THIS CAN HAPPEN: VOLUME XXXII & XXXIII
Dr. Gangadhar Sahoo
This can Happen vol.XXXII:-
(SORRY ! WE ARE HANDICAPPED)
Dr. Gangadhar Sahoo.
It's an incidence in early 2000 . I was in Head of the second unit ObGy, VSSMedicalCollegeBurla . I was in routine ward round . All my team members including the postgraduate students and staff sisters were present in the round. We started the round from the ground floor. There were ten beds from 11 to 20 , fully occupied with mostly post cesarean cases. Since it was a tertiary referral hospital and the only medical college in Western Odisha, all complicated and difficult cases were being admitted. So cesarean section rate was quite high. The scene of the postnatal ward was worse than a platform. Not only the ward was overcrowded with attendants but also very congested with their belongings kept on the floor surrounding the patient's bed . Sometimes patients were accommodated on the floor at the time of scarcity of beds.
That was the second postoperative day of a caesarian case in bed number 15 . She was a case of previous CS , no living issue with severe pre-eclampsia . It was an elective cesarean . All necessary investigations along with cardilogical check up were done before operation . Preoperative anaesthesiologist's advice was followed. The operation was uneventful.
In the morning round the patient was found to be ambulatory. Her vitals were within normal limits, bowel moved, bladder function was normal and breastfeeding was started. We advised her regarding her diet and instructed the staff sister in charge to convert all the parenteral medicines to oral . After completing the round in the ground floor we went to other wards. After completing rounds in three wards , I came to labor room . It was the regular practice at that time for the consultants to see the emergency cases of their respective units in the labor ward and advise as and when required.
While I was discussing with the team of doctors and staff sister regarding the management of a critically ill eclampsia patient , I saw my post graduate in charge of the ground floor ward came rushing almost breathless and said, "Sir ! The patient in bed no. 15 is restless, rolling on the bed with severe chest pain and shortness of breath. I have given an analgesic injection and started the oxygen inhalation. Please attend the case and advise. " Then she ran back. Immediately the stretcher from the labor room was sent to the ward and the patient was brought to the labor room.
Since it was a working day and OT was running, the anaesthesiologist rushed to the labor room from the OT. The patient was struggling with pain, dyspnoeic, tachypnoeic and restless. Anaesthesiologist tried for intubation but failed. She breathed her last within a few minutes in front of all of us . We could do nothing to save her . We were just the silent spectators. What might be the cause of this sudden deterioration? A completely healthy woman about to be discharged , had to meet this tragic end without giving time to the treating team to react, was unbelievable. The death news of this patient spread like a wildfire. She was a patient from the Burla market . Her husband was a businessman, having a grocery shop in the town. Her relatives, friends and other persons of different age groups from the locality were gathering in the labor room. Gradually the crowd was swelling. Apprehending a rush of crowd and trouble there after I took the lead to break the news . I called her husband, a few relatives and the so-called local VIPs into the duty room of the labor ward. Since I was the treating physician and I was with the patient since morning , I know everything about the patient. I could sense the disapproval on the faces of all present there. I overheard someone blaming the system and someone talking of negligence. But I also could find some sympathizers.
Everyone had one question, " What happened? Why did she die ? She was alright. Within a span of a few seconds she died. Is it a heart attack? " I showed them all the reports including the cardiology report which were normal. Then I explained to them in detail what might have happened. From the symptoms and signs it was clinically evident that only one condition can cause such a type of sudden death. Most probably it was a massive pulmonary thrombosis . To another person's query of how to confirm it , I explained that only postmortem can. Actually it was one of the rarest of rare cases. In my long clinical practice that was the first case I had encountered. I explained to them ,"Even in the best of the best-equipped hospitals and best of best hands, the survival rate is almost 0%." All the relatives of the patient could understand the problem. Then politely I suggested to them that as per the hospital protocol a postmortem should be done in such types of unnatural deaths not only for the sake of diagnosis but also for academic purposes. All of them unanimously said,"Sir! You are not only our doctor, you are our God . You have saved many serious patients. You have tried your best. It's our bad luck that we lose our patient. Please don't suggest postmortem. Unnecessarily we will be harassed .Allow us to take the body . We will be highly obliged." The husband of the deceased gave an undertaking and took the dead body.
We had a sigh of relief. I thank God because we were saved from an impending law and order situation. But still I felt guilty of losing a young mother and at the same time depriving the newborn of the mother's love. I took it as an accident and as a lesson. Accident because I had neither thought of such a complication nor seen it . Only I had read in the Obstetrics books that massive pulmonary vessel thrombosis is a cause of maternal mortality. Though rare it does occur. Lesson because no pregnancy is safe unless otherwise proved. My slogan for the labor room, “ HOPE FOR THE BEST AND BE PREPARED FOR THE WORST.”
This can Happen vol.XXXIII:-
(My first experience in a rural tubectomy camp)
Dr. Gangadhar Sahoo.
It was the 29th July 1979 , when I was appearing the MD ObGyn final oral, practical and clinical examination. On that day I received my appointment letter( after conquering OPSC) posted in one of the remote most PHCs in Sambalpur District. After the examination I went to my village to meet my parents and other family members. All were happy to know that I had done well in the examination and at the same time got a Govt. job. After 3 days I came back to Burla and from their to my place of posting. Within a few days I was deputed to another PHC, Dava PHC, where both the doctor posts were vacant and it was run by a pharmacist.
The main objective of my deputation was to conduct tubectomy camps as there were no operating hands . Since I had completed post graduate course, everyone had a high expectation on me. When I reached there, I received a ceremonial welcome not only from the staffs of the PHC but from the people of the locality. For the first time a specialist is being posted in Dava PHC. So people were standing in ques holding garlands to to have a glimpse of me and welcome me . It was simply awesome and beyond my imagination. I felt myself as the incarnation of God.That was a memorable day in my life . Every thing was ready for my comfortable work and stay. Since that was the first day of my life where I had taken the independent charge as the head of the Institution , I was a bit nervous at the same time anxious and curious.
I called a staff meeting on that day in the afternoon to welcome my staffs and appraise them of their duties and responsibilities.
In that meeting a plan was prepared for the month. It was decided to hold four tubectomy camps in that month in different places. The staffs were very happy to hear that announcement.
The first camp was fixed a week later in a village around 15 km away from the head Quarters. The health assistant and ANM of that area under the supervision of the LHV started their work in registering the eligible cases and preparing the camp.
On that day I along with the health assistant Mr. Panda and the clinical health assistant Mr. Garnaik reached the site (an UP school) at about 9am . Already 30 cases had been registered and the process of registration was continuing. There was no guide line for selection, no clinical evaluation, no investigation and no preparation. "First come first serve " was the rule. The cases were carried from their home by bullock carts and put in two class rooms on the floor. One ANM was enrolling the cases, taking their signature/thumb impression on a form and injecting one dose of tetanus toxoid. In another class room three tables were put for tubectomy operation (family planning operation) for 3 operating surgeons myself, Mr. Garnaik and another surgeons deputed from the Sub-divisional Headquarters Hospital. I told my staff, " Let the other two operate and let me observe today. " Operation started at about 10 O'clock. Two patients were put on the two bare tables. One ANM applied the antiseptics on the abdomen and covered their faces .
Surgeons were washing their hands with soap and water and coming for surgery. They were not putting on gloves what to speak of mask, gown and head cap .With bare hands without gloves, under local xylocain anaesthesia they were operating under torch light. One sister standing in between two tables was assisting two surgeons. I was marking the skill of the two surgeons. They were hardly taking 10 minutes from skin to skin. In cases who were not cooperating were given vocal anaesthesia. There were expert staffs who were skilled in administering vocal anaesthesia. In some cases if one tube was delivered then the assistant was giving vocal anaesthesia in an amazing way ," Son producing tube is operated and daughter tube is left. Please cooperate or that will be left ."
I had never experienced such type of inhuman methods of surgery in my PG carrier. I was in a dilemma what to do ! People have gathered in large number to see their consultant operate .
They were expecting something extraordinary from me . But I was in a state of total confusion. Should I operate or should not I? If operate there was every chance of embarrassment, if not today then when? At last I decided to operate the last case and asked Mr. Garnaik to assist me . With gloved hand I operated. When I entered into the peritoneal cavity I felt like I was in an ocean and searching for a small sea fish. My two fingers were busy in exploring the abdominal cavity but unable to find the uterus, what to speak of the delicate tubes . By that time 10 minutes had passed. The patient had started straining and the attendants had become impatient and started grumbling.
Then I asked Mr.Gadnaik to bail me out . He obliged and finished the job within five minutes. During PG carrier , I had the privilege of working under the umbrella of experienced people and luxury of anaesthesia. So I had never faced any trouble during tubectomy. Even during my internship, I had the opportunity of doing one tubectomy operation under the guidance of late Dr. D K Pattanaik, who was a clinical tutor at that time.
"When you are in Rome, be a Roman. " The sooner you adopt the changing environment, the better. If you challenge the change by finding fault with the system, you can not thrive. Survival of the fittest is the rule. I learnt the techniques of the operation from Mr. Garnaik and slowly became a skilled tubectomy surgeons in rural set up . So I admire Mr. Garnaik as my Guru.
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