube whether constructive or destructive is a high risk factor for tubal pregnancy. This is the Gospel truth."
Left side damaged tube was excised. The right side tube was examined. On precautionary measure that side tube was also excised. Whole abdominal cavity was cleaned of any retained blood or clot to avoid infection and adhesion in future. Cavity was thoroughly inspected for bleeding and foreign bodies like tetra and gauze. Once satisfied we planned for closure. To our surprise we found in one place peritoneum was caught by two Allis tissue forceps. I thought why those two instruments were still there unmarked? Most probably while opening the peritoneal cavity the peritoneum was caught by those two forces. At that time everyone was busy in operation and auto transfusion and had forgotten to remove the forceps. When I went to remove the forceps I found that a piece of intestine was caught along with the peritoneum by the two forceps and cut open. Fecal matter was coming out though that small opening. I thank God for gifting me those two forceps which were kept unknowingly and unintentionally to show me the blunder committed by me, so that the poor patient should not suffer for my fault. For none of her fault she had already suffered a lot, not any more. The silent intestinal injury was diagnosed. I could manage to repair the injury and saved the patient from an inevitable fatal morbidity. I was doubly fortunate because God saved the patient through me from two fatal injuries, one from the ruptured ectopic and the other from the silent intestinal injury. I was happier than the patient.
It's said that if God wants to save, no one on this earth can do any harm to him / her. That patient was a bright example.
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