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A STITCH IN TIME

A STITCH IN TIME

Mr. Suresh was a 27-year-old construction site supervisor who presented to the Emergency Department towards the end of the day with abdominal distension, vomiting and constipation. This had started around three days earlier and he was treated at two other hospitals but with his symptoms getting worse he was referred to BCMCH. Picking up on the clinical clues, the emergency physician wasted no time in alerting the Surgery team. The surgeon on-call who first saw him in the Emergency Department diagnosed Suresh to be in frank intestinal obstruction and sepsis (infection of the bloodstream). He had almost no urine output and his total white cell counts were very low, indicating a severe sepsis status – this was a medical and surgical emergency. A simple x-ray of the abdomen confirmed the intestinal obstruction, and based on clinical and radiologic findings, the surgeons met his relatives and impressed on them the need for emergency surgery. He was resuscitated and wheeled to the Operation Theatre for abdominal surgery the same night.

The operating surgeons found that he had a congenital anomaly (abnormality since birth) causing intestinal obstruction. While that could be corrected, the surgical team realised that it would not be possible to close the abdomen as the bowel loops were very distended and oedematous (swollen). Closing it under tension would be dangerous and also worsen his kidney function. So they decided to close the abdomen temporarily with a sterile cover, called a laparostomy procedure. This is a cost effective way to temporarily close the abdomen using readily available material like a urobag. It is also a part of damage control surgery. He was then monitored in the ICU. He was initially on a ventilator – this was not an easy task with part of his intestines in the urobag but the critical care consultants and nursing staff rose to the challenge. Two days later, Suresh underwent a second surgery. During this procedure, the urobag was removed, the bowels emptied and the skin closed. After this second surgery, he was shifted back to the ICU. His condition deteriorated for some time with a fall in haemoglobin levels. The factors in his favour were his age and his approach to life. Suresh remained a positive individual and cooperated with all the respiratory exercises and physiotherapy despite the pain and discomfort. His kidney function improved without the need for dialysis. The surgeons regularly met his relatives to keep them informed of the treatment plan, the daily condition and the progress and they trusted us the doctors to provide the best possible care for their son.

All this while, Suresh had to be kept fasting as his abdomen was distended not ready to process normal food. Without regular nutrition he was growing weaker. As a result, he was transfused blood and Total Parenteral Nutrition (TPN) was instituted. As a result of the continued round-the-clock care and with his nutritional needs being met, he started turning the corner. He was started on an oral diet after almost two weeks from his first surgery. Once his general condition stabilized, he was shifted to the ward. Unfortunately, he developed a wound infection, not an uncommon occurrence following bowel surgery in sick patients. A Negative Pressure Wound Therapy (NPWT) was instituted in the ward and aided by antibiotics, the infection was controlled and the wound resumed normal healing. NPWT is a technique used to promote wound healing in large wounds. A negative pressure is applied to the wound over an airtight dressing and opened after three to four days. This helps in the removal of infected fluids and promotes faster growth of healthy tissue. This treatment technique is regularly used in BCMCH to treat difficult-to-treat foot ulcers in diabetic patients. A commercial NPWT dressing was done to enable Suresh to walk around. His first few steps after this brush with death filled Suresh with much needed hope for the future. He was finally ready to be discharged and returned home after a month in hospital.

Prolonged hospitalization requiring ICU care and multiple surgeries can be a financial burden on individuals and families. The hospital management, made aware of the financial needs of Suresh’s family by the treating surgeons, came forward to subsidize treatment by offering concessions on the final bill. The family was also supported by close relatives who contributed to his treatment costs.

Suresh had his first review after discharge in the Surgery OPD last week and he is doing fine. His abdominal wound may take another two weeks to heal, after which he will be able to return to work and continue a normal life. We thank the doctors, nurses and other personnel in the Emergency Department, Operation Theatre, Anaesthesiology, Intensive Care Unit, Cardiology, and Surgery who came together and worked as a team to provide Suresh with the urgent and necessary surgical and medical care. They have yet again highlighted that quick thinking and compassionate care go hand-in-hand at BCMCH. We are also grateful to his brothers, his mother and other close relatives for trusting the surgery and critical care teams through difficult times and motivating Suresh on the path of recovery.

(The name of the patient has been changed to maintain confidentiality)